Fincen Form 103-N - Multiple Persons Or Multiple Agents
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FinCEN Form 103-N (Rev. 12-03) (Formally Form 8852)
Multiple Persons or Multiple Agents
(Complete applicable parts below if box 2 or box 16 on page 1 is checked.)
(Continued)
Part I
Section A Person(s) on Whose Behalf Transaction(s) Is Conducted (Patron)
3 Individual’s last name or Entity’s name
4 First name
5 M.I.
7 SSN or EIN
6 Permanent address (number, street, and apt. or suite no.)
8 City
9 State
11 Country code
12 Date of birth
10 ZIP code
____/____/________
(if not U.S.)
M M
D D
Y Y Y Y
13 Method used to verify identify:
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 identify: a
Examined identification credential
b
Known patron - information onfile
c
Other
28 Describe identification credential: a
Driver’s license/State ID b
Passport
c
Alien registration
d
Other
e Issued by:
f
Number:
CTRC-N INSTRUCTIONS
involving or aggregating at least $5,000
designated 24-hour period that
in cash. Do not use Form 103-N to (a)
aggregate to more than $10,000 in cash
General Instructions
report suspicious transactions of $10,000
are reportable if the transactions are the
Who Must File. Any Nevada casino
or less or (b) indicate that a transaction
same type transactions within the same
that qualifies as a 6A licensee pursuant
of more than $10,000 is suspicious.
monitoring area or if different type
to Nevada Gaming Commission
transactions occur within the same visit
When a suspicious transaction requires
Regulation 6A (Reg. 6A), generally
at one location. Do not use Form 105
immediate attention, telephone 1-800-
casinos
with
greater
than
to report receipts of cash in excess of
800-2877 between 9:00 a.m. and 6:00
$10,000,000 in annual gross gaming
$10,000 that occur at non-gaming areas;
p.m. Eastern Standard Time (EST). An
revenue and with over $2,000,000 of
instead use Form 8300, Report of Cash
Internal Revenue Service (IRS) agent will
table games statistical win.
Payments Over $10,000 Received in a
direct the call to the local office of the
Trade or Business.
Exceptions. Certain persons are not
IRS Criminal Investigation Division (CID).
considered patrons pursuant to Reg.
In an emergency, consult directory
When and Where to File. File each
6A. Transactions with these persons
assistance for the local IRS Criminal
Form 103-N by the 15th calendar day
are not reportable. See Reg. 6A for
Investigation Division (CID) office.
after the day of the transaction with the:
details.
Definitions. Certain terms, such as the
IRS Detroit Computing Center
Identification Requirements. Before
terms “patron,” “designated 24-hour
ATTN: CTRC-N
completing a reportable transaction
period,” “same type of transactions” and
P. O. Box 32621
with a patron, a 6A licensee must
“6A licensee,” are defined in Reg. 6A.
Detroit, MI 48232-5604
obtain a valid, reliable identification
Penalties. Civil and/or criminal penalties
Keep a copy of each form filed for five
credential from the patron. See Reg.
may be assessed for failure to comply with
years from the date of filing.
6A for details.
Reg. 6A. See Nevada Revised Statutes
Suspicious Transactions. If a suspicious
What to File. A 6A licensee must file
463.125, 463.360 and 207.195.
transaction involves more than $10,000
a Form 103-N for a reportable
Specific Instructions
in cash, complete Form 103-N as well
transactions with a patron as outlined
as a FinCEN Form102, Suspicious
in Reg. 6A. A reportable transaction
Note: Additional information that cannot
Activity Report by Casinos (SARC). Also,
is a transaction that involves more than
fit on the front and back of the Form 103-
casinos are required to use the SARC
$10,000 in cash. Also, smaller
N must be submitted along with the item
form to report suspicious activities
transactions occurring within a
number associated with the additional
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