Fincen Form 110 Designation Of Exempt Person
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1
2110
Designation of Exempt Person
FinCEN Form
(Formerly form TD F 90-22.53)
Previous editions will not be accepted after January 2006
August 2005
Please type or print. Complete all parts that apply. See instructions.
OMB No.1506-0012
Send your completed form to: IRS Detroit Computing Center, Attn: Designation of Exempt Person, P. O. Box 33112, Detroit, MI 48232-0112
Part I
Filing Information
1 Indicate the type of filing by checking a, b, c, or d (check only one)
a
Initial designation
b
Biennial renewal
c
Exemption amended
d
Exemption revoked
2 Effective date of the exemption
__________ / __________ / __________
MM
DD
YYYY
Part II
Exempt Person Information
4 Doing business as (DBA)
3 Legal name of the exempt person
5 Address
*9 EIN or SSN
7 State
8 ZIP Code
6 City
10 Type of exempt person, check box a, b, c, d, e, or f (check only one)
a
Bank
b
Government agency/Governmental authority
c
Listed company
d
Listed company subsidiary
e
Eligible non-listed business
f
Payroll customer
11 If this is a biennial renewal, and the exempt person is an eligible non-listed business or a payroll customer,
a
Yes
b
No
( 10 e or f above) has there been a change in control of the exempt person during the last two calender years?
Part III
Filer Information
12 Name of bank
13 Address
16 ZIP Code
15 State
17 EIN
14 City
18 Indicate the bank’s primary federal regulator by
a
OCC
b
FDIC
c
FRS
d
OTS
e
NCUA
f
IRS
checking a, b, c, d, e, or f (check only one)
19 If this designation is also being made for one or more affiliated banks, check this box.
See Part V of the instructions for the procedure for listing additional affiliated bank(s) and requirements of the biennial renewal certification.
Part IV
Signature
I am authorized to sign this form on behalf of the bank granting the exemption and any listed bank subsidiaries. I declare that the information
provided is true, correct and complete.
20 Signature (If item 1a, c, or d is checked, sign here)
21 Print name
24 Telephone number - (include area code)
23 Date of signature
22 Title
(
_____ / _____ / _______
)
MM
DD
YYYY
Part V
Biennial Renewal Certification
Complete this part only if you are filing a biennial renewal (Item 1b checked).
I certify on behalf of the bank that its system of monitoring the transactions in currency of an exempt person for suspicious activity has been
applied as necessary, but at least annually, to this exempt person.
26 Print name
25 Signature (If item 1b is checked, sign here)
29 Telephone number - (include area code)
28 Date of signature
27 Title
(
)
_______ / ______ / ________
MM
DD
YYYY
Catalog Number 47385C
Rev. 08/05
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