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Currency Transaction Report By Casinos 103 - Nevada
| Currency Transaction Report By Casinos Form. This is a Nevada form and can be used in Audit Division Nevada Gaming Commission And State Gaming Contol Board Statewide . |
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FINCEN Form (March 2011) 103 1 If this is an amended report check here Department of the Treasury FINCEN Previous editions will not be accepted after September 2011. Please type or print. Items marked with an asterisk* are considered critical. (See instructions.) (Complete all applicable parts--See instructions) Currency Transaction Report by Casinos and complete the form in its entirety. OMB No. 1506-0005 Part I Person(s) Involved in Transaction(s) 2 Section A--Person(s) on Whose Behalf Transaction(s) Is Conducted (Customer) *3 Individual's last name or Organization's name 6 Doing business as (DBA) *7 Permanent address (number, street, and apt. or suite no.) *9 City *10 State *11 ZIP code *12 Country code (if not U.S.) b c *4 First name Multiple persons 5 M.I. *8 SSN or EIN *13 Date of birth c MM __/__/____ DD YYYY *14 Method used to verify identity: a Examined identification credential/document Driver's license/State ID b Number: Passport Known Customer - information on file Alien registration z Other Organization *15 Describe identification credential: a Issued by: 16 Customer's Account Number Section B--Individual(s) Conducting Transaction(s) - If other than above (Agent) 18 Individual's last name 21 Address (number, street, and apt. or suite no.) 23 City 28 Method used to verify identity: Issued by: 24 State a 25 ZIP code 26 Country code (if not U.S.) b c 19 First name 17 Multiple agents 20 M.I. 22 SSN 27 Date of birth ___/___/____ MM DD YYYY Examined identification credential/document Driver's license/State ID Number: Known Customer - information on file Alien registration z Other 30 Multiple transactions 29 Describe identification credential: a b Passport Part II Amount and Type of Transaction(s). Complete all items that apply. *31 CASH IN: (in U.S. dollar equivalent) a Purchase(s) of casino chips, tokens, and other gaming instruments b Deposit(s) (front money or safekeeping) c Payment(s) on credit (including markers) d Currency wager(s) including money plays e Currency received from wire transfer(s) out f Purchase(s) of casino check(s) $ g Currency exchange(s) h Bills inserted into gaming devices z Other (specify): Enter total of CASH IN transaction(s) *33 Date of transaction (see instructions) MM DD .00 .00 .00 .00 .00 .00 .00 .00 .00 *32 CASH OUT: (in U.S. dollar equivalent) a Redemption(s) of casino chips, tokens, TITO tickets, and other gaming instruments b Withdrawal(s) of deposit (front money or safekeeping) c Advance(s) on credit (including markers) d Payment(s) on wager(s) (Including race book and OTB or sports pool) e Currency paid from wire transfer(s) in f Negotiable instrument(s) cashed (including checks) g Currency exchange(s) h Travel and complimentary expenses and gaming incentives i z Payment for tournament, contest or other promotions Other (specify): Enter total of CASH OUT transaction(s) 34 Foreign currency used: $ .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 .00 $ YYYY .00 $ (Country) ____/___/____ Part III Casino Reporting Transactions *36 Casino's legal name *37 Employer Identification Number (EIN) *35 Casino's trade name *38 Address where transaction occurred (See instructions) *40 State *41 ZIP code 43 Title of approving official *39 City b Card club c Tribal authorized casino State licensed casino *42 Type of gaming a Institution z Other (specify) (Check only one) 44 Signature of approving official 45 Date of signature Sign Here ___/___/____ MM DD 46 Type or print preparer's name YYYY 47 Type or print name of person to contact ( 48 Contact telephone number ) For Paperwork Reduction Act Notice, see page 4. Cat. No. 37041B American LegalNet, Inc. www.FormsWorkFlow.com (03-11) FinCEN Form 103 (03-1 1) Page 2 Multiple Persons or Multiple Agents (Complete applicable parts below if box 2 or box 17 on page 1 is checked.) Part I Person(s) Involved in Transaction(s) *4 First name 5 M.I. Section A--Person(s) on Whose Behalf T ransaction(s) Is Conducted (Customer) *3 Individual's last name or Organization's name 6 Doing business as (DBA) *7 Permanent address (number, street, and apt. or suite no.) *9 City *10 State *11 ZIP code *12 Country (if not U.S.) *8 SSN or EIN ___ ___ ___ ___ ___ ___ ___ *13 Date of birth ___ ___/___/____ MM DD YYYY *14 Method used to verify identity: Issued by: 16 Customer's Account Number a Examined identification credential/document Driver's license/State ID b Passport c Number: b Known Customer - information on file Alien registration z Other c Organization *15 Describe identification credential: a Section B--Individual(s) Conducting Transaction(s) - If other than above (Agent) 18 Individual's last name 19 First name 22 SSN ___ ___ ___ ___ ___ ___ ___ ___ 20 M.I. 21 Address (number, street, and apt. or suite no.) 23 City 24 State 25 ZIP code 26 Country (if not U.S.) 27 Date of birth ___/___/____ MM DD YYYY 28 Method used to verify identity: 29 Describe identification credential: Issued by: a a Examined identification credential/document Driver's license/State ID b Passport c Number: b Known Customer - information on file z Other Alien registration General Instructions Form 103. Use this revision of Form 103 for filing on reportable transactions. Suspicious Transactions. If a transaction is greater than $10,000 in currency as well as suspicious, casinos must file a Form 103 and must report suspicious transactions and activities on FinCEN Form 102 , Suspicious Activity Report by Casinos (SARC). Also, casinos are required to use the SARC form to report suspicious activities involving or aggregating at least $5,000 in funds. Do not use Form 103 to(a) report suspicious transactions involving $10,000 or less in currency or (b) indicate that a transaction of more than $10,000 is suspicious. In situations involving suspicious transactions requiring immediate attention, such as when a reportable transaction is ongoing, the casino or card club shall immediately notify by telephone, , appropriate law enforcement and regulatory authorities in addition to filing a timely suspicious activity report. received (Cash In) or currency disbursed (Cash Out) of more than $10,000 in a gaming day. A gaming day is the normal business day of the casino by which it keeps its books and records for business, accounting, and tax purposes. Multiple transactions must be treated as a single transaction if the casino has knowledge that: (a) they are made by or on behalf of the same person, and (b) they result in either Cash In or Cash Out by the casino totaling more
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