Fincen Form 107 - Registration Of Money Services Business - 2011
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1
2Registration of Money
FinCEN Form 107
Services Business
March 201 1
Please type or print. Always complete entire report.
Previous editions will not be
See instructions for items marked with an asterisk ( * ).
OMB No.1506-0013
accepted after September 30, 2011
Complete and send to: Enterprise Computing Center-Detroit, Attn: Money Services Business Registration, P. O. Box 33116, Detroit, MI 48232-0116
Part I
Filing Information
1 Indicate the type of filing by checking a, b, or d below (Check only one). If filing a
correction, check “c” and either a, b, or d.
a
Initial registration
b
Renewal
c
Correcting a prior filing
d
Re-registration
2 If you checked item 1 d please indicate the reason(s). Check all that apply .
a
Re-registered under state law
b
More than 10 percent transfer of equity interest
c
More than 50 percent increase in agents
Part II
Registrant Information
*3 Legal name of the money services business
4 Doing business as
*7 State 8 ZIP Code
*6 City
*5 Address
*9 EIN (entity), SSN/ITIN (individual)
10 Telephone number (include area code)
11 E-mail address (If available)
(
)
Part III
Owner or Controlling Person
13 First name
14 Middle initial
12 Individual’s last name, or organization’s name
15 Address
19 Country (if other than US)
17 State 18 ZIP Code/Postal Code
16 City
22 SSN/ITIN (individual), EIN (entity)
20 Telephone number - (include area code)
21 Date of birth
(
______ / ______ / _______
)
MM
DD
YYYY
23 Skip this item if you completed item 22.
If the owner or controlling person is an individual enter their form of identification, the ID number, and the issuing state or country.
a
Driver ’s license/state ID
b
Passport
c
Alien registration
z
Other _________________________
e
ID number
f
Issuing state or country
Part IV
Money Services and Product Information
24 S tates and/or territories where the registrant, it s agents or branches are located. Check box a, b, or c as appropriate ( Check only one) and
do not check individual st ate/territory boxes. If box a, b, or c
does not apply , check as many st ate/territory boxes as necessary .
a
All States & Territories
b
All States c
All Territories
Alabama (AL)
Georgia (GA)
Maryland (MD)
New York (NY)
South Dakota (SD)
Alaska (AK)
Guam (GU)
Massachusetts (MA)
North Carolina (NC)
Tennessee (TN)
American Somoa (AS)
Hawaii (HI)
Michigan (MI)
North Dakota (ND)
Texas (TX)
Arizona (AZ)
Idaho (ID)
N. Mariana Isls. (MP)
Minnesota (MN)
Utah (UT)
Arkansas (AR)
Illinois (IL)
Mississippi (MS)
Ohio (OH)
Vermont (VT)
California (CA)
Indiana (IN)
Missouri (MO)
Oklahoma (OK)
Virgin Islands (VI)
Colorado (CO)
Iowa (IA)
Montana (MT)
Oregon (OR)
Virginia (VA)
Connecticut (CT)
Kansas (KS)
Nebraska (NE)
Palau (PW)
Washington (WA)
Delaware (DE)
Kentucky (KY)
Nevada (NV)
Pennsylvania (PA)
West Virginia (WV
District of Columbia (DC)
Louisiana (LA)
New Hampshire (NH)
Puerto Rico (PR)
Wisconsin (WI)
FS of Micronesia (FM)
Maine (ME)
New Jersey (NJ)
Rhode Island (RI)
Wyoming (WY)
Florida (FL)
Marshall Islands (MH)
New Mexico (NM)
South Carolina (SC)
Catalog Number 39578N
Rev. 3/11
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