Form FinCEN 112 FinCEN 112 BSA-CTR

Bank Secrecy Act
Currency Transaction Report

FinCEN Form 112
1 Type of filing (check box that applies):
Part I

a

Initial report

Person Involved in Transaction 2 a

Correct/amend prior report

Person conducting transaction on own behalf

2c
Person on whose behalf transaction is conducted
a
*4 Individual’s last name or entity’s legal name
b
8 Alternate name, e.g., AKA - individual or DBA - entity
*10 Address (number, street, and apt. or suite no.)

b

OMB Control Number
1506-00xx
c

FinCEN directed Backfiling

Person conducting Transaction for another
3
Multiple Transactions
d
Courier service (private)
6 M. I.
If entity *5 First name
a. Unk
7 Gender a. Male
b. Fem.
Unk
c. Unk
9 Occupation or type of business
9a NAICS Code
a. Unk

*11 City

a. Unk

b

*12 State a. Unk *13 ZIP/Postal code a. Unk

16 TIN type
*14 Country
*17 Date of birth
a
EIN
a. Unk
*15 TIN
____/____/_______
* (If 15 is
code
b
SSN/ITIN
a. Unk
MM DD YYYY
known)
a. Unk
c
Foreign
19 E-mail address
18a Ext.
18 Contact phone number
(If available)
(If any)
(If available)
*20 Form of identification
d
Alien registration
a. Unk
c
Passport
b
Driver’s license/State I.D.
used to verify identity:
z
Other (describe) _______________________ e Issuing State: _____ f Country: _____
g Number: _________________________________
21 Cash in amount for individual
22 Cash out amount for individual
or entity listed in item 4
$
or entity listed in item 4
$
.00
.00
Acct. number(s) included in item 21
Acct. number(s) included in item 22
a________________________
a__________________________ b____________________________
b____________________________
Part II
24 a

Armored car (FI contract)

b

ATM

c

Mail Deposit or Shipment

$ _____________________ .00

$______________________ .00

b Payment(s)
c Currency received for funds
transfer(s) out
d Purchase of negotiable
instrument(s)
e Currency exchange(s)

$ ______________________ .00

g Purchase(s) of casino chips, tokens,
and other gaming instruments
$______________________ .00
h Currency wager(s) including money
plays

$ _____________________ .00

i

$______________________ .00

Bills inserted into gaming devices

z Other (specify):_________________ $______________________ .00
26 Foreign cash in______________________________________

$_____________________ .00
$ ____________________ .00

d Negotiable instrument(s) cashed

$ ____________________ .00

e Currency exchange(s)

$_____________________ .00

f Currency from prepaid access

$ ____________________ .00

g Redemption(s) of casino chips,
tokens, TITO tickets, and other
gaming instruments
h Payment(s) on wager(s) (including race
book and OTB or sports pool)
i Travel and complimentary expenses and
gaming incentives
j Payment for tournament, contest or
other promotions
z Other (specify):_________________

* 33 Address (number, street, and apt. or suite no.)
*37 Type of financial
Institution
(Check only one)

a
c
z

31 Alternate name, e.g., trade name, DBA
*34 City

*35 State

Casino/Card club
b
Depository institution
MSB
d
Securities/Futures
Other (specify)___________________________

$_____________________ .00
$_____________________ .00
$ ____________________ .00
$_____________________ .00

*36 ZIP/Postal code

State licensed casino
38 If 37a is checked, indicate a
b
Tribal auth. casino
type (Check only one)
c
Card club d
Other (specify) ______________
39f ID number

39 Financial institution ID number (Check one box to indicate type)
a.
CRD number
b.
IARD number
c.
NFA number
d.
SEC ID number e.
RSSD number
*40 Contact office

$ ____________________ .00

*29 Primary Federal regulator
(See Instructions)
*32 EIN

Financial Institution Where Transaction(s) Takes Place

*30 Legal name of financial institution

MM DD YYYY

Aggregated transactions

28 Foreign cash out _____________________________________
a Foreign country (two letter code) ______ (see instructions)

a Foreign country (two letter code) ______ (see instructions)
Part III

e

b Advance(s) on credit (including markers) $_____________________ .00
c Currency paid from funds
$ ____________________ .00
transfer(s) in

$______________________ .00
$ _____________________ .00

Night Deposit

*27 Total cash out
a Withdrawal(s)

$ ______________________ .00

D

f Currency to prepaid access

d

A
R

$ _____________________ .00

*25 Total cash in
a Deposit(s)

T
F

___/___/______

*23 Date of transaction

Amount and Type of Transaction(s). Check all boxes that apply.

*41 Phone number

41a Ext.

42 Date filed
___/_ __/_____
MM DD YYYY

For Paperwork Reduction Act Notice, see page 4.

Cat. No. 37683N

(Rev. 17 (04-19-11)