Fincen Form 103-N - Multiple Persons Or Multiple Agents Page 2
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FinCEN Form 103-N (Rev. 3-03)
information on plain paper attached to
Item 14. Describe Identification
Items 6, 8, 9, 10 and 11. Address. Enter
the Form 103-N. Type or print the
Credential. Check box a, b, c or d as
the permanent street address including
patron’s name, social security number (or
applicable. If Item d is checked,
apartment or suite number, road or route
EIN), date of the transaction, licensee’s
specifically indicate the credential
number, city, state, zip code and two
name and licensee’s EIN (i.e., Items 3, 4,
examined (e.g., Military ID). For all types
letter country code (if not United States)
5, 7, 33, 37, 38 and 39) on all additional
of credentials, enter the issuer of the
of the patron. Use two-letter postal
sheets so that, if the sheets becomes
credential such as the state or country
abbreviations for the state (e.g., NV for
separated, they may be associated with
(using two-letter abbreviations or codes)
Nevada, CA for California). If the patron
the Form 103-N.
in the space provided for box e (see
is from a foreign country use the required
instructions for items 10 and 11). Enter
two-letter country code (e.g., JA for
Item 1 a. Amends Prior Report. Check
the identification number contained on
Japan) found at the FinCEN web site at
box a if the report corrects an error in a
the credential in the space provided for
or
previously filed report or provides
box f.
call the FinCEN Help Line at 1-800-949-
information for a previously filed report.
2732 and select option 5.
Staple a copy of the original report
Item 15. Customer Account Number.
behind the amended one. Complete Part
Enter the patron’s account number
If the patron has no residence street
III in its entirety, but only complete those
associated with the transaction. If no
address, the patron refuses to provide a
other entries on the form that are being
account number exists, indicate “N/A.”
residence street address or only provides
amended.
a post office box for an address, indicate
Section B - Individual(s) Conducting
“NONE,” “REFUSED” or the post office
Item 1 b. Supplemental Report. Check
Transaction(s) If Other Than Above
box number in Item 6 as applicable.
box b if the report is for additional same
(Agent)
type transactions occurring subsequent
Item 7. Social Security Number (SSN)
Note: Complete Section B if an agent is
to a same type transaction that was
or Employer Identification Number
involved in the transaction. If an agent is
reported on a Form 103-N during the
(EIN). Enter the patron’s SSN or EIN. If a
not involved in the transaction, leave
same designated 24-hour period. See
patron refuses to provide an SSN or EIN
Section B blank.
Reg. 6A for details.
indicate “REFUSED” in Item 7. If a patron
Item 16. Multiple Agents. Check Item
does not have an SSN or EIN indicate
Part I - Person(s) Involved in
16 if more than one agent was involved
“NONE” in Item 7.
Transaction(s)
in the transaction(s) for the same patron.
Item 12. Date of Birth. Enter the
Note: Section A must be completed. If
Complete Section B on both page 1 and
patron’s date of birth if it is indicated on
an individual conducts a transaction on
on page 2 for all agents conducting the
the patron’s identification credential or
his or her own behalf (i.e., a patron),
transaction(s).
contained in the 6A licensee’s records. If
complete Section A and leave Section B
Items 17, 18, and 19. Individual’s
the date of birth is unavailable indicate
blank. If an individual conducts a
Name. Enter the agent’s last name in
“NA” in Item 12. Enter the date in MM/
transaction on behalf of another
Item 17, first name in Item 18 and middle
DD/YYYY format, with a zero preceding
individual (i.e., an agent conducts a
initial in Item 19 (if no middle initial leave
any single digit number (e.g., September
transaction for a patron), complete
Item 19 blank).
19, 1963 must be entered as 09/19/
Section B for the agent and Section A for
1963).
the patron.
Items 20, 22, 23, 24 and 25. Address.
Enter the agent’s permanent address.
Item 13. Method Used to Verify
Section A - Person(s) on Whose Behalf
Refer to instructions for Items 6, 8, 9, 10
Identity. Check box a if the patron’s
Transaction is Conducted (Patron)
and 11.
identification credential was examined.
Item 2. Multiple Persons. Check Item
Check box b if, in accordance with Reg.
Item 21. Social Security Number (SSN).
2 if the transaction is for the benefit of
6A, the patron was a “known patron” and
Enter the agent’s SSN. If an agent refuses
two or more patrons or if the transaction
the information needed to complete
to provide an SSN indicate “REFUSED”
is conducted by two or more patrons who
Form 103-N was taken from the 6A
in Item 21. If an agent does not have an
are benefiting from the transaction.
licensee’s records. If Item a or b is
SSN indicate “NONE” in Item 21.
Complete Section A on both page 1 and
checked, Item 14 must be completed. If
on page 2 for all patrons benefiting from
Item 26. Date of Birth. Enter the agent’s
the patron is an entity, check Item c,
the transaction.
date of birth if it is indicated on the
complete Section B and do not complete
agent’s identification credential or
Item 14. If an agent is involved in the
Items 3, 4 and 5. Individual’s/Entity’s
contained in the 6A licensee’s records. If
transaction for a patron other than an
Name. Enter the patron’s last name in
the date of birth is unavailable indicate
entity and the patron’s identification
Item 3, first name in Item 4 and middle
“NA” in Item 26. Refer to instructions for
credential was unavailable or information
initial in Item 5 (if no middle initial leave
Item 12 for format of date entry.
for the patron was not available from the
Item 5 blank). If the patron is an entity,
6A licensee’s records, check Item d and
enter both the legal name (name used in
Item 27. Method Used to Verify
indicate “U/A” in the space provided.
Federal tax filings) and any “DBA” name
Identity. Check box a if the agent’s
in Item 3 (Item 4 may also be used if more
identification credential was examined.
space is required.).
Check box b if, in accordance with Reg.
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