Fillable Fincen Form 103 - Currency Transaction Report By Casinos (Page 3 of 4) in pdf

Page 3

FinCEN Form 103 (Instructions 8-08)

Section A. Person(s) on Whose Behalf

File each Form 103 by the 15th calendar day after the

credential/document. Check box b if you examined an

Transaction(s) Is Conducted (Customer)

day of the transaction with the:

acceptable internal casino record (i.e., credit, deposit,

or check cashing account record, or a CTRC worksheet)

Item 2. Multiple persons.—Check Item 2 if this

IRS Enterprise Computing Center-Detroit

containing previously verified identification information

transaction is being conducted on behalf of more than

ATTN: CTRC

on a “known customer.” Check box c if the transaction

one person. For example, if John and Jane Doe cash a

P .O. Box 32621

is conducted on behalf of an organization. If box a or b

check made out to them jointly at the casino, more than

Detroit, MI 48232

is checked, you must complete Item 15. If box c is

one individual has conducted the transaction.

checked, do not complete Item 15.

Enter information in Section A for one of the individuals;

A casino must retain a copy of each Form 103 filed for

provide information for the other individual on page 2,

5 years from the date of filing.

Item *15. Describe identification credential.— If

Section A. Attach additional sheets as necessary.

item 14c above is checked, leave item 15 blank. If a

Penalties. Civil and/or criminal penalties may be

driver’s license, passport, or alien registration card was

Items *3, *4, and 5. Individual/Organization name.—

assessed for failure to file a CTRC or supply information,

used to verify the individual’s identity, check as

If the person on whose behalf the transaction(s) is

or for filing a false or fraudulent CTRC. See 31 U.S.C.

appropriate box a, b, or c. If you check box z, you

conducted is an individual, put his/her last name in

5321, 5322, and 5324.

must specifically identify the type of document used

Item 3, first name in Item 4 and middle initial in Item 5.

(e.g., enter “military ID” for a military or military/

If there is no middle initial, leave Item 5 BLANK. If the

Definitions. For purposes of Form 103, the terms below

dependent identification card). A statement such as

transaction is conducted on behalf of an organization,

have the following meanings:

“known customer” in box z is not sufficient for

enter the name in Item 3, enter XX in item 4, and

completion of Form 103. Enter in Item 15, issued by,

identify the individual conducting the transaction in

Agent. Any individual who conducts a currency

the two-letter state postal code, two-letter country code,

Section B.

transaction on behalf of another individual or

or the name of the issuer for that document, and enter

organization.

in Item 15 the number shown on that official document

Item 6 Doing business as (DBA) name.

—If an

in the space provided. If item 15 information is unknown,

organization has a separate “doing business as” (DBA)

Currency. The coin and paper money of the United

check box “z” other, and enter XX in the text field

States or of any other country that is circulated and

name, first enter in Item 3 the organization’s legal name

provided.

(e.g., Smith Enterprises, Inc.) and then enter here in

customarily used and accepted as money.

Item 6 the DBA name of the business (e.g., Smith Casino

Item 16. Customer account number.—Enter the

Tours). If no DBA name leave item 6 BLANK.

Customer. Any person involved in a currency transaction

account number which corresponds to the transaction

whether or not that person participates in the casino’s

being reported and which the casino has assigned to

Items *7, *9, *10, *11, and *12. Address.—Enter the

gaming activities.

the person whose name is entered in Item 3. If the

permanent street address, city, two-letter state

person has more than one account number affected by

abbreviation used by the U.S. Postal Service, and ZIP

Person. An individual, corporation, partnership, trust

the transaction, enter the account number that

code of the person identified in Item 3. Also, enter in

or estate, joint stock company, association, syndicate,

corresponds to the majority of currency being reported.

Item 7 the apartment or suite number and road or route

joint venture, or any other unincorporated organization

If the transaction does not involve an account number,

number. Do not enter a P . O. box number unless the

or group.

enter “XX” in the space.

person has no street address. If the person is from a

foreign country, enter any state/territory code (Canada/

Organization. Person other than an individual.

Section B. Individual(s) Conducting Transaction(s)

Mexico only) as well as the appropriate two-letter country

– If Other Than Above (Agent)

code (For state/country code list go to

Transaction In Currency (Currency Transaction).

reg_bsaforms.html or call 1-800-949-2732 option 5). If

The physical transfer of currency from one person to

Complete Section B if an individual conducts a

country is U. S., leave Item 12 BLANK. Enter XX in any

another.

transaction on behalf of another person(s) listed in Section

item that is unknown/not applicable.

A. If an individual conducts a transaction on his/her

Negotiable Instruments. All checks and drafts

own behalf, leave Section B BLANK.

Item *8. Social security number (SSN) or Employer

(including business, personal, bank, cashier’s, and third-

identification number (EIN).—Enter the SSN (if an

party), traveler’s checks, money orders, and promissory

Item 17. Multiple agents.—If, during a gaming day,

notes, whether or not they are in bearer form.

individual) or EIN (if other than an individual) of the

more than one individual conducts transactions on behalf

person identified in Items 3 through 5. If that individual

of an individual or organization listed in Section A,

Specific Instructions

is a nonresident alien individual who does not have an

check this box and complete Section B. List one of the

SSN, enter “XX” in this space

individuals on the front of the form and the other

individual(s) on page 2, Section B. Attach additional

Note: Items marked with an asterisk (3, 4, 7 – 12, 13,

Item *13. Date of birth.—Enter the customer’s date

sheets as necessary.

14, 15, 31- 33 and items 35-42 in Part III) are considered

of birth (DOB) if it is known to the casino through an

critical and must be completed as required by line item

existing internal record or reflected on an appropriate

Items 18, 19, and 20. Name of individual.— Refer to

instruction. Social Security Number, Item 8, must be

identification document or credential presented to the

and follow instructions for completing items 3, 4, and 5.

completed unless: Country Code, Item 12, is recorded

casino to verify the customer’s identity (see

(as long as it is not the U.S.), Passport Number, Item 15 b,

Identification Requirements above). Internal casino

Items 21, 23, 24, 25, and 26. Address.— Refer to and

issued by, and number are recorded, or Nonresident Alien

records can include those for casino customers granted

follow instructions for completing items 7, 9, 10, 11,

Registration Number, Item 15 c, issued by, and number,

accounts for credit, deposit, or check cashing, or on

and 12.

are recorded.

whom a CTRC containing verified identity has been

filed. If such records do not indicate the DOB, a casino

Item 22. Social security number (SSN).— Refer to

Item 1. Amends prior report.—Check Item 1 if this

should ask the customer for the DOB. If the DOB is not

and follow instructions for completing item 8.

Form 103 amends a previously filed report. Staple a

available from any of these sources, the casino should

copy of the original report behind the amended one.

enter “XX” in the “mm” month position of the date field.

Item 27. Date of birth.—Enter the individual’s date of

Complete Part III in its entirety, but complete only

Eight numerals must be inserted for each date. Enter

birth. For proper format, see the instructions under

those other entries that are being amended.

the date in the format “mm/dd/yyyy”, where “mm” is

Item 13 above.

the month, “dd” is the day, and “yyyy” is the year. Zero

Part I. Person(s) Involved in Transaction(s)

(0) should precede any single-digit number. For example,

Item 28. Method used to verify identity.—Any

if the individual’s birth date is June 1, 1948, enter “06/

individual listed in Items 18 through 20 must present an

Note: Section A must be completed in all cases. If an

01/1948” in Item 13.

official document to verify his/her name and address.

individual conducts a transaction on his/her own behalf,

See the instructions under Item 14 above for more

complete only section A. If a transaction is conducted

Item *14. Method used to verify identity.—If an

information. After completing Item 28, you must also

by an individual on behalf of another person(s),

individual conducts the transaction(s) on his/her own

complete Item 29.

complete Section A for each person on whose behalf

behalf, his/her name and address must be verified by

the transaction is conducted; complete Section B for

examination of an official credential/document or internal

Item 29. Describe identification credential.—

the individual conducting the transaction.

record containing identification information on a known

Describe the identification credential used to verify the

customer (see Identification Requirements above).

individual’s name and address. See the instructions

Check box a if you examined an official identification

under Item 15 above for more information.

Fincen Form 103 - Currency Transaction Report By Casinos Page 3

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