Fincen Form 103 - Currency Transaction Report By Casinos
Download a blank fillable Fincen Form 103 - Currency Transaction Report By Casinos in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Fincen Form 103 - Currency Transaction Report By Casinos with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2103
Currency Transaction Report by Casinos
FINCEN Form
(Formerly Form 8362)
Previous editions will not be accepted after September 30, 2003.
(Rev. March 2003)
Please type or print.
Department of the Treasury
(Complete all applicable parts--See Instructions)
OMB No. 1506-0005
FINCEN
1 If this Form 103 (CTRC) is submitted to amend a prior report check here:
and attach a copy of the original CTRC to this form.
Person(s) Involved in Transaction(s)
Part I
Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted (Customer)
2
Multiple persons
4 First name
5 M.I.
3 Individual’s last name or Organization’s name
6 Permanent address (number, street, and apt. or suite no.)
7 SSN or EIN
10 ZIP code
11 Country (if not U.S.)
12 Date of birth
8 City
9 State
____/____/________
M M
D D
Y Y Y Y
13 Method used to verify identify:
a
Examined identification credential/document
b
Known Customer - information on file
c
Organization
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 persons
17 Individual’s last name
18 First name
19 M.I.
20 Address (number, street, and apt. or suite no.)
21 SSN
22 City
23 State
25 Country (if not U.S.)
26 Date of birth
24 ZIP code
____/____/________
M M
D D
Y Y Y Y
27 Method used to verify identify:
a
Examined identification credential/document
b
Known Customer - information on file
c
Organization
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 all items that apply.
Part II
29.
Multiple transactions
31 CASH OUT: (in U.S. dollar equivalent)
30 CASH IN: (in U.S. dollar equivalent)
a Purchase(s) of casino chips, tokens, and
a Redemption(s) of casino chips, tokens, and
$
$
.
.
00
00
other gaming instruments
other gaming instruments
.
.
00
00
b Withdrawal(s) of deposit (front money of safekeeping)
b Deposit(s) (front money or safekeeping)
.
.
00
00
c Payments(s) on credit (including markers)
c
Advance(s) on credit (including markers)
.
.
00
d Payment(s) on wager(s), including slot jackpot(s)
d Currency wager(s)
00
.
.
00
00
e Currency received from wire transfer(s) out
e
urrency paid from wire transfer(s) in
C
.
.
00
f
Negotiable instrument(s) cashed (including checks)
00
f Purchase(s) of casino check(s)
.
.
g Currency exchange(s)
00
00
g Currency exchange(s)
h Travel and complimentary expenses and
.
.
00
00
h Other (specify):
gaming incentives
.
00
i
Payment for tournament, contest or other promotions
.
00
j
Other (specify):
0
.
$
.
$
0
00
00
i Enter total of CASH IN transaction(s)
k Enter total of CASH OUT transaction(s)
32 Date of transaction
33 Foreign currency used:
____/____/________
____/____/________
(see instructions)
(Country)
M M
M M
D D
D D
Y Y Y Y
Y Y Y Y
Part III
Casino Reporting Transactions
34 Casino’s trade name
35 Casino’s legal name
36 Employer identification number (EIN)
37 Address (number, street, and apt. or suite no.) where transaction occurred
39 State
38 City
40 ZIP code
41 Title of approving official
42 Signature of approving official
43 Date of signature
____/____/________
Sign
M M
D D
Y Y Y Y
44 Type or print preparer’s name
46 Contact telephone number
45 Type or print name of person to contac
Here
)
(
103
For Paperwork Reduction Act Notice, see page 4.
Cat. No. 37041B
FinCEN Form
(Rev. 3-03)
(Formerly Form 8362)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial