Form FinCEN Form 112 FinCEN Form 112 Bank Secrecy Act Currency Transaction Report

FinCEN Report 112

Bank Secrecy Act
Currency Transaction Report

December 2011
BSA E-File Only
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
1506-0064
c

FinCEN directed Backfiling

Person conducting transaction for another
3
Multiple transactions
d
Courier service (private)
6 M. I.
Unk
*5 First name
a. Unk
7 Gender a. Male
If entity
b. Fem.
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

*25 Total cash in
a Deposit(s)

$ _____________________ .00
$______________________ .00

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

$ ______________________ .00

h Currency wager(s) including money
plays

$ _____________________ .00

i

$______________________ .00

Bills inserted into gaming devices

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

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

a
c
z

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):_________________

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

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

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

*35 State

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

*36 ZIP Code

State licensed casino
38 If 37a is checked, indicate a
b
Tribal auth. casino
type (Check only one)
c
Card club z
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.
RSSD number e.
SEC number
*40 Contact office

MM DD YYYY

Aggregated transactions
$_____________________ .00
$ ____________________ .00

Financial Institution Where Transaction(s) Takes Place

*30 Legal name of financial institution

e

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

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

Night Deposit

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

$______________________ .00

g Purchase(s) of casino chips, tokens,
and other gaming instruments
$______________________ .00

d

*27 Total cash out
a Withdrawal(s)

$ ______________________ .00

$ _____________________ .00

___/___/______

*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. 18.2 (9-8-11)