FinCEN Identifier Application

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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)
        a. Residential address 
        b. 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)
    a. State-issued driver’s license
    b. State/local/Tribe-issued ID
    c. U.S. passport
    d. 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)
    a. Country/Jurisdiction(select from list of countries/jurisdictions)
    b. 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)
    c. 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)
    d. 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. 
        a. I agree (check the box to certify)