Form FINCEN-103-N Currency Transaction Report Casinos - Nevada

FINCEN Form

103-N

Currency Transaction Report by Casinos

(Formerly Form 8852)
(Rev. December 2003)

Nevada

Previous editions will not be accepted after May 31, 2004.
Please type or print.
(Complete all applicable parts--See Instructions)

Department of the Treasury
FINCEN

1 Check appropriate box(es) if:

a

Amends prior report

b

OMB No. 1506-0003

Supplemental report

Part I Person(s) Involved in Transaction(s)
Section A Person(s) on Whose Behalf Transaction(s) Is Conducted (Patron)

2

Multiple persons

4 First name

3 Individual’s last name or Entity’s name

5 M.I.

7 SSN or EIN

6 Permanent address (number, street, and apt. or suite no.)

d

___

Alien registration

___

MM

DD

Known Patron - information on file

c

___

Passport

___

f

___

Driver’s license/State ID b

e Issued by:

____/____/________

___

14 Describe identification credential: a

b

12 Date of birth

11 Country code
(if not U.S.)

___

Examined identification credential/document
Other

___

___

___

___

___

___

___

a
d

___

___

13 Method used to verify identity:

10 ZIP code

___

___

___

9 State

8 City

c

YYYY

Organization

Other

Number:

15 Customer’s Account Number

Section B Individual(s) Conducting Transaction(s) - If other than above (Agent)
17 Individual’s last name

16

Multiple agents

18 First name

19 M.I.

20 Permanent address (number, street, and apt. or suite no.)

21 SSN

d Table game cash bet lost
e Non-table game cash bet.
f Other (specify)

MM

c

DD

YYYY

Other

Other

Number:

29

Multiple transactions 30

Dissimilar transactions

32 CASH OUT: (in U.S. dollar equivalent)
a Redemption of casino chips, tokens,
and other gaming instrumentalities
b Withdrawal of deposit (front money of safekeeping)

. 00
. 00
. 00
. 00
. 00
. 00

c Payments on credit (including markers)

$

. 00
. 00
. 00
. 00
. 00
. 00

c Advance on credit (including markers)
d Payment on bet (including slot jackpot)
e

Currency paid from wire transfer in

f

Negotiable instrument cashed (including checks)

g Travel and complimentary expenses and
gaming incentives

. 00
. 00
. 00
. 00

h Payment for tournament, contest or other promotions
i Other (specify)
g Enter total amount of CASH IN transaction

____/____/________
MM

DD

. 00

$

YYYY

$
j Enter total amount of CASH OUT transaction
35 Foreign currency
A.M.
P.M.
used (country code)

34 Time of
transaction

___

33 Date of transaction
(see instructions)

___

$

b Deposit (front money or safekeeping)

d

___

Alien registration

___

c

___

Passport

____/____/________

___

Known patron - information on file

Amount and Type of Transaction(s) (Complete Box 31 or 32)

31 CASH IN: (in U.S. dollar equivalent)
a Purchase of casino chips, tokens,
and other gaming instrumentalities

26 Date of birth

25 Country code
(if not U.S.)

___

___

Part II

f

___

Driver’s license/State ID b

e Issued by:

___

___

___

b

___

Examined identification credential

___

28 Describe identification credential: a

___

___

27 Method used to verify identity: a

24 ZIP code

___

___

23 State

___

___

22 City

:

36 Additional information

Part III

Casino Reporting Transaction(s)

37 Casino’s trade name

38 Casino’s legal name

39 Employer identification number (EIN)
___

___

___

___

(

)

45 Country code
(if not U.S.)

___

___

___

47 Signature of recorder/handler

___

___

___

___

___

___

___

___

46 Name and title of recorder/handler

___

41 Contact Telephone Number

43 State 44 ZIP code

42 City

___

___

___

40 Address (number, street, and apt. or suite no.) where transaction occurred

48 Date of signature

____/____/________
Sign
Here

MM

49 Name and title of reviewer

50 Signature of reviewer

YYYY

____/____/________
MM

For Paperwork Reduction Act Notice, see page 4.

DD

51 Date of signature

Cat. No. 23511I

DD

YYYY

FinCEN Form 103-N (Rev. 12-03)
(Formerly Form 8852)

Page 2

FinCEN Form 103-N (Rev. 12-03) (Formerly Form 8852)

Multiple Persons or Multiple Agents
(Complete applicable parts below if box 2 or box 16 on page 1 is checked.)

Part I (Continued)
Section A Person(s) on Whose Behalf Transaction(s) Is Conducted (Patron)
4 First name

3 Individual’s last name or Entity’s name

5 M.I.

7 SSN or EIN

6 Permanent address (number, street, and apt. or suite no.)

___

d

___

____/____/________
MM

Known Patron - information on file
Alien registration

___

c

___

Passport

___

f

b

12 Date of birth

11 Country code
(if not U.S.)

___

Driver’s license/State ID b

e Issued by:

___

Examined identification credential/document
Other

___

___

___

___

___

___

14 Describe identification credential: a

___

a
d

___

___

13 Method used to verify identity:

___

10 ZIP code

___

___

9 State

8 City

DD

c

YYYY

Organization

Other

Number:

15 Customer’s Account Number

Section B Individual(s) Conducting Transaction(s) - If other than above (Agent)
17 Individual’s last name

18 First name

19 M.I.

20 Permanent address (number, street, and apt. or suite no.)

21 SSN
___

___

d

___

Alien registration

___

26 Date of birth

Known patron - information on file
c

___

25 Country code
( if not U.S.)

___

Exceptions. Certain persons are not
considered patrons pursuant to Reg.
6A. Transactions with these persons
are not reportable. See Reg. 6A for
details.

___

Who Must File. Any Nevada casino
that qualifies as a 6A licensee pursuant
to Nevada Gaming Commission
Regulation 6A (Reg. 6A), generally
casinos
with
greater
than
$10,000,000 in annual gross gaming
revenue and with over $2,000,000 of
table games statistical win.

Passport

___

CTRC-N INSTRUCTIONS
General Instructions

f

b

___

Driver’s license/State ID b

e Issued by:

___

___

Examined identification credential

___

___

___

28 Describe identification credential: a

___

___

27 Method used to verify identity: a

24 ZIP code

___

23 State

___

___

22 City

c

____/____/________
MM

DD

YYYY

Other

Other

Number:

designated 24-hour period that
aggregate to more than $10,000 in cash
are reportable if the transactions are the
same type transactions within the same
monitoring area or if different type
transactions occur within the same visit
at one location. Do not use Form 105
to report receipts of cash in excess of
$10,000 that occur at non-gaming areas;
instead use Form 8300, Report of Cash
Payments Over $10,000 Received in a
Trade or Business.

involving or aggregating at least $5,000
in cash. Do not use Form 103-N to (a)
report suspicious transactions of $10,000
or less or (b) indicate that a transaction
of more than $10,000 is suspicious.

When and Where to File. File each
Form 103-N by the 15th calendar day
after the day of the transaction with the:

When a suspicious transaction requires
immediate attention, telephone 1-800800-2877 between 9:00 a.m. and 6:00
p.m. Eastern Standard Time (EST). An
Internal Revenue Service (IRS) agent will
direct the call to the local office of the
IRS Criminal Investigation Division (CID).
In an emergency, consult directory
assistance for the local IRS Criminal
Investigation Division (CID) office.

Identification Requirements. Before
completing a reportable transaction
with a patron, a 6A licensee must
obtain a valid, reliable identification
credential from the patron. See Reg.
6A for details.

IRS Detroit Computing Center
ATTN: CTRC-N
P. O. Box 32621
Detroit, MI 48232-5604

Definitions. Certain terms, such as the
terms “patron,” “designated 24-hour
period,” “same type of transactions” and
“6A licensee,” are defined in Reg. 6A.

Keep a copy of each form filed for five
years from the date of filing.

What to File. A 6A licensee must file
a Form 103-N for a reportable
transactions with a patron as outlined
in Reg. 6A. A reportable transaction
is a transaction that involves more than
$10,000 in cash. Also, smaller
transactions occurring within a

Suspicious Transactions. If a suspicious
transaction involves more than $10,000
in cash, complete Form 103-N as well
as a FinCEN Form102, Suspicious
Activity Report by Casinos (SARC). Also,
casinos are required to use the SARC
form to report suspicious activities

Penalties. Civil and/or criminal penalties
may be assessed for failure to comply with
Reg. 6A. See Nevada Revised Statutes
463.125, 463.360 and 207.195.
Specific Instructions
Note: Additional information that cannot
fit on the front and back of the Form 103N must be submitted along with the item
number associated with the additional

Page

FinCEN Form 103-N (Rev. 3-03)

information on plain paper attached to
the Form 103-N. Type or print the
patron’s name, social security number (or
EIN), date of the transaction, licensee’s
name and licensee’s EIN (i.e., Items 3, 4,
5, 7, 33, 37, 38 and 39) on all additional
sheets so that, if the sheets becomes
separated, they may be associated with
the Form 103-N.
Item 1 a. Amends Prior Report. Check
box a if the report corrects an error in a
previously filed report or provides
information for a previously filed report.
Staple a copy of the original report
behind the amended one. Complete Part
III in its entirety, but only complete those
other entries on the form that are being
amended.
Item 1 b. Supplemental Report. Check
box b if the report is for additional same
type transactions occurring subsequent
to a same type transaction that was
reported on a Form 103-N during the
same designated 24-hour period. See
Reg. 6A for details.

Items 6, 8, 9, 10 and 11. Address. Enter
the permanent street address including
apartment or suite number, road or route
number, city, state, zip code and two
letter country code (if not United States)
of the patron. Use two-letter postal
abbreviations for the state (e.g., NV for
Nevada, CA for California). If the patron
is from a foreign country use the required
two-letter country code (e.g., JA for
Japan) found at the FinCEN web site at
www.fincen.gov/reg_bsaforms.html or
www.fincen.gov/req_bsaforms.html
call the FinCEN Help Line at 1-800-9492732 and select option 5.
If the patron has no residence street
address, the patron refuses to provide a
residence street address or only provides
a post office box for an address, indicate
“NONE,” “REFUSED” or the post office
box number in Item 6 as applicable.

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

Item 7. Social Security Number (SSN)
or Employer Identification Number
(EIN). Enter the patron’s SSN or EIN. If a
patron refuses to provide an SSN or EIN
indicate “REFUSED” in Item 7. If a patron
does not have an SSN or EIN indicate
“NONE” in Item 7.

Note: Section A must be completed. If
an individual conducts a transaction on
his or her own behalf (i.e., a patron),
complete Section A and leave Section B
blank. If an individual conducts a
transaction on behalf of another
individual (i.e., an agent conducts a
transaction for a patron), complete
Section B for the agent and Section A for
the patron.

Item 12. Date of Birth. Enter the
patron’s date of birth if it is indicated on
the patron’s identification credential or
contained in the 6A licensee’s records. If
the date of birth is unavailable indicate
“NA” in Item 12. Enter the date in MM/
DD/YYYY format, with a zero preceding
any single digit number (e.g., September
19, 1963 must be entered as 09/19/
1963).

Section A - Person(s) on Whose Behalf
Transaction is Conducted (Patron)

Item 13. Method Used to Verify
Identity. Check box a if the patron’s
identification credential was examined.
Check box b if, in accordance with Reg.
6A, the patron was a “known patron” and
the information needed to complete
Form 103-N was taken from the 6A
licensee’s records. If Item a or b is
checked, Item 14 must be completed. If
the patron is an entity, check Item c,
complete Section B and do not complete
Item 14. If an agent is involved in the
transaction for a patron other than an
entity and the patron’s identification
credential was unavailable or information
for the patron was not available from the
6A licensee’s records, check Item d and
indicate “U/A” in the space provided.

Item 2. Multiple Persons. Check Item
2 if the transaction is for the benefit of
two or more patrons or if the transaction
is conducted by two or more patrons who
are benefiting from the transaction.
Complete Section A on both page 1 and
on page 2 for all patrons benefiting from
the transaction.
Items 3, 4 and 5. Individual’s/Entity’s
Name. Enter the patron’s last name in
Item 3, first name in Item 4 and middle
initial in Item 5 (if no middle initial leave
Item 5 blank). If the patron is an entity,
enter both the legal name (name used in
Federal tax filings) and any “DBA” name
in Item 3 (Item 4 may also be used if more
space is required.).

3

Item 14. Describe Identification
Credential. Check box a, b, c or d as
applicable. If Item d is checked,
specifically indicate the credential
examined (e.g., Military ID). For all types
of credentials, enter the issuer of the
credential such as the state or country
(using two-letter abbreviations or codes)
in the space provided for box e (see
instructions for items 10 and 11). Enter
the identification number contained on
the credential in the space provided for
box f.
Item 15. Customer Account Number.
Enter the patron’s account number
associated with the transaction. If no
account number exists, indicate “N/A.”
Section B - Individual(s) Conducting
Transaction(s) If Other Than Above
(Agent)
Note: Complete Section B if an agent is
involved in the transaction. If an agent is
not involved in the transaction, leave
Section B blank.
Item 16. Multiple Agents. Check Item
16 if more than one agent was involved
in the transaction(s) for the same patron.
Complete Section B on both page 1 and
on page 2 for all agents conducting the
transaction(s).
Items 17, 18, and 19. Individual’s
Name. Enter the agent’s last name in
Item 17, first name in Item 18 and middle
initial in Item 19 (if no middle initial leave
Item 19 blank).
Items 20, 22, 23, 24 and 25. Address.
Enter the agent’s permanent address.
Refer to instructions for Items 6, 8, 9, 10
and 11.
Item 21. Social Security Number (SSN).
Enter the agent’s SSN. If an agent refuses
to provide an SSN indicate “REFUSED”
in Item 21. If an agent does not have an
SSN indicate “NONE” in Item 21.
Item 26. Date of Birth. Enter the agent’s
date of birth if it is indicated on the
agent’s identification credential or
contained in the 6A licensee’s records. If
the date of birth is unavailable indicate
“NA” in Item 26. Refer to instructions for
Item 12 for format of date entry.
Item 27. Method Used to Verify
Identity. Check box a if the agent’s
identification credential was examined.
Check box b if, in accordance with Reg.

Page 4

FinCEN Form103-N (Rev. 3-03)

6A, the agent was a “known patron” and
the information needed to complete
Form 103-N was taken from the 6A
licensee’s records.

Item 33. Date of Transaction. Enter the
date of the transaction. Refer to
instructions for Item 12 for format of date
entry.

Item 28. Describe Identification
Credential. Complete for agent’s
identification credential. Refer to
instructions for Item 14.

Item 34. Time of Transaction. Enter the
time of the transaction and check either
AM or PM (for midnight transactions
check AM, for noon transactions check
PM). For multiple same type transactions
or dissimilar transactions enter the time
of the last transaction.

Part II - Amount and Type of
Transaction(s)
Item 29. Multiple Same Type
Transactions. Check this item if the
reportable transaction consisted of
multiple, same type transactions
aggregated pursuant to Reg. 6A.
Item 30. Dissimilar Transactions.
Check this item if the reportable
transaction consists of different types of
transactions aggregated pursuant to Reg.
6A.
Note: Complete either Item 31 or 32;
do not complete both items.
Item 31. CASH IN.—Enter the dollar or
United States dollar equivalent amount
of the cash-in transaction on the
appropriate line, a, b, c, d, e or f, and
repeat the amount on line g. If the
reportable cash-in transaction involved
more than one type of transaction, enter
the amount associated with each
different transaction type on the
appropriate lines, a, b, c, d, e and f, and
enter the total of the cash-in transactions
on line g. If any dollar amount entry is
made on line f, specify the type of
transaction in the space provided. Round
amounts up to whole dollars (e.g .,
$10,220.12 must be entered as
$10,221).
Item 32. CASH OUT. Enter the dollar
or United States dollar equivalent
amount of the cash-out transaction on
the appropriate line, a, b, c, d, e, f, g, h
or i, and repeat the amount on line j. If
the reportable cash-out transaction
involved more than one type of
transaction, enter the amount associated
with each different transaction type on
the appropriate lines, a, b, c, d, e, f, g, h
or i, and enter the total of the cash-out
transactions on line j. If any dollar
amount entry is made on line i, specify
the type of transaction in the space
provided. Round amounts up to whole
dollars (e.g., $10,220.12 must be entered
as $10,221).

Item 35. Foreign Currency. If foreign
currency is involved, identify the country
of issue using a two-letter country code.
Refer to instructions for Item 11. If more
than one country of issue is involved
indicate the country associated with
largest amount of United States dollar
equivalent.
Item 36. Additional Information. Use
this space for any additional comments
that need to be made regarding the
transaction or the persons involved in the
transaction.
Part III - Casino
Transaction(s)

Reporting

Item 37. Casino’s Trade Name. Enter
the “DBA” name of the 6A licensee as
indicated on the casino’s Nevada gaming
license.
Item 38. Casino’s Legal Name. Enter
the legal name of the 6A licensee as
indicated on the casino’s Nevada gaming
license.
Item 39. Employer Identification
Number (EIN). Enter the casino’s EIN.
Items 40, 42, 43, 44, and 45. Address.
Enter the street address, city, state, and
zip code of the location where the
transaction occurred (e.g., casino
address, branch office address). If the
transaction occured outside th e United
states, include the country code. Use
two-letter abbreviations and codes for
state and country. Include province
code, if any, for foreign countries. Refer
to instructions for item 11 for information
about abbreviations.
Item 41. Contact Telephone Number.
Enter the business telephone number,
including area code, of an individual that
is to be contacted regarding questions
about this report.

Item 46, 47 and 48. Name, Title and
Signature of the Recorder/Handler and
Date of Signature. Print or type the
name and title of the person who
handled/recorded the transaction in Item
46. The handler/recorder signs the form
in Item 47 and the date the form was
signed is recorded in Item 48. Refer to
instructions for Item 12 for format of date
entry.
Item 49, 50 and 51. Name, Title and
Signature of the Reviewer and Date of
Signature. Print or type the name and
title of the person who performed the
accounting department review of the
form in Item 49. The reviewer signs the
form in Item 50 and the date the form
was signed is recorded in Item 51. Refer
to instructions for Item 12 for format of
date entry.
Paperwork Reduction Act Notice. The
requested information is useful in
criminal, tax, and regulatory
investigations and proceedings. Pursuant
to Nevada Gaming Commission
Regulation 6A (Reg. 6A), Nevada casinos
classified as “6A licensees” are required
to provide the requested information.
Reg. 6A is administered by the Nevada
Gaming Control Board and Nevada
Gaming Commission. Nevada casinos
comply with Reg. 6A in lieu of 31 U.S.C.
5313 and 31 CFR Part 103 based upon
an exemption granted to the state of
Nevada by the U.S. Department of the
Treasury.
You are not required to provide the
requested information unless the form
displays a valid OMB number. The time
needed to complete this form will vary
depending on individual circumstances.
The estimated average time is 19
minutes. If you have comments
concerning the accuracy of this time
estimate or suggestions to improve this
form, you may write to the Financial
Crimes Enforcement Network, Attn:
Office of Regulatory Programs, Post
Office Box 39, Vienna, VA 22183-0039.
Do not send a completed form to this
address. Instead, see When and Where
to File above.