Form FinCEN 103 FinCEN 103 Currency Transaction Report by Casinos and Card Clubs

FINCEN Form

Currency Transaction Report by Casinos

103

Previous editions will not be accepted after February, 2009.
Please type or print. Items marked with an asterisk* are considered critical. (See instructions.)

(Rev. August 2008)
Department of the Treasury
FINCEN

(Complete all applicable parts--See instructions)

1 If this is an amended report check here:

Part I

OMB No. 1506-0005

and attach a copy of the original CTRC to this form.

Person(s) Involved in Transaction(s)

Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted (Customer)
*3 Individual’s last name or Organization’s name

2

Multiple persons

*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

*14 Method used to verify identity:

a

*12 Country code
(if not U.S.)

Examined identification credential/document

*15 Describe identification credential: a
Issued by:

Driver’s license/State ID b
Number:

Passport

b

*13 Date of birth

___/___/____
MM

Known Customer - information on file

c

Alien registration

z

DD

c

YYYY

Organization

Other

16 Customer’s Account Number

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

17

20 M.I.

21 Address (number, street, and apt. or suite no.)

23

City

28

Method used to verify identity:

24 State
a

22 SSN

Driver’s license/State ID b

Issued by:

$

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

Deposit(s) (front money or safekeeping)

d

Currency wager(s) including money plays

e

Currency received from wire transfer(s) out

f

Purchase(s) of casino check(s)

g

Currency exchange(s)

.00
.00

h Bills inserted into gaming devices
Other (specify):

c

DD

Alien registration

z

YYYY

Other

*33 Date of transaction
(see instructions)

____/____/________
MM

DD

30

Multiple transactions

.00
.00
.00

Advance(s) on credit (including markers)

.00

d Payment(s) on wager(s) (Including race book
and OTB or sports pool)
e Currency paid from wire transfer(s) in
f

Negotiable instrument(s) cashed (including checks)

g

Currency exchange(s)

.00
.00
.00

h Travel and complimentary expenses and
gaming incentives
i

0 .00

$

Enter total of CASH IN transaction(s)

.00
.00
.00
0 .00

Payment for tournament, contest or other promotions
Other (specify):

$

Enter total of CASH OUT transaction(s)
34 Foreign currency used:

(Country)

YYYY

Casino Reporting Transactions

*35 Casino’s trade name

*40 State *41 ZIP code

43 Title of approving official

*37 Employer Identification Number (EIN)

*36 Casino’s legal name

*39 City

*38 Address where transaction occurred (See instructions)

Sign
Here

MM

Known Customer - information on file

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

z

Part III

c

___/___/____

Amount and Type of Transaction(s). Complete all items that apply.

c Payment(s) on credit (including markers)

z

Passport

b

27 Date of birth

Number:

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

26 Country code
(if not U.S.)

25 ZIP code

Examined identification credential/document

29 Describe identification credential: a

Part II

Multiple agents

19 First name

State licensed casino
*42 Type of gaming a
Institution
Other (specify)
(Check only one) z
44 Signature of approving official

b

Card club

c

Tribal authorized casino

45 Date of signature

___/___/____
MM

46 Type or print preparer’s name

For Paperwork Reduction Act Notice, see page 4.

47 Type or print name of person to contact

(
Cat. No. 37041B

DD

YYYY

48 Contact telephone number

)
(Rev. 8-08)

FinCEN Form 103 (Rev. 8-08)

Page

2

Multiple Persons or Multiple Agents
(Complete applicable parts below if box 2 or box 17 on page 1 is checked.)

Part I

Person(s) Involved in Transaction(s)

Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted (Customer)
*3 Individual’s last name or Organization’s name

*4 First name

5 M.I.

6 Doing business as (DBA)
*7 Permanent address (number, street, and apt. or suite no.)

*8 SSN or EIN

*15 Describe identification credential: a

Examined identification credential/document
Driver’s license/State ID b

Issued by:

Passport

b

___/___/____

Known Customer - information on file

c

Alien registration

z

___

a

___

*13 Date of birth

*12 Country (if not U.S.)

MM

*14 Method used to verify identity:

___

___

___

*10 State *11 ZIP code

___

___

City

___

*9

c

DD

YYYY

Organization

Other

Number:

16 Customer’s Account Number

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

19 First name

20 M.I.

22 SSN

21 Address (number, street, and apt. or suite no.)

29 Describe identification credential:

a

Driver’s license/State ID b

Issued by:

General Instructions
Form 103. Use this revision of Form 103 for filing on
reportable transactions.
Suspicious Transactions. If a transaction is greater
than $10,000 in currency as well as suspicious, casinos
must file a Form 103 and must report suspicious
transactions and activities on FinCEN Form 102,
Suspicious Activity Report by Casinos (SARC). Also,
casinos are required to use the SARC form to report
suspicious activities involving or aggregating at least
$5,000 in funds. Do not use Form 103 to (a) report
suspicious transactions involving $10,000 or less in
currency or (b) indicate that a transaction of more
than $10,000 is suspicious.

In situations involving suspicious transactions
requiring immediate attention, such as when a
reportable transaction is ongoing, the casino or
card club shall immediately notify, by telephone,
appropriate law enforcement and regulatory
authorities in addition to filing a timely
suspicious activity report.

Who must file. Any organization duly licensed or
authorized to do business as a casino, gambling
casino, or card club in the United States and having
gross annual gaming revenues in excess of $1 million
must file Form 103. This includes the principal
headquarters and every domestic branch or place
of business of the casino or card club. The
requirement includes state-licensed casinos (both
land-based and riverboat), tribal casinos, and statelicensed and tribal card clubs. Since card clubs are
subject to the same reporting rules as casinos, the
term “casino” as used in these instructions refers to
both a casino and a card club.
What to file. A casino must file Form 103 for each
transaction involving either currency received (Cash

Passport

b
c

___

Examined identification credential/document

___

a

___

27 Date of birth

___/___/____
MM

28 Method used to verify identity:

___

___

26 Country (if not U.S.)

25 ZIP code

___

___

24 State

___

23 City

DD

YYYY

Known Customer - information on file
Alien registration

z

Other

Number:

In) or currency disbursed (Cash Out) of more than
$10,000 in a gaming day. A gaming day is the normal
business day of the casino by which it keeps its books
and records for business, accounting, and tax purposes.
Multiple transactions must be treated as a single
transaction if the casino has knowledge that: (a) they
are made by or on behalf of the same person, and (b)
they result in either Cash In or Cash Out by the casino
totaling more than $10,000 during any one gaming day.
Reportable transactions may occur at a casino cage,
gaming table, and/or slot machine/video lottery terminal.
The casino should report both Cash In and Cash Out
transactions by or on behalf of the same customer on a
single Form 103. Do not use Form 103 to report receipts
of currency in excess of $10,000 by non-gaming
businesses of a casino (e.g., a hotel); instead, use Form
8300, Report of Cash Payments Over $10,000 Received
in a Trade or Business.
Exceptions. A casino does not have to report
transactions with:
• domestic banks; or
• currency dealers or exchangers, or check cashers, as
defined in 31 C.F.R. § 103.11(uu), and which are
conducted pursuant to a contractual or other agreement
covering the financial services in 31 C.F.R.
§§103.22(b)(2)(i)(H),103.22(b)(2)(ii)(G),
and103.22(b)(2)(ii)(H).
Also, a casino does not have to report the following
types of transactions:
• Cash ins when it is the same physical currency
previously wagered in a money play on the same table
game without leaving the table;
• Bills inserted into electronic gaming devices in multiple
transactions (unless a casino has knowledge pursuant to
31 C.F.R. 103.22(c)(3));
• Cash outs won in a money play when it is the same
physical currency wagered, (Note: However, when a
customer increases a subsequent cash bet (i.e., money
play), at the same table game without departing, the

increase in the amount of the currency bet would represent
a new bet of currency and a transaction in currency.) or,
• Jackpots from slot machines or video lottery terminals.
Identification requirements. All individuals (except
employees conducting transactions on behalf of armored
car services) conducting a reportable transaction(s) for
themselves or for another person must be identified by
means of an official or otherwise reliable record.
Acceptable forms of identification include a driver’s
license, military or military dependent identification card,
passport, alien registration card, state issued identification
card, cedular card (foreign), or a combination of other
unexpired documents that contain an individual’s name
and address and preferably a photograph and are
normally acceptable by financial institutions as a means
of identification when cashing checks for persons other
than established customers.
For casino customers granted accounts for credit,
deposit, or check cashing, or on whom a CTRC containing
verified identity has been filed, acceptable identification
information obtained previously and maintained in the
casino’s internal records may be used as long as the
following conditions are met. The customer’s identity is
reverified periodically, any out-of-date identifying
information is updated in the internal records, and the
date of each reverification is noted on the internal record.
For example, if documents verifying an individual’s
identity were examined and recorded on a signature
card when a deposit or credit account was opened, the
casino may rely on that information as long as it is
reverified periodically.
When and where to file: This form can be e-filed
through the Bank Secrecy Act E-filing System.
Go to http://bsaefiling.fincen.treas.gov/index.jsp to register.
This form is also available for download on the Web at
www.fincen.gov, or may be ordered by calling the IRS
Forms Distribution Center at (800) 829-3676.

FinCEN Form 103 (Instructions 8-08)

File each Form 103 by the 15th calendar day after the
day of the transaction with the:
IRS Enterprise Computing Center-Detroit
ATTN: CTRC
P.O. Box 32621
Detroit, MI 48232
A casino must retain a copy of each Form 103 filed for
5 years from the date of filing.
Penalties. Civil and/or criminal penalties may be
assessed for failure to file a CTRC or supply information,
or for filing a false or fraudulent CTRC. See 31 U.S.C.
5321, 5322, and 5324.
Definitions. For purposes of Form 103, the terms below
have the following meanings:
Agent. Any individual who conducts a currency
transaction on behalf of another individual or
organization.
Currency. The coin and paper money of the United
States or of any other country that is circulated and
customarily used and accepted as money.
Customer. Any person involved in a currency transaction
whether or not that person participates in the casino’s
gaming activities.
Person. An individual, corporation, partnership, trust
or estate, joint stock company, association, syndicate,
joint venture, or any other unincorporated organization
or group.
Organization. Person other than an individual.
Transaction In Currency (Currency Transaction).
The physical transfer of currency from one person to
another.
Negotiable Instruments. All checks and drafts
(including business, personal, bank, cashier’s, and thirdparty), traveler’s checks, money orders, and promissory
notes, whether or not they are in bearer form.

Specific Instructions
Note: Items marked with an asterisk (3, 4, 7 – 12, 13,
14, 15, 31- 33 and items 35-42 in Part III) are considered
critical and must be completed as required by line item
instruction. Social Security Number, Item 8, must be
completed unless: Country Code, Item 12, is recorded
(as long as it is not the U.S.), Passport Number, Item 15 b,
issued by, and number are recorded, or Nonresident Alien
Registration Number, Item 15 c, issued by, and number,
are recorded.
Item 1. Amends prior report.—Check Item 1 if this
Form 103 amends a previously filed report. Staple a
copy of the original report behind the amended one.
Complete Part III in its entirety, but complete only
those other entries that are being amended.
Part I. Person(s) Involved in Transaction(s)
Note: Section A must be completed in all cases. If an
individual conducts a transaction on his/her own behalf,
complete only section A. If a transaction is conducted
by an individual on behalf of another person(s),
complete Section A for each person on whose behalf
the transaction is conducted; complete Section B for
the individual conducting the transaction.

Page 3

Section A. Person(s) on Whose Behalf
Transaction(s) Is Conducted (Customer)
Item 2. Multiple persons.—Check Item 2 if this
transaction is being conducted on behalf of more than
one person. For example, if John and Jane Doe cash a
check made out to them jointly at the casino, more than
one individual has conducted the transaction.
Enter information in Section A for one of the individuals;
provide information for the other individual on page 2,
Section A. Attach additional sheets as necessary.
Items *3, *4, and 5. Individual/Organization name.—
If the person on whose behalf the transaction(s) is
conducted is an individual, put his/her last name in
Item 3, first name in Item 4 and middle initial in Item 5.
If there is no middle initial, leave Item 5 BLANK. If the
transaction is conducted on behalf of an organization,
enter the name in Item 3, enter XX in item 4, and
identify the individual conducting the transaction in
Section B.

Item 6 Doing business as (DBA) name.—If an

organization has a separate “doing business as” (DBA)
name, first enter in Item 3 the organization’s legal name
(e.g., Smith Enterprises, Inc.) and then enter here in
Item 6 the DBA name of the business (e.g., Smith Casino
Tours). If no DBA name leave item 6 BLANK.
Items *7, *9, *10, *11, and *12. Address.—Enter the
permanent street address, city, two-letter state
abbreviation used by the U.S. Postal Service, and ZIP
code of the person identified in Item 3. Also, enter in
Item 7 the apartment or suite number and road or route
number. Do not enter a P. O. box number unless the
person has no street address. If the person is from a
foreign country, enter any state/territory code (Canada/
Mexico only) as well as the appropriate two-letter country
code (For state/country code list go to www.fincen.gov/
reg_bsaforms.html or call 1-800-949-2732 option 5). If
country is U. S., leave Item 12 BLANK. Enter XX in any
item that is unknown/not applicable.
Item *8. Social security number (SSN) or Employer
identification number (EIN).—Enter the SSN (if an
individual) or EIN (if other than an individual) of the
person identified in Items 3 through 5. If that individual
is a nonresident alien individual who does not have an
SSN, enter “XX” in this space
Item *13. Date of birth.—Enter the customer’s date
of birth (DOB) if it is known to the casino through an
existing internal record or reflected on an appropriate
identification document or credential presented to the
casino to verify the customer’s identity (see
Identification Requirements above). Internal casino
records can include those for casino customers granted
accounts for credit, deposit, or check cashing, or on
whom a CTRC containing verified identity has been
filed. If such records do not indicate the DOB, a casino
should ask the customer for the DOB. If the DOB is not
available from any of these sources, the casino should
enter “XX” in the “mm” month position of the date field.
Eight numerals must be inserted for each date. Enter
the date in the format “mm/dd/yyyy”, where “mm” is
the month, “dd” is the day, and “yyyy” is the year. Zero
(0) should precede any single-digit number. For example,
if the individual’s birth date is June 1, 1948, enter “06/
01/1948” in Item 13.
Item *14. Method used to verify identity.—If an
individual conducts the transaction(s) on his/her own
behalf, his/her name and address must be verified by
examination of an official credential/document or internal
record containing identification information on a known
customer (see Identification Requirements above).
Check box a if you examined an official identification

credential/document. Check box b if you examined an
acceptable internal casino record (i.e., credit, deposit,
or check cashing account record, or a CTRC worksheet)
containing previously verified identification information
on a “known customer.” Check box c if the transaction
is conducted on behalf of an organization. If box a or b
is checked, you must complete Item 15. If box c is
checked, do not complete Item 15.
Item *15. Describe identification credential.— If
item 14c above is checked, leave item 15 blank. If a
driver’s license, passport, or alien registration card was
used to verify the individual’s identity, check as
appropriate box a, b, or c. If you check box z, you
must specifically identify the type of document used
(e.g., enter “military ID” for a military or military/
dependent identification card). A statement such as
“known customer” in box z is not sufficient for
completion of Form 103. Enter in Item 15, issued by,
the two-letter state postal code, two-letter country code,
or the name of the issuer for that document, and enter
in Item 15 the number shown on that official document
in the space provided. If item 15 information is unknown,
check box “z” other, and enter XX in the text field
provided.
Item 16. Customer account number.—Enter the
account number which corresponds to the transaction
being reported and which the casino has assigned to
the person whose name is entered in Item 3. If the
person has more than one account number affected by
the transaction, enter the account number that
corresponds to the majority of currency being reported.
If the transaction does not involve an account number,
enter “XX” in the space.
Section B. Individual(s) Conducting Transaction(s)
– If Other Than Above (Agent)
Complete Section B if an individual conducts a
transaction on behalf of another person(s) listed in Section
A. If an individual conducts a transaction on his/her
own behalf, leave Section B BLANK.
Item 17. Multiple agents.—If, during a gaming day,
more than one individual conducts transactions on behalf
of an individual or organization listed in Section A,
check this box and complete Section B. List one of the
individuals on the front of the form and the other
individual(s) on page 2, Section B. Attach additional
sheets as necessary.
Items 18, 19, and 20. Name of individual.— Refer to
and follow instructions for completing items 3, 4, and 5.
Items 21, 23, 24, 25, and 26. Address.— Refer to and
follow instructions for completing items 7, 9, 10, 11,
and 12.
Item 22. Social security number (SSN).— Refer to
and follow instructions for completing item 8.
Item 27. Date of birth.—Enter the individual’s date of
birth. For proper format, see the instructions under
Item 13 above.
Item 28. Method used to verify identity.—Any
individual listed in Items 18 through 20 must present an
official document to verify his/her name and address.
See the instructions under Item 14 above for more
information. After completing Item 28, you must also
complete Item 29.
Item 29. Describe identification credential.—
Describe the identification credential used to verify the
individual’s name and address. See the instructions
under Item 15 above for more information.

Page 4

FinCEN Form103 (Instructions 6-08)

Part II. Amount and Type of Transaction(s)
Part II identifies the type of transaction(s) reported
and the amount(s) involved. You must complete all
items that apply.
Item 30. Multiple transactions.—Check this box if
multiple currency transactions, none of which
individually exceeds $10,000, comprise this report.
Items *31 and *32. Cash in and cash out.— Enter in
the appropriate spaces provided in Items 31 and/or
32, the specific currency amount for each “type of
transaction” for a reportable Cash In or Cash Out. If
the casino engages in a Cash In or a Cash Out
transaction that is not listed in Items 31a through 31h or
Items 32a through 32i, specify the type of transaction
and the amount of currency in Item 31z or 32z,
respectively. Enter the total amount of the reportable
Cash In transaction(s) in Item 31 in the space provided.
Enter the total amount of the reportable Cash Out
transaction(s) in Item 32 in the space provided.
If less than a full dollar amount is involved increase
the figure to the next higher dollar. For example, if the
currency total is $20,500.25, show it as $20,501.00.
If there is a currency exchange, list it separately
with both the Cash In and Cash Out totals. If foreign
currency is exchanged, use the U.S. dollar equivalent
on the day of the transaction.
Payment(s) on credit, Item 31c, includes all forms
of cash payments made by a customer on a credit
account or line of credit, or in redemption of markers
or counter checks. Currency received from wire
transfer(s) out, Item 31e, applies to cash received
from a customer when the casino sends a wire transfer
on behalf of a customer.
Bills inserted into gaming devices (Item 31h), includes
the amount of all paper currency inserted into a bill
validator on a slot machine, video lottery terminal, or
other electronic gaming device, used in conjunction with
a customer’s “slot club account” (magnetic strip card),
aggregated by that account and which is posted to a
casino’s slot monitoring system.
Redemptions of chips, tokens, TITO tickets and
other gaming instruments, Item 32a, includes all cash
redemptions of slot machine or video lottery tickets to
a customer. Payments on wagers, Item 32d, includes
all cash paid on race book or sports pool betting tickets
to a customer. Currency paid from wire transfer(s) in,
Item 32e, applies to cash paid to a customer when the
casino receives a wire transfer on behalf of a customer.
Travel and complimentary expenses and gaming
incentives, Item 32h, includes reimbursements for a
customer’s travel and entertainment expenses and cash
complementaries (“comps”).
Determining Whether Transactions
Meet The Reporting Threshold
Only cash transactions that, alone or when
aggregated, exceed $10,000 should be reported on
Form 103. A casino must report multiple currency
transactions when it has knowledge that such transactions
have occurred. This includes knowledge gathered
through examination of books, records, logs, information
retained on magnetic disk, tape or other machinereadable media, or in any manual system, and similar
documents and information that the casino maintains
pursuant to any law or regulation or within the ordinary
course of its business.
Cash In and Cash Out transactions for the same
customer are to be aggregated separately and must
not be offset against one another. If there are both
Cash In and Cash Out transactions which each exceed

$10,000, enter the amounts in Items 31 and 32 and
report on a single Form 103.

File above). For proper format, see the instructions for
Item 13 above.

Example 1. Person A purchases $11,000 in
chips with currency (one Cash In entry); and later
receives currency from a $6,000 redemption of chips
and a $2,000 credit card advance (two Cash Out
entries). Complete Form 103 as follows:
Cash In of “$11,000” is entered in Item 31a (purchase
of chips) and also in the Total Cash In entry at the
bottom of Item 31. No entry is made for Cash Out. The
two Cash Out transactions equal only $8,000, which
does not meet the BSA reporting threshold.

Item 34. Foreign currency.—If foreign currency is
involved, identify the country of issuance by entering
the appropriate two-letter country code. If multiple
foreign currencies are involved, identify the country
for which the largest amount in U.S. Dollars is
exchanged.

Example 2. Person B deposits $5,000 in currency to
his front money account and pays $10,000 in currency
to pay off an outstanding credit balance (two Cash In
entries); receives $7,000 in currency from a wire transfer
(one Cash Out entry); and presents $2,000 in small
denomination U.S. Currency to be exchanged for an
equal amount in U.S. $100 bills. Complete Form 103 as
follows:
Cash In of “$5,000” is entered in Item 31b (deposit),
“$10,000” is entered in Item 31c (payment on credit),
“$2,000” is entered in Item 31g (currency exchange),
and Cash In Total of “$17,000” is entered in Item 31 in
the space provided for “total Cash-in.” In determining
whether the transactions are reportable, the currency
exchange is aggregated with both the Cash In and the
Cash Out amounts. The result is a reportable $17,000
Cash In transaction. No entry is made for Cash Out.
The total Cash Out amount only equals $9,000, which
does not meet the BSA reporting threshold.
Example 3. Person C deposits $7,000 in currency to
his front money account and pays $9,000 in currency
to pay off an outstanding credit balance (two Cash In
entries); receives $2,500 in currency from a withdrawal
from a safekeeping account, $2,500 in currency from a
wire transfer and cashes a personal check of $7,500
(three Cash Out entries); and presents Canadian dollars
which are exchanged for $1,500 in U.S. Dollar
equivalent. Complete Form 103 as follows:
Cash In of “$7,000” is entered in Item 31b (deposit),
“$9,000” is entered in Item 31c (payment on credit),
“$1,500” is entered in Item 31g (currency exchange),
and a Cash In total of “$17,500” is entered in Item 31
in the space provided for “total Cash-in.” Cash Out of
“$2,500” is entered in Item 32b (withdrawal of deposit),
“$2,500” is entered in Item 32e (wire transfer), “$7,500”
is entered in Item 32f (negotiable instrument cashed),
“$1,500” is entered in Item 32g (currency exchange)
and a Cash Out Total of “$14,000” is entered in Item
32 in the space provided for “total Cash-out.” In this
example, both the Cash In and Cash Out totals exceed
$10,000, and each must be reflected on Form 103.
Example 4. Person D purchases $10,000 in chips
with currency and places a $10,000 cash bet (two
Cash In entries); and later receives currency for an
$18,000 redemption of chips and $20,000 from a
payment on a cash bet (two Cash Out entries). Complete
Form 103 as follows:
Cash In of “$10,000” is entered in Items 31a and
31d and a Cash In total of “$20,000” is entered in Item
31 in the space provided for “total Cash-in.” Cash Out
of “$18,000” is entered in Item 32a (redemption of
chips), “$20,000” is entered in Item 32d (payment on
bets) and a Cash Out Total of “$38,000” is entered in
Item 32 in the space provided for “total Cash-out.” In
this example, both the Cash In and Cash Out totals
exceed $10,000, and each must be reflected on Form
103.
Item *33. Date of transaction.—Enter the gaming
day on which the transaction occurred (see What To

Part III. Casino Reporting Transaction(s)
Item *35. Casino’s trade name.—Enter the name by
which the casino does business and is commonly known.
Do not enter a corporate, partnership, or other entity
name, unless such name is the one by which the casino
is commonly known.
Item *36. Casino’s legal name.—Enter the legal name
as shown on required tax filings. This name will be
defined as the name indicated on a charter or other
document creating the entity, and which is identified
with the casino’s established EIN.
Item *37. Employer identification number (EIN).—
Enter the casino’s EIN.
Items *38, *39, *40, and *41. Address.—Enter the
street address, city, state, and ZIP code of the casino
(or branch) where the transaction occurred. Do not
use a P.O. box number.
Item *42. Type of gaming institution.—Check the
appropriate box to indicate the type of gaming
institution. Check box “a” for a land-based or riverboat
casino that is duly licensed by a state, territory or
insular possession of the United States; check box “c”
to indicate a tribal casino (e.g., a Class III gaming
operation or a Class II gaming operation using video
lottery terminals). Check box “b” for a card club, gaming
club, and card room or gaming room (including one
operating on Indian lands). If you check box “z” for
“other” specify the type of gaming institution
(e.g.,racino).
Items 43 and 44. Title and signature of approving
official.—The official who is authorized to review and
approve Form 103 must indicate his/her title and sign
the form.
Item 45. Date the form is signed.—The approving
official must enter the date the Form 103 is signed. For
proper format, see the instructions for Item 13 above.
Item 46. Preparer’s name.—Type or print the full
name of the individual preparing Form 103. The preparer
and the approving official may be different individuals.
Items 47 and 48. Contact person/telephone
number.—Type or print the name and commercial
telephone number of a responsible individual to contact
concerning any questions about this Form 103.
Paperwork Reduction Act Notice.—The requested
information is useful in criminal, tax, and regulatory
investigations and proceedings. Financial institutions are
required to provide the information under 31 U.S.C. 5313
and 31 CFR Part 103, commonly referred to as the Bank
Secrecy Act (BSA). The BSA is administered by the U.S.
Department of the Treasury’s Financial Crimes Enforcement
Network (FinCEN). You are not required to provide the
requested information unless a form displays a valid OMB
control number. The time needed to complete this form will
vary depending on individual circumstances. The estimated
average time is 30 minutes. Send comments regarding this
burden estimate, including suggestions for reducing the
burden, to the Office of Management and Budget, Paperwork
Reduction Project, Washington, DC 20503 and to the
Financial Crimes Enforcement Network, Attn.: Paperwork
Reduction Act, P.O. Box 39, Vienna VA 22183-0039.