Free FinCEN Form 102 (4-2003) - Federal


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FinCEN Form 102

Suspicious Activity Report by Casinos and Card Clubs
OMB No. 1506 - 0006

April 2003 Please type or print. Always complete entire report. Items Previous editions will not be accepted after December 31, 2003 marked with an asterisk * are considered critical (see instructions). 1 Check the box if this report corrects a prior report (see instructions on page 6)

Part I

Subject Information

2 Check box (a)

if more than one subject *4 First name

box (b)

subject information unavailable 5 Middle initial

*3 Individual's last name or entity's full name 6 also known as (AKA- individual), doing business as (DBA- entity) *8 Address

7 Occupation / type of business *9 City

*10 State

*11 ZIP code

*12 Country (if not U.S.)

13 Vehicle license # / state (optional) a. number b. state Account open ? Yes No 16 Date of birth

*14 SSN / ITIN (individual) or EIN (entity)

*15 Account number

No account affected

*17 Government issued identification (if available) d e Number: 18 Phone number - work

a

Driver's license/state ID

b

Passport

d

____/____/_______ MM DD YYYY Alien registration

Other ___________________________________________ f Issuing state or country________________________ 19 Phone number - home

(
a f

)

(
b g Agent Concessionaire c h

)
Junket / tour operator Other (Explain in Part VI) d

20 E-mail address (if available)

21 Affiliation or relationship to casino/card club Customer Supplier Employee e Check cashing operator

22 Does casino/card club still have a business association and/or an employee/employer relationship with suspect? a Yes b No If no , why? c Barred d Resigned e Terminated f

23 Date action taken(22)

Other (Specify in Part VI) _____/_____/_________ MM DD YYYY

Part II

Suspicious Activity Information
*25 Total dollar amount involved in suspicious activity To _____/_____/_________ MM DD YYYY g h i j k l

*24 Date or date range of suspicious activity From _____/_____/_________ MM DD YYYY Type of suspicious activity: Bribery/gratuity Check fraud (includes counterfeit) Credit/debit card fraud (incl. counterfeit) Embezzlement/theft Large currency exchange(s) Minimal gaming with large transactions

$

,
m n o p q

,

,

.00

* 26 a b c d e f

Misuse of position Money laundering No apparent business or lawful purpose Structuring Unusual use of negotiable instruments (checks) Use of multiple credit or deposit accounts

Unusual use of wire transfers Unusual use of counter checks or markers False or conflicting ID(s) Terrorist financing Other (Describe in Part VI)

Part III
a b c d

Law Enforcement or Regulatory Contact Information
e f g h U.S. Customs Service U.S. Secret Service Local law enforcement State gaming commission i j k l State law enforcement Tribal gaming commission Tribal law enforcement Other (List in item 28)

27 If law enforcement or a regulatory agency has been contacted (excluding submission of a SARC), check the appropriate box. DEA U.S. Attorney (** 28) IRS FBI

28 Other authority contacted (for box 27 g through l) ** List U.S. Attorney office here. 30 Telephone number of individual contacted in box 29

29 Name of person contacted (for all of box 27) 31 Date Contacted _____/_____/_________ MM DD YYYY

(

)
Cataloge Number 35636U

Part IV
*35 Address *36 City

Reporting Casino or Card Club Information
*33 Legal name of casino or card club *34 EIN

2

*32 Trade name of casino or card club

*37 State *38 ZIP code

39 Type of gaming institution a State licensed casino b Tribal licensed casino c Card club d Other (specify)______________________

Part V
*43 Title/Position

Contact for Assistance
*41 First name 42 Middle initial *45 Date report prepared _____/_____/_________ MM DD YYYY *44 Work phone number

*40 Last name of individual to be contacted regarding this report

(
Part VI

)

Suspicious Activity Information - Narrative*

Explanation/description of suspicious activity(ies). This section of the report is critical. The care with which it is completed may determine whether or not the described activity and its possible criminal nature are clearly understood by investigators. Provide a clear, complete and chronological description (not exceeding this page and the next page) of the activity, including what is unusual, irregular, or suspicious about the transaction(s), using the checklist below as a guide as you prepare your account. m. Indicate whether funds or assets were recovered and, if so, enter a. Describe the conduct that raised suspicion. the dollar value of the recovery in whole dollars only. b. Explain whether the transaction(s) was completed or only attempted. n. Indicate any additional account number(s), and any domestic or c. Describe supporting documentation and retain such documentation for foreign bank(s) account numbers which may be involved. your file for five years. o. Indicate for a foreign national any available information on subject's d. Explain who benefited, financially or otherwise, from the passport(s), visa(s), and/or identification card(s). Include date, country, transaction(s), how much and how (if known). city of issue, issuing authority, and nationality. e. Describe and retain any admission or explanation of the p. Describe any suspicious activities that involve transfer of funds to or transaction(s)provided by the subject(s), witness(s), or other person(s). from a foreign country, or any exchanges of a foreign currency. Indicate to whom and when it was given. Include witness or other Identify the currency, country, sources and destinations of funds. person ID. q. Describe subject(s) position if employed by the casino or card club f. Describe and retain any evidence of cover-up or evidence of an (e.g., dealer, pit supervisor, cage cashier, host, etc.). attempt to deceive federal or state examiners, or others. r. Indicate the type of casino or card club filing this report, if this is not g. Indicate where the possible violation of law(s) took place (e.g., clear from Part IV. branch, cage, specific gaming pit, specific gaming area). s. Describe the subject only if you do not have the identifying informah. Indicate whether the suspicious activity is an isolated incident or tion in Part I or if multiple individuals use the same identification. Use relates to another transaction. descriptors such as male, female, age, etc. i. Indicate whether there is any related litigation. If so, specify the t . Indicate any wire transfer in or out identifier numbers, including the name of the litigation and the court where the action is pending. transfer company's name. j. Recommend any further investigation that might assist law enforcement authorities. u. If correcting a prior report, complete the form in its entirety and k. Indicate whether any information has been excluded from this note the changes here in Part VI. report; if so, state reasons. l. Indicate whether any U.S. or foreign currency and/or U.S. or foreign negotiable instrument(s) were involved. If foreign, provide the NOTE: Information already provided in earlier parts of this form amount, name of currency, and country of origin. need not necessarily be repeated if the meaning is clear. Tips on SAR Form preparation and filing are available in the SAR Activity Review at www.fincen.gov/pub_reports.html.

Supporting documentation should not be filed with this report. Maintain the information for your files.
Do not include legal disclaimers in this narrative. Continue on next page as necessary.

Suspicious Activity Report Narrative (continued from page 2)

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.

FinCEN Form 102a
Safe Harbor Federal law (31 U.S.C. 5318(g)(3)) provides complete protection from civil liability for all reports of suspicious transactions made to appropriate authorities, including supporting documentation, regardless of whether such reports are filed pursuant to this report's instructions or are filed on a voluntary basis. Specifically, the law provides that a financial institution, and its directors, officers, employees and agents, that make a disclosure of any possible violation of law or regulation, including in connection with the preparation of suspicious activity reports, "shall not be liable to any person under any law or regulation of the United States, any constitution, law, or regulation of any State or political subdivision of any state, or under any contract or other legally enforceable agreement (including any arbitration agreement), for such disclosure or for any failure to provide notice of such disclosure to the person who is the subject of such disclosure or any other person identified in the disclosure". Notification Prohibited Federal law (31 U.S.C. 5318(g)(2)) provides that a financial institution, and its directors, officers, employees, and agents who, voluntarily by means of a suspicious activity report, report suspicious transactions to the government, may not notify any person involved in the transaction that the transaction has been reported. In situations involving suspicious transactions requiring immediate attention, such as when a reportable transaction is ongoing, the financial institution shall immediately notify, by telephone, appropriate law enforcement and financial institution regulatory authorities in addition to filing a timely suspicious activity report. When To File A Report: 1. Every casino and card club (for purposes of 31 CFR 103, a "reporting casino"), shall file with FinCEN, to the extent and in the manner required by 31 CFR 103, a report of any suspicious transaction relevant to a possible violation of law or regulation. A casino may also file with FinCEN, by using the Suspicious Activity Report by Casinos (SARC), a report of any suspicious transaction that it believes is relevant to the possible violation of any law or regulation but whose reporting is not required by 31 CFR 103. 2. A transaction requires reporting under the terms of 31 CFR 103.21 if it is conducted or attempted by, at, or through a casino, and involves or aggregates at least $5,000 in funds or other assets, and the casino knows, suspects, or has reason to suspect that the transaction (or a pattern of transactions of which the transaction is a part): (i)Involves funds derived from illegal activity or is intended or conducted in order to hide or disguise funds or assets derived from illegal activity (including, without limitation, the ownership, nature, source, location, or control of

SAR- Casinos and Card Clubs Instructions
such funds or assets) as part of a plan to violate or evade any federal law or regulation or to avoid any transaction reporting require-ment under federal law or regulation; (ii) Is designed, whether through structuring or other means, to evade any requirements of 31 CFR 103 or of any other regulations promulgated under the Bank Secrecy Act, Public Law 91-508, as amended, codified at 12 U.S.C. 1829b, 12 U.S.C. 1951-1959, and 31 U.S.C. 5311-5332; (iii) Has no business or apparent lawful purpose or is not the sort in which the particular customer would normally be expected to engage, and the casino knows of no reasonable explanation for the transaction after examining the available facts, including the background and possible purpose of the transaction; or (iv) Involves use of the casino to facilitate criminal activity. 3. A SARC shall be filed no later than 30 calendar days after the date of the initial detection by the reporting casino of facts that may constitute a basis for filing a SAR under this section. If no suspect is identified on the date of such initial detection, a casino may delay filing a SARC for an additional 30 calendar days to identify a suspect, but in no case shall reporting be delayed more than 60 calendar days after the date of such initial detection. In situations involving violations that require immediate attention, such as ongoing money laundering schemes, the reporting casino shall immediately notify by telephone an appropriate law enforcement authority in addition to filing timely a SARC. Casinos wishing to voluntarily report suspicious transactions that may relate to terrorist activity may call FinCEN's Financial Institutions Hotline at 1-866-556-3974 in addition to filing timely a SARC if required by 31 CFR 103. 4. Exceptions. A casino is not required to file a SARC for a robbery or burglary committed or attempted that is reported to appropriate law enforcement authorities. 5. The Bank Secrecy Act requires financial institutions to file currency transaction reports (CTRs) in accordance with the Department of the Treasury's implementing regulations (31 CFR Part 103). These regulations require a financial institution to file a CTR whenever a currency transaction exceeds $10,000. CFR 31 103.22(b)(2) requires that all casinos and card clubs file using FinCEN 103 (CTRC). If a currency transaction exceeds $10,000 and is suspicious, the institution must file both a CTRC reporting the currency transaction and a suspicious activity report reporting the suspicious aspects of the transaction. If a currency transaction is $10,000 or less and is suspicious, the institution should only file a suspicious activity report. Appropriate records must be maintained in each case. See: 31 CFR Part 103. General Instructions A. Abbreviations and Definitions:

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1. AKA--also known as 2. DBA--doing business as 3. DEA--Drug Enforcement Administration 4. EIN--Employer Identification Number 5. FBI--Federal Bureau of Investigation 6. IRS--Internal Revenue Service (AML or CI) 7. ITIN--Individual Taxpayer Identification Number 8. SSN--Social security number B. How to Make a Report:

1. This form should be e-filed through the Bank Secrecy Act E-Filing System. Go to http://bsaefiling.fincen.treas.gov to register. This form is also available for download on the Financial Crimes Enforcement Network's Web site at www.fincen.gov, or may be ordered by calling the IRS Forms Distribution Center at (800) 829-3676. If not filed electronically, send each completed suspicious activity report to: Detroit Computing Center ATTN: SARC P.O. Box 32621 Detroit, MI 48232-5980 2. While all items should be completed fully and accurately, items marked with an asterisk (*) are considered critical and must be completed according to the provisions of paragraph 3 below and any special item instructions. 3. If the information for a critical item marked with an asterisk (*) is not known or not applicable, enter special response "XX" as appropriate to complete the item. Non-asterisk fields should be left blank if the information is unknown or not applicable. NOTE: The XX response for unknown may not be used in item 24 (suspicious activity "From" date), the check boxes in item 26 (one or more boxes must be checked), and in Parts IV, V or VI. 4.Complete each suspicious activity report by providing as much information as possible on initial and corrected reports. 5. Do not include supporting documentation with the suspicious activity report filed. Identify and retain a copy of the suspicious activity report and all supporting documentation or business record equivalents for your files for five (5) years from the date of the suspicious activity report. All supporting documentation such as, canceled checks, confessions, credit bureau reports, credit slips/vouchers, deposit/withdrawal slips, multiple transaction logs, player rating records, slot club records, identification credentials, spreadsheets, photographs, surveillance audio and/or video recording media, and surveillance logs. For casinos that have hotels, and in the absence of any information other than a customer's name, other supporting documentation such as credit/debit

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cards, guest folios, and safety deposit box registrations. All supporting documentation referenced above must be made available to appropriate authorities upon request. 6. If more than one subject is being reported, make a copy of page 1 and complete only the subject information Part I, and attach the additional page(s) behind page 1. If more space is needed to complete any other item(s), identify that item in Part VI by "item number", and provide the additional information. 7. Type or complete the report using block written letters. 8. Enter all dates in MM/DD/YYYY format where MM = month, DD = day, and YYYY = year. Precede any single number with a zero, i.e., 01, 02, etc. 9. Enter all telephone numbers with (area code) first and then the seven numbers, using the format, (XXX) XXX-XXXX. List international telephone and fax numbers in Part VI. 10. Always enter an individual's name by entering the last name, first name, and middle initial (if known). If a legal entity is listed, enter its name in the last name field. 11. Enter all identifying numbers (Alien registration, Driver's License/State ID, EIN, ITIN, Foreign National ID, Passport, SSN, etc.) starting from left to right. Do not include spaces, dashes or other punctuation. 12. Enter all Post Office ZIP codes with at least the first five numbers (all nine (ZIP+4)) if known) and listed from left to right. 13. Enter all monetary amounts in U.S. Dollars. Use whole dollar amounts rounded up when necessary. Use this format: $0,000,000.00. If foreign currency is involved, state name of the currency and country of origin. 14. Addresses, general. Enter the permanent street address, city, two letter state/territory abbreviation used by the U.S. Postal Service and ZIP code (ZIP+4 if known) of the individual or entity. A post office box number should not be used for an individual, unless no other address is available. For an individual also enter any apartment number or suite number, and road or route number. If a P.O. Box is used for an entity, enter the street name, suite number, and road or route number. If the address of the individual or entity is in a foreign country, enter the city, province or state, postal code and the name of the country. Complete any part of the address that is known, even if the entire address is not known. If from the United States, leave country box blank. C. Specific Suspicious Activity Report Preparation Instructions: Item 1-- *Check box, "corrects prior report", if this report is filed to correct a previously filed SARC. To correct a report, a new SARC must be completed in its entirety. Also note corrected information in Part VI, (see line "u"). Part I Subject Information
Note: Enter information about the person(s) or entity involved that caused this report to be filed, not the victim of the activity.

reporting casino or card club has knowledge of a subject's separate "AKA" or an entity's DBA name, enter it in item 6. Item 7-- Occupation/type of business. Fully identify the occupation, profession or business of the individual or entity shown in Items 3 through 5 (e.g., accountant, attorney, carpenter, truck driver, check casher, etc.). Do not use nondescript terms such as merchant, self-employed, businessman, or salesperson. If the subject's business activities can be described more fully than just by occupation, provide additional information in Part VI. Indicate in Item 7 if unknown. Items *8, *9, *10, *11 and *12-- *Address. See General Instructions B12 and B14. Item 13-Vehicle license number (optional). Enter the subject's vehicle license plate number and issuing state, if known or available. Item *14-- *SSN/ITIN (individual) or EIN (entity). See General Instruction B11 and definitions. If the subject named in Items 3 through 5 is a U.S. Citizen or an alien with a SSN, enter his or her SSN in Item 13. If that individual is an alien who has an ITIN, enter that number. If the subject is an entity, enter the EIN. If unknown, enter XX in the first two spaces. Item *15-- *Account number. See General Instruction B11. Enter the number of any account in or through which the suspicious activity occurred. If an account is not affected or if no affected account is known, mark the "no account affected" box. Check box to indicate if the account is open or closed. If more than one account is affected, provide the additional information in Part VI. Item 16-- Date of birth. See General Instruction B8. If an individual is named in Items 3 through 5, enter the date of birth. If t h e month and/or day is not available or is unknown, fill in with zeros (e.g., "01/00/1969" indicates an unknown date in January, 1969). Item *17-- *Government issued identification (if available). See General Instruction B11. Check the appropriate box(es) showing the type of document used to verify the subject's identity. If you check box "d" (Other), be sure to specify the type of document used. In box "e" list the number of the identifying document. In box "f" list the issuing state or country. If more space is required, enter the information in Part VI. If all information for item 17 is unknown, check box "d" and enter "XX" in the space proved for "other." Items 18, 19-- Telephone numbers See General Instruction B9 (telephone). List any additional number(s) (e.g., hotel, cell, fax, international etc.) in Part VI.

Casinos and card clubs may rely upon their own internal records, including copies of federal forms, which contain verified customer information, to identify the subjects of these reports. These records may include credit, deposit, or check cashing account records; or a filed FinCEN Form 103 (CTRC ), IRS Form W-2G, (Certain Gambling Winnings) (e.g., pertaining to a keno or slot win), IRS form W-9 (Request for Taxpayer Identification Number and Certification), or any tax or other form containing such customer information. If casinos do not have verified identification information on the customer, they should consult whatever other sources of customer information that are available within internal records (player rating records, slot club records, etc.). If the subject is an "unknown," casinos that offer hotels including conference/seminar facilities, entertainment venues, and resort amenities should consider using whatever other internal sources are available to obtain customer identification such as credit/debit card numbers; hotel registrations ­ e.g., guest folios, safe deposit box registrations; show, spa, transportation and/ or tour reservations; etc. Item 2 -- Multiple Subjects. If there are multiple subjects involved, check box "2a" and complete a separate Part I for each subject. Check box "2b" only if NO critical* subject information is available. If ANY subject information is available, record that information in Part 1, leave box "2b" blank, and insert the appropriate special response "XX" in any critical item for which data is missing. This will alert law enforcement and regulatory users of the BSA database that this information has not been inadvertently omitted. Items *3, *4, and 5--Name of Subject. See General Instruction B10. If the subject is an entity, enter the legal name in item 3, enter XX in item 4 and leave item 5 blank. If the entity is operated under a different trade or business name than its legal name, enter the entity's legal name in Item 3 (e.g., Smith Enterprises, Inc.) and the name of the business in Item 6 (e.g., Smith's Tours). If more than one Part I is required, make a copy of page 1 and provide the additional information. Item 6-- also known as (AKA-individual), or doing business as (DBA-entity). If a

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Item 20-- E-mail address List e-mail address if available. Item 21-- Affiliation/relationship to casino. If box "d" (employee) is checked, indicate in Part VI the subject's position (e.g., dealer, pit supervisor, cage cashier, host, etc.) and the subject's involvement. If box "h" (other) is checked, briefly describe in Part VI. Items 22 and 23-- Continuing business association and/or employer/employee relationship. If the "no" box is checked, check the appropriate box to indicate what action occurred that ended the relationship. Indicate the date that action was taken in Item 23 (see General Instruction B8). PART II Suspicious Activity Information* Item 24-- *Date or date range of suspicious activity. See General Instruction B8. Enter the date of the reported activity in the "From" field. If more than one day, indicate the duration of the activity by entering the first date in the "From" field and the last date in the "To" field. If the same individual or organization conducts multiple or related activities within the 30 calendar day period after the date of initial detection, the reporting institution may consider reporting the suspicious transactions on one form but only if doing so will fully describe what has occurred. A new report must be filed for other related suspicious transactions committed after the initial detection period. "XX" may not be used in the "From" date entry. Item 25-- *Total dollar amount. See General Instruction B13. Enter the total dollar value of the funds or asset(s) involved in the suspicious activity which is conducted by the same individual or organization within the 30 calendar day period after the date of initial detection. For multiple or related suspicious transactions, show the breakdown of this aggregated total in Part VI. For individual(s) with a relationship to the casino (reference Item 21 "b" through "h"), the value of this item can be zero (0). Do not use any words, such as "thousand", "million", etc. If unknown, enter "XX" right justified. Item 26-- *Type of suspicious activity. Check the box(es), which best identify the suspicious activity. If the activity involves exchanging numerous small denomination bills for large denomination bills at the cage, after the subject engages in minimal or no gaming activity, check boxes "e" and "f". Check box "j" for Structuring when a subject acting alone, in conjunction with, or on behalf of other subjects, conducts or attempts to conduct activity designed to evade any recordkeeping or reporting requirement promulgated under the Bank Secrecy Act. Check box "o" if the ID presented does not match the individual or if multiple ID's conflict. If you check box "q" for Other, you must describe, in Part VI, the type of suspicious activity that occurred that is not listed in Item 26. Use of "XX" does not apply to this item. At least one box must be checked. Part III Law Enforcement or Regulatory Contact Information Note: If no contact, go to Part IV. Item 27, 28, and 29-- Contacting enforcement authorities. See General Instructions "A. Abbreviations and Definitions" for law enforcement and regulatory identities. If the casino/card club has contacted any law enforcement or regulatory agency about the suspicious activity, by telephone or written communication (excluding submission of a SARC), check the appropriate box in item 27. In Item 28 provide the name of the authority contacted if box "b" or boxes "g" through "l" are checked. In Item 29, provide the name of the individual contacted for all of box 27. Contact with law enforcement agencies does not eliminate the requirement to file the SARC. Item 30-- Telephone number. See General Instruction B9. Enter telephone number of the individual listed in item 29. Item 31-- Date contacted. See General Instruction B8. Part IV Reporting Casino or Card Club Information* Item *32-- *Casino or card club's trade name*. Enter the name by which the casino or card club does business and is commonly known. Do not enter a corporate, partnership, or other entity name unless such name is the one by which the casino is commonly known. Item *33-- *Casino or card club's legal name. Enter the legal name as shown on required tax filings, only if different from the trade name shown in Item 32. The legal name should match the name shown on the charter or other document creating the entity, and which is identified with the casino's established employer identification number. Item *34-- *Employer identification number. Enter the institution's nine-digit EIN. Items *35, *36, *37, and *38-- *Address. See General Instruction B14. Item 39-- Type of gaming institution. Check the appropriate box for the type of gaming institution. Check box "a" for a land-based or riverboat casino that is duly licensed by a State, Territory or Insular Possession of the United States. Check box "b" for a tribal casino (i.e., a Class III gaming operation). Check boxes "a" and "b" for a tribal casino duly licensed by a state gaming regulatory agency. Check box "c" for a card club, gaming club, and card room or gaming room (including one operating on Indian lands). If you check box "d" for "Other", be sure to specify the type of gaming institution (e.g., race track). Part V Contact for Assistance* Items *40, *41, and 42-- *Contact individual. See General Instruction B10. Item *43 *Title/Position-- Enter the job title/ position of the contact individual. Item *44 *Work phone number-- See General Instruction B9. Item *45 *Date report prepared-- See General Instructions item B8. PART VI *Suspicious Activity Information -- Narrative. See FinCEN Form102, page 2 for instructions.

Paperwork Reduction Act Notice: The purpose of this form is to provide an effective means for financial institutions to notify appropriate law enforcement agencies of suspicious transactions that occur by, through, or at the financial institutions. This report is required by law, pursuant to authority contained in 31 U.S.C. 5318(g). Information collected on this report is confidential (31 U.S.C. 5318(g)). Federal securities regulatory agencies and the U.S. Departments of Justice and Treasury, and other authorized authorities may use and share this information. Public reporting and record keeping burden for this form is estimated to average 45 minutes per response, and includes time to gather and maintain information for the required report, review the instructions, and complete the information collection. Send comments regarding this burden estimate, including suggestions for reducing the burden, to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20503 and to the Financial Crimes Enforcement Network, Attn.: Paperwork Reduction Act, P.O. Box 39, Vienna VA 22183-0039. The agency may not conduct or sponsor, and an organization (or a person) is not required to respond to, a collection of information unless it displays a currently valid OMB control number.