Fincen Form 103-N - Multiple Persons Or Multiple Agents Page 3
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FinCEN Form103-N (Rev. 3-03)
6A, the agent was a “known patron” and
Item 33. Date of Transaction. Enter the
Item 46, 47 and 48. Name, Title and
the information needed to complete
date of the transaction. Refer to
Signature of the Recorder/Handler and
Form 103-N was taken from the 6A
instructions for Item 12 for format of date
Date of Signature. Print or type the
licensee’s records.
name and title of the person who
entry.
handled/recorded the transaction in Item
Item 28. Describe Identification
Item 34. Time of Transaction. Enter the
46. The handler/recorder signs the form
Credential. Complete for agent’s
time of the transaction and check either
in Item 47 and the date the form was
identification credential. Refer to
AM or PM (for midnight transactions
signed is recorded in Item 48. Refer to
check AM, for noon transactions check
instructions for Item 14.
instructions for Item 12 for format of date
PM). For multiple same type transactions
entry.
Part II - Amount and Type of
or dissimilar transactions enter the time
Transaction(s)
Item 49, 50 and 51. Name, Title and
of the last transaction.
Signature of the Reviewer and Date of
Item 29. Multiple Same Type
Item 35. Foreign Currency. If foreign
Signature. Print or type the name and
Transactions. Check this item if the
currency is involved, identify the country
title of the person who performed the
reportable transaction consisted of
of issue using a two-letter country code.
accounting department review of the
multiple, same type transactions
Refer to instructions for Item 11. If more
form in Item 49. The reviewer signs the
aggregated pursuant to Reg. 6A.
than one country of issue is involved
form in Item 50 and the date the form
indicate the country associated with
Item 30. Dissimilar Transactions.
was signed is recorded in Item 51. Refer
largest amount of United States dollar
Check this item if the reportable
to instructions for Item 12 for format of
equivalent.
transaction consists of different types of
date entry.
transactions aggregated pursuant to Reg.
Item 36. Additional Information. Use
Paperwork Reduction Act Notice. The
6A.
this space for any additional comments
requested information is useful in
that need to be made regarding the
Note: Complete either Item 31 or 32;
criminal,
tax,
and
regulatory
transaction or the persons involved in the
do not complete both items.
investigations and proceedings. Pursuant
transaction.
to Nevada Gaming Commission
Item 31. CASH IN.—Enter the dollar or
Regulation 6A (Reg. 6A), Nevada casinos
Part
III
-
Casino
Reporting
United States dollar equivalent amount
classified as “6A licensees” are required
Transaction(s)
of the cash-in transaction on the
to provide the requested information.
appropriate line, a, b, c, d, e or f, and
Item 37. Casino’s Trade Name. Enter
Reg. 6A is administered by the Nevada
repeat the amount on line g. If the
the “DBA” name of the 6A licensee as
Gaming Control Board and Nevada
reportable cash-in transaction involved
indicated on the casino’s Nevada gaming
Gaming Commission. Nevada casinos
more than one type of transaction, enter
license.
comply with Reg. 6A in lieu of 31 U.S.C.
the amount associated with each
5313 and 31 CFR Part 103 based upon
Item 38. Casino’s Legal Name. Enter
different transaction type on the
an exemption granted to the state of
the legal name of the 6A licensee as
appropriate lines, a, b, c, d, e and f, and
Nevada by the U.S. Department of the
indicated on the casino’s Nevada gaming
enter the total of the cash-in transactions
Treasury.
license.
on line g. If any dollar amount entry is
You are not required to provide the
made on line f, specify the type of
Item 39. Employer Identification
requested information unless the form
transaction in the space provided. Round
Number (EIN). Enter the casino’s EIN.
displays a valid OMB number. The time
amounts up to whole dollars (e.g .,
needed to complete this form will vary
Items 40, 42, 43, 44, and 45. Address.
$10,220.12 must be entered as
Enter the street address, city, state, and
depending on individual circumstances.
$10,221).
zip code of the location where the
The estimated average time is 19
Item 32. CASH OUT. Enter the dollar
minutes. If you have comments
transaction occurred (e.g., casino
or United States dollar equivalent
concerning the accuracy of this time
address, branch office address). If the
amount of the cash-out transaction on
transaction occured outside th e United
estimate or suggestions to improve this
the appropriate line, a, b, c, d, e, f, g, h
states, include the country code. Use
form, you may write to the Financial
or i, and repeat the amount on line j. If
Crimes Enforcement Network, Attn:
two-letter abbreviations and codes for
the reportable cash-out transaction
Office of Regulatory Programs, Post
state and country. Include province
involved more than one type of
code, if any, for foreign countries. Refer
Office Box 39, Vienna, VA 22183-0039.
transaction, enter the amount associated
to instructions for item 11 for information
Do not send a completed form to this
with each different transaction type on
address. Instead, see When and Where
about abbreviations.
the appropriate lines, a, b, c, d, e, f, g, h
to File above.
Item 41. Contact Telephone Number.
or i, and enter the total of the cash-out
Enter the business telephone number,
transactions on line j. If any dollar
including area code, of an individual that
amount entry is made on line I, specify
is to be contacted regarding questions
the type of transaction in the space
about this report.
provided. Round amounts up to whole
dollars (e.g., $10,220.12 must be entered
as $10,221).
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