Fincen Form 102 - Suspicious Activity Report By Casinos And Card Clubs
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1
2
3Suspicious Activity Report
FinCEN
by Casinos and Card Clubs
Form 102
March 20 11
Please type or print. Always complete entire report. Items
Previous editions will not be
marked with an asterisk * are considered critical (see instructions).
OMB No. 1506 - 0006
accepted after September 30, 2011
1 Check the box if this report corrects a prior report (see instructions on page 6)
Part I
Subject Information
2 Check box (a)
if more than one subject
box (b)
subject information unavailable
5 Middle initial
*3 Individual’s last name or entity’s full name
*4 First name
6 also known as (AKA- individual), doing business as (DBA- entity)
7 Occupation / type of business
*8 Address
*9 City
*10 State
*12 Country (if not U.S.)
13 Vehicle license # / st ate (optional)
*11 ZIP code
a. number
b. state
*14 SSN / ITIN (individual) or EIN (entity)
16 Date of birth
*15 Account number
No account af fected
Account open ? Yes
___/___/_______
No
MM DD YYYY
*17 Government issued identification (if available)
a
Driver’s license/state ID
b
Passport
d
Alien registration
d
Other ___________________________________________
e Number:
f Issuing state or country________________________
18 Phone number - work
19 Phone number - home
20 E-mail address (if available)
(
)
(
)
21 Affiliation or relationship to casino/card club
a
Customer
b
Agent
c
Junket / tour operator
d
Employee
e
Check cashing operator
f
Supplier
g
Concessionaire
h
Other (Explain in Part VI)
22 Does casino/card club still have a business association and/or an employee/employer relationship with suspect?
23 Date action taken(22)
____/____/______
a
Yes b
No If no , why? c
Barred
d
Resigned
e
Terminated
f
Other (S pecify in Part VI)
MM
DD
YYYY
Part II
Suspicious Activity Information
*24 Date or date range of suspicious activity
*25 Total dollar amount involved in suspicious activity
From _____/_____/_________
To _____/_____/_________
.00
$
,
,
,
MM
DD
YYYY
MM
DD
YYYY
* 26 Type of suspicious activity:
a
Bribery/gratuity
g
Misuse of position
m
Unusual use of wire transfers
b
Check fraud (includes counterfeit)
h
Money laundering
n
Unusual use of counter checks
c
Credit/debit card fraud (incl. counterfeit)
i
No apparent business or lawful purpose
or markers
d
Embezzlement/theft
o
False or conflicting ID(s)
j
Structuring
e
Large currency exchange(s)
p
Terrorist financing
k
Unusual use of negotiable instruments (checks)
f
Minimal gaming with large transactions
q
Other (Describe in Part VI)
l
Use of multiple credit or deposit accounts
Part III
Law Enforcement or Regulatory Contact Information
27 If law enforcement or a regulatory agency has been contacted (excluding submission of a SARC), check the appropriate box.
a
DEA
e
U.S. Customs Service
i
State law enforcement
b
U.S. Attorney (** 28)
f
U.S. Secret Service
j
Tribal gaming commission
c
IRS
g
Local law enforcement
k
Tribal law enforcement
d
FBI
h
State gaming commission
l
Other (List in item 28)
28 Other authority cont acted (for box 27 g through l) ** List U.S. Attorney office here.
29 Name of person contacted (for all of box 27)
30 Telephone number of individual
31 Date Contacted
contacted in box 29
_____/____/_______
(
)
MM
DD
YYYY
03/11
Cataloge Number 35636U
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