FinCEN Identifier Application

Appendix—FinCEN Identifier Application Summary of Data Fields

Note: Form is only available to persons who have already obtained login.gov accounts and have signed in through login.gov. Lines that must be filled in for a report to be accepted are identified with the * symbol next to the line number. Italicized text provides a description and/or explanation of lines and response options for purposes of this PRA notice.

Filing Information

1. FinCEN ID (assigned by FinCEN and cannot be edited; populates automatically if individual has already applied for and received a FinCEN Identifier, based on the linkage; empty if filer has not already received a FinCEN Identifier)

2. Date Last Amended (assigned by FinCEN and cannot be edited; populates automatically with the date the information associated with the FinCEN Identifier was last updated if individual has already applied for and received a FinCEN Identifier, based on the linkage between login.gov account and FinCEN Identifier assigned to the account; line 2 is empty if filer has not already received a FinCEN Identifier)

Part I. Individual Information

Full legal name and date of birth:

3. * First name

4. Middle name (required if individual has a middle name)

5. * Last name

6. Suffix (required if the individual’s name has a suffix)

7. * Date of birth

Current address: (report both business address and residential address if the FinCEN ID will be used for both a Company Applicant and a Beneficial Owner)

8. * Address type (check the box that applies to the type of address to be provided in lines 9-13)

1. Residential address

2. Business address

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

10. * City

11. * Country/Jurisdiction (select from list of countries/jurisdictions)

12. * State (select from list when United States, Canada, or Mexico was selected in line 11; if a U.S. Territory was selected in line 11, line 12 populates automatically with the selected U.S. Territory; if a foreign country was selected in line 11, line 12 remains empty)

13. * ZIP/Foreign postal code

Form of identification and issuing jurisdiction:

14. * Identifying document type (select one from list of lines 14a-14d)

1. State-issued driver’s license

2. State/local/Tribe-issued ID

3. U.S. passport

4. Foreign passport (can only be provided if individual does not possess document type listed in 14a, 14b, or 14c)

15. * Identifying document number

16. * Identifying document issuing jurisdiction (select country/jurisdiction in line 16a and complete lines 16b-16d if applicable)

1. Country/Jurisdiction(select from list of countries/jurisdictions)

2. State (select from list when the United States was selected in line 16a and the identifying document is issued by a State; if a U.S. Territory was selected in line 16a, line 16b populates automatically with the selected U.S. Territory; if a foreign country was selected in line 16a, line 16b remains empty)

3. Local/Tribal (select from list when the United States was selected in line 16a and the identifying document is issued by a local jurisdiction or Tribe; if local jurisdiction or Tribe is not included in the list, select “Other” and go to line 16d; if a U.S. Territory or foreign country was selected in line 16a, line 16c remains empty)

4. Other local/Tribal name (enter name of local jurisdiction or Tribe that was not included in the list for line 16c)

17. * Identifying document image (attach image of identifying document referred to in lines 14-16) (upload instructions will be provided here)

Certification

18. * I certify that the information furnished is true, correct, and complete. I understand that the willful provision to FinCEN of false or fraudulent information in this application may result in civil or criminal penalties.

    1. I agree (check the box to certify)

2