Form FinCEN 110 FinCEN 110 Designation of Exempt Person

FinCEN Form

Designation of Exempt Person

110

Previous editions will not be accepted after September 2011
Please type or print. Complete all parts that apply.

March 2011

OMB No.1506-0012

See instructions.

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, c, or d (check only one)
a

Initial designation

c

Exemption amended

2 Effective date of the exemption

Exemption revoked

__________ / __________ / __________
MM

Part II

d

DD

YYYY

Exempt Person Information
4 Doing business as (DBA)

3 Legal name of the exempt person
5 Address
7 State

6 City

*9 EIN or SSN

8 ZIP Code

10 Type of exempt person, check box c, d, e, or f (check only one)
c

Listed company

d

Listed company subsidiary

Part III

e

Eligible non-listed business

f

Payroll customer

Filer Information

11 Name of bank
12 Address
14 State

13 City
17 Indicate the bank’s primary federal regulator by
checking a, b, c, d, e, or f (check only one)

a

15 ZIP Code

OCC

b

16 EIN

FDIC

c

FRS

d

OTS

e

NCUA

f

IRS

18 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).

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.
19 Signature
21 Title

20 Print name
22 Date of signature

_____ / _____ / _______
MM

DD

YYYY

(

23 Telephone number - (include area code)

)

If filing this form as a paper submission, please mail to the following address:
IRS Detroit Computing Center
Attn: Designation of Exempt Person
P.O. Box 331 12
Detroit, MI 48232-0112

Catalog Number 47385C

Rev. 03/11

FinCEN Form 110 Designation of Exempt Person
General Information
The Bank Secrecy Act and its implementing
regulations require banks to file currency transaction reports on transactions in currency of more
than $10,000. The regulations also permit a bank
to exempt certain customers from currency transaction reporting in accordance with 31 CFR
1020.315.
Banks are the only type of financial institutions that may exempt customers from CTR filing
requirements. The term bank is defined in 31
CFR 1010.100(d); and includes savings and loan
associations, thrift institutions, and credit unions.
The customers that the bank may exempt
are called “exempt persons.” An exempt person
may be a bank, government agency/government
authority, listed company, listed company subsidiary, eligible non-listed business, or payroll customer.
A bank may, but is not required to, use this
form to notify the Treasury that the bank has revoked the designation of a customer as an exempt person.

5. List all U.S. telephone numbers with area code
first and then the seven-digit phone number
, using
the format (XXX) XXX-XXXX.
6. Enter identifying numbers starting from left to
right. Do not include spaces, dashes, or other
punctuation. Identifying numbers include social
security number (SSN), employer identification
number (EIN), and individual taxpayer identification
number (ITIN).
7. Enter all Post Office ZIP Codes from left to
right with at least the first five numbers, or with all
nine (ZIP + 4) if known.

Item 1--Type of filing. Check only one of the three
boxes. The bank will file an initial designation just
once, marking item 1a to signify the initial
designation. If amending a report (1c checked)
complete the amended report in it s entirety.

Part II Exempt Person Information

3. Do not include supporting documents.
4. Enter all dates in MM / DD / YYYY format
where MM= month, DD= day , and YYYY= year.
Precede any single number with a zero,i.e., 01,02,
etc.

Item 11--Name of bank. Enter the bank’s full legal
name.

Item 18--Affiliated banks. A parent bank holding
company or one of its bank subsidiaries may make
the designation of exempt person on behalf of all
bank subsidiaries of the holding company so long
as the designation lists each bank subsidiary that
will treat the customer as an exempt person. If you
are making such a designation, check the box in
item 18. List the name and address of each bank
subsidiary by completing Part III of an additional
Designation of Exempt Person form for each bank
subsidiary. Complete the additional forms by entering the bank’ s name and address in Items 1 1
through 17, and copy the information from Part IV,
items 20 through 23 of your Designation of Exempt Person form onto each additional form.
Submit the additional forms by attaching them to
your Designation of Exempt Person form. The database will accept up to a total of 20 entries.

Item 2--Effective date of the exemption. For initial
designation, enter the date of the first transaction
to be exempted.
-For exemptions amended, if the effective date of
the exemption is not being amended, the date
entered should be the same date the bank used in
the “effective date of the exemption box” when the
initial designation was made; or if the effective
date of the exemption is being amended, enter
the date of the first transaction to be exempted.
-If the DOEP form is used to revoke an exemption,
enter the day after the last transaction to be
exempted.

Send your completed form to:
IRS Detroit Computing Center
Attn: Designation of Exempt Person
P.O. Box 33112
Detroit, MI 48232-01 12

Part III Filer Information

Specific Instructions

General Instructions

When and where to file
Any bank that wishes to designate a customer
as an exempt person must file FinCEN Form 110,
Designation of Exempt Person, with the IRS Detroit
Computing Center no later than 30 days after the
first transaction to be exempted.

Item 10--Type of exempt person. Check only one
of the four boxes, c, d, e, or f.

Item 12, 13, 14 and 15--Address. Enter the bank’s
headquarters address.

Part I Filing Information

2. Complete the form in accordance with specific
instructions for each item. Unless there is a specific
instruction to the contrary, leave blank any items
that do not apply .

Item 9--EIN or SSN. Enter the EIN of the exempt
person. If a sole proprietorship does not have an
EIN, enter the social security number (SSN).

8. Addresses: Enter the permanent street address,
city, two-letter state or territory abbreviation used
by the U.S. Postal Service and ZIP Code (ZIP+4 if
known) of the exempt person or entity.A post office
box number should not be used , unless no other
address i s available. Also enter any apartment
number, suite number, or road or route number. If a
P.O. Box is used for an entity
, enter the street name,
suite number, and road or route number .

FinCEN encourages banks to use the exemption procedure to the fullest extent. FinCEN also
reminds banks of their continuing obligation to
monitor for, and report suspicious activity with respect to transactions of all customers, including
currency transactions conducted by exempt persons.

1. 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 Financial Crimes Enforcement Network’s Web site
at www.fincen.gov, or may be ordered by calling the
IRS Forms Distribution Center at (800) 829-3676

home address of the sole proprietor , unless they
are the same.

Item 3--Legal name of the exempt person. Enter
the full legal name of the exempt person as it is
shown on the charter or other document creating
the entity . For exempt persons that are sole
proprietorship, enter the first and last name of the
proprietor.
Item 4--Doing business as (DBA). If applicable,
enter the separate DBA name of the exempt person.
Item 5, 6, 7 and 8--Address. Enter the permanent
address of the business location of the exempt
person. For exempt persons doing business at more
than one physical location, enter the local headquarters address or local address of the exempt
person. For sole proprietorship, enter the business
address of the sole proprietorship rather than the

Item 16--EIN. Enter the bank’s employer identification number (EIN).
Item 17--Primary regulator. Check only one of the
following six boxes, OCC, FDIC, FRS, OTS, NCUA,
or IRS.

Only one signature is required for this form
Part IV Signature
Item 19--Signature. An authorized of ficial of the
bank shall sign the form.
Item 20-- Print name. Enter the name of the bank
official who signed the form.
Item 21--Title. Enter the title of the bank official
who signed the form.
Item 22--Date of signature. Enter the current date
the form was signed.
Item 23--Telephone number. Enter the phone
number of the bank official who signed the form.

Paperwork Reduction Act Notice: The purpose of this form is to provide an effective means for banks and depository institutions to exempt eligible customersrom
f currency
transaction reporting. This report is required by law, pursuant to 31 CFR 1020.315 Federal law enforcement and regulatory agen cies, including the U.S. Department of
Treasury and other authorized authorities, may use and share this information. You are not required to provide the requested i nformation unless a form displays a valid
OMB control number. Public reporting and recordkeeping burden for this form is estimated to average 70 minutes per response, an d includes time to gather and maintain
information for the required report, review the instructions, and complete the information collection. The record retention pe riod is five years. Send comments regarding
this burden estimate, including suggeations for reduciing the burden, to Financial Crimes Enforcement Network, Attention: Paperwork Reduction Act, P. O. Box 39, V ienna,
VA 22183-0039.