Fincen Form 103-N - Currency Transaction Report By Casinos Nevada
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1
2103-N
Currency Transaction Report by Casinos
Nevada
FINCEN Form
(Formerly Form 8852)
Previous editions will not be accepted after May 31, 2004.
(Rev. December 2003)
Please type or print.
Department of the Treasury
(Complete all applicable parts--See Instructions)
OMB No. 1506-0003
FINCEN
1 Check appropriate box(es) if:
a
Amends prior report
b
Supplemental report
Part I
Person(s) Involved in Transaction(s)
Section A Person(s) on Whose Behalf Transaction(s) Is Conducted (Patron)
2
Multiple persons
4 First name
M.I.
3 Individual’s last name or Entity’s name
5
6 Permanent address (number, street, and apt. or suite no.)
7 SSN or EIN
9 State
8 City
10 ZIP code
11 Country code
12 Date of birth
____/____/________
(if not U.S.)
M M
D D
Y Y Y Y
13 Method used to verify identity:
a
Examined identification credential/document
b
Known Patron - information on file
c
Organization
d
Other
14 Describe identification credential: a
Driver’s license/State ID b
Passport
c
Alien registration
d
Other
e Issued by:
f
Number:
15 Customer’s Account Number
Section B Individual(s) Conducting Transaction(s) - If other than above (Agent)
16
Multiple agents
17 Individual’s last name
18 First name
19 M.I.
20 Permanent address (number, street, and apt. or suite no.)
21 SSN
22 City
23 State
24 ZIP code
25 Country code
26 Date of birth
____/____/________
(if not U.S.)
M M
D D
Y Y Y Y
27 Method used to verify identity: a
Examined identification credential
b
Known patron - information on file
c
Other
28 Describe identification credential: a
Driver’s license/State ID b
Passport
c
Alien registration
d
Other
e Issued by:
f
Number:
Amount and Type of Transaction(s) (Complete Box 31 or 32)
Part II
29
Multiple transactions
30
Dissimilar transactions
31 CASH IN: (in U.S. dollar equivalent)
32 CASH OUT: (in U.S. dollar equivalent)
a Redemption of casino chips, tokens,
a Purchase of casino chips, tokens,
$
$
.
.
00
00
and other gaming instrumentalities
and other gaming instrumentalities
.
.
00
00
b Withdrawal of deposit (front money of safekeeping)
b Deposit (front money or safekeeping)
.
.
00
c Advance on credit (including markers)
c Payments on credit (including markers)
00
.
00
.
d Payment on bet (including slot jackpot)
d Table game cash bet lost
00
.
.
00
00
e Currency paid from wire transfer in
e Non-table game cash bet.
.
.
f Other (specify)
f
Negotiable instrument cashed (including checks)
00
00
g Travel and complimentary expenses and
.
00
gaming incentives
.
00
h Payment for tournament, contest or other promotions
.
00
i Other (specify)
.
.
$
$
g Enter total amount of CASH IN transaction
00
00
j Enter total amount of CASH OUT transaction
33 Date of transaction
34 Time of
35 Foreign currency
____/____/________
A.M.
P.M.
:
(see instructions)
transaction
used (country code)
M M
D D
Y Y Y Y
36 Additional information
Casino Reporting Transaction(s)
Part III
37 Casino’s trade name
38 Casino’s legal name
39 Employer identification number (EIN)
40 Address (number, street, and apt. or suite no.) where transaction occurred
41 Contact Telephone Number
(
)
43 State
44 ZIP code
45 Country code
42 City
(if not U.S.)
46 Name and title of recorder/handler
48 Date of signature
47 Signature of recorder/handler
____/____/________
Sign
M M
D D
Y Y Y Y
49 Name and title of reviewer
50 Signature of reviewer
51 Date of signature
Here
____/____/________
M M
D D
Y Y Y Y
For Paperwork Reduction Act Notice, see page 4.
103-N
Cat. No. 23511I
FinCEN Form
(Rev. 12-03)
(Formerly Form 8852)
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