Fincen Form 103 - Currency Transaction Report By Casinos
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1
2
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4Currency Transaction Report by Casinos
103
FINCEN Form
Previous editions will not be accepted after February, 2009.
(Rev. August 2008)
Please type or print. Items marked with an asterisk* are considered critical. (See instructions.)
Department of the Treasury
(Complete all applicable parts--See instructions)
OMB No. 1506-0005
FINCEN
1 If this is an amended 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)
Multiple persons
2
*3 Individual’s last name or Organization’s name
*4 First name
5 M.I.
6 Doing business as (DBA)
*8 SSN or EIN
*7 Permanent address (number, street, and apt. or suite no.)
*10 State *11 ZIP code
*9 City
*12 Country code
*13 Date of birth
___/___/____
(if not U.S.)
M M
D D
Y Y Y Y
*14 Method used to verify identity:
a
Examined identification credential/document
b
Known Customer - information on file
c
Organization
*15 Describe identification credential: a
Driver’s license/State ID b
Passport
c
Alien registration
z
Other
Number:
Issued by:
16 Customer’s Account Number
Section B--Individual(s) Conducting Transaction(s) - If other than above (Agent)
17
Multiple agents
18 Individual’s last name
19 First name
20 M.I.
21 Address (number, street, and apt. or suite no.)
22 SSN
23
City
24 State
25 ZIP code
26 Country code
27 Date of birth
___/___/____
(if not U.S.)
M M
D D
Y Y Y Y
28 Method used to verify identity:
a
Examined identification credential/document
b
Known Customer - information on file
29 Describe identification credential: a
Driver’s license/State ID b
Passport
c
Alien registration
z
Other
Issued by:
Number:
Amount and Type of Transaction(s). Complete all items that apply.
Part II
30.
Multiple transactions
*32 CASH OUT: (in U.S. dollar equivalent)
*31 CASH IN: (in U.S. dollar equivalent)
a
Redemption(s) of casino chips, tokens, TITO tickets,
$
.
a Purchase(s) of casino chips, tokens, and
00
$
.
00
and other gaming instruments
other gaming instruments
.
00
.
b
Withdrawal(s) of deposit (front money of safekeeping)
00
b
Deposit(s) (front money or safekeeping)
.
00
.
c
Advance(s) on credit (including markers)
00
c Payment(s) on credit (including markers)
.
d Payment(s) on wager(s) (Including race book
00
.
00
d Currency wager(s) including money plays
and OTB or sports pool)
.
.
00
00
e
Currency received from wire transfer(s) out
e
Currency paid from wire transfer(s) in
.
.
00
f
00
Negotiable instrument(s) cashed (including checks)
f
Purchase(s) of casino check(s)
.
.
00
00
g Currency exchange(s)
g Currency exchange(s)
h Travel and complimentary expenses and
.
.
00
00
h Bills inserted into gaming devices
gaming incentives
.
.
00
00
z
Other (specify):
i
Payment for tournament, contest or other promotions
.
00
z
Other (specify):
.
.
$
$
0
00
00
0
Enter total of CASH IN transaction(s)
Enter total of CASH OUT transaction(s)
*33 Date of transaction
34 Foreign currency used:
____/____/_____
(see instructions)
M M
D D
Y Y Y Y
(Country)
Part III
Casino Reporting Transactions
*35 Casino’s trade name
*37 Employer Identification Number (EIN)
*36 Casino’s legal name
*39 City
*38 Address where transaction occurred (See instructions)
*40 State
*41 ZIP code
*42 Type of gaming
a
State licensed casino
b
Card club
c
Tribal authorized casino
Institution
z
Other (specify)
(Check only one)
43 Title of approving official
45 Date of signature
44
Signature of approving official
___/___/____
M M
D D
Y Y Y Y
Sign
46 Type or print preparer’s name
48 Contact telephone number
47 Type or print name of person to contact
Here
)
(
(Rev. 8-08)
For Paperwork Reduction Act Notice, see page 4.
Cat. No. 37041B
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