Fincen Form 110 PDF Details

In the realm of financial regulation and compliance, the FinCEN Form 110 plays a pivotal role by allowing banks to designate certain customers as exempt from the Currency Transaction Reporting (CTR) requirements set forth under the Bank Secrecy Act. Initially known as the TD F 90-22.53, this form underwent revisions and was renamed FinCEN Form 110 in August 2005, with a stipulation that earlier editions of the form would not be accepted after January 2006. Designed to streamline the process and ensure efficient reporting, the FinCEN Form 110 must be completed with utmost precision, providing detailed information about the filing institution and the exempt entity, including the legal name, address, and type of exempt person. Upon completion, the form is sent to the IRS Detroit Computing Center, reflecting an intricate balance between regulatory compliance and operational efficiency. By facilitating the designation of exempt persons, it effectively reduces the burden on financial institutions in reporting transactions over $10,000, whilst still maintaining a robust framework to deter and detect financial crimes. The form further underscores the continuing obligation of banks to monitor transactions for any suspicious activities, even among exempt persons, thereby playing a crucial role in the broader objectives of the Financial Crimes Enforcement Network (FinCEN) to combat money laundering and finance-related crimes. Given its significance, the FinCEN Form 110 embodies a critical aspect of financial regulatory compliance, making its accurate and timely filing a key responsibility of eligible banking institutions.

QuestionAnswer
Form NameFincen Form 110
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesproprietorship, fincen 110 renewal, OTS, FinCEN

Form Preview Example

FinCEN Form 110

(Formerly form TD F 90-22.53)

August 2005

Designation of Exempt Person

Previous editions will not be accepted after January 2006

Please type or print. Complete all parts that apply. See instructions.

OMB No.1506-0012

Send your completed form to: IRS Detroit Computing Center, Attn: Designation of Exempt Person, P. O. Box 33112, Detroit, MI 48232-0112

Part I

 

Filing Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

Indicate the type of filing by checking a, b, c, or d (check only one)

 

 

 

 

 

 

a

Initial designation

b

Biennial renewal

c

Exemption amended

d

Exemption revoked

 

 

 

 

 

 

 

 

 

 

 

 

2

Effective date of the exemption

 

__________ / __________ / __________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YYYY

 

 

 

Part II

 

Exempt Person Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

Legal name of the exempt person

 

 

 

 

4

Doing business as (DBA)

 

 

 

 

 

 

 

 

 

 

 

 

5

Address

 

 

 

 

 

 

 

 

6 City

7 State

8 ZIP Code

*9 EIN or SSN

10 Type of exempt person, check box a, b, c, d, e, or f (check only one)

a

d

Bank

b

Listed company subsidiary

e

Government agency/Governmental authority

c

Eligible non-listed business

f

Listed company Payroll customer

11 If this is a biennial renewal, and the exempt person is an eligible non-listed business or a payroll customer,a ( 10 e or f above) has there been a change in control of the exempt person during the last two calender years?

Yes b

No

Part III

Filer Information

12 Name of bank

13Address

14City

15 State

16 ZIP Code

17 EIN

18 Indicate the bank’s primary federal regulator by

a

checking a, b, c, d, e, or f (check only one)

 

OCC b

FDIC c

FRS d

OTS e

NCUA f

IRS

19 If this designation is also being made for one or more affiliated banks, check this box.

See Part V of the instructions for the procedure for listing additional affiliated bank(s) and requirements of the biennial renewal certification.

Part IV

Signature

I am authorized to sign this form on behalf of the bank granting the exemption and any listed bank subsidiaries. I declare that the information provided is true, correct and complete.

20 Signature (If item 1a, c, or d is checked, sign here)

21 Print name

22 Title

23 Date of signature

_____ / _____ / _______

MM DD YYYY

24 Telephone number - (include area code)

( )

Part V

Biennial Renewal Certification

Complete this part only if you are filing a biennial renewal (Item 1b checked).

I certify on behalf of the bank that its system of monitoring the transactions in currency of an exempt person for suspicious activity has been applied as necessary, but at least annually, to this exempt person.

25 Signature (If item 1b is checked, sign here)

26 Print name

27 Title

28 Date of signature

 

 

29

Telephone number - (include area code)

_______ / ______ / ________

(

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Catalog Number 47385C

 

 

 

 

 

 

 

 

 

 

Rev. 08/05

FinCEN Form 110 Designation of Exempt Person

General Information

The Bank Secrecy Act and its implementing regulations require banks to file currency transaction reports on transactions in currency of more than $10,000. The regulations also permit a bank to ex- emptcertaincustomersfromcurrencytransactionre- porting in accordance with 31 CFR 103.22.

Banks are the only type of financial institutions that may exempt customers from CTR filing require- ments. Thetermbankisdefinedin31CFR103.11(c); and includes savings and loan associations, thrift in- stitutions, and credit unions.

The customers that the bank may exempt are called “exempt persons”. An exempt person may be a bank, government agency/government authority, listed company, listed company subsidiary, eligible non-listed business, or payroll customer, as defined in 31 CFR 103.22.

Abankmay,butisnotrequiredto,usethisform to notify the Treasury that the bank has revoked the designation of a customer as an exempt person.

FinCEN encourages banks to use the exemp- tion procedure to the fullest extent. FinCEN also re- minds banks of their continuing obligation to moni- tor for, and report suspicious activity with respect to transactionsofallcustomers,includingcurrencytrans- actions conducted by exempt persons.

When and where to file

Any bank that wishes to designate a customer as an exempt person must file FinCEN Form 110, Designation of Exempt Person, with the IRS Detroit Computing Center no later than 30 days after the first transaction to be exempted.

The biennial renewal must be filed by March 15 of the second calendar year following the year of the initial designation, and every other March 15 thereafter. If the bank missed filing the biennial renewal timely, contact DCC at 800-800-2877 for instructions.

Send your completed form to:

IRS Detroit Computing Center Attn: Designation of Exempt Person P.O. Box 33112

Detroit, MI 48232-0112

General Instructions

1.This form can be e-filed through the Bank Secrecy Act E-filing System. Go to http://bsaefiling.fincen.treas.gov/index.jsp 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.

2.Complete the form in accordance with specific instructions for each item. Unless there is a specific instruction to the contrary, leave blank any items that do not apply.

3.Do not include supporting documents.

4. Enter all dates in MM / DD / YYYY format where MM=month,DD=day,andYYYY=year.Precedeany single number with a zero, i.e., 01,02, etc.

5.List all U.S. telephone numbers with area code first and then the seven-digit phone number, using the format (XXX) XXX-XXXX.

6.Enter identifying numbersstartingfromlefttoright. Do not include spaces, dashes, or other punctuation. Identifying numbers include social security number (SSN), employer identification number (EIN), and individual taxpayer identification number (ITIN).

7.Enter all Post Office ZIP Codes from left to right with at least the first five numbers, or with all nine (ZIP + 4) if known.

8.Addresses: Enter the permanent street address, city, two-letter state or territory abbreviation used by theU.S.PostalServiceandZIPCode(ZIP+4ifknown) of the exempt person or entity. A post office box number should not be used ,unless no other address is available. Also enter any apartment number, suite number, or road or route number. If a P.O. Box is usedforanentity,enterthestreetname,suitenumber, and road or route number.

Specific Instructions

Part I Filing Information

Item 1--Type of filing. Check only one of the four boxes.Thebankwillfileaninitialdesignationjustonce, marking item 1a to signify the initial designation. Additionally,withregardtonon-listedbusinesses(item 10echecked)orpayrollcustomers(item10fchecked), the bank must file the form biennially to renew the exempt status of these customers, marking item 1b to signify the biennial renewal. If amending a report (1c checked) complete the amended report in its entirety. Item 2--Effective date of the exemption. For initial designation, enter the date of the first transaction to be exempted.

-For biennial renewal, the effective date of the exemption will be the same date the bank used in the “effective date of the exemption box” when the initial designation was filed.

-For exemptions amended, if the effective date of the exemption is not being amended, the date entered shouldbethesamedatethebankusedinthe“effective date of the exemption box” when the initial designation was made; or if the effective date of the exemption is being amended, enter the date of the first transaction to be exempted.

-If the DOEP form is used to revoke an exemption, enterthedayafterthelasttransactiontobeexempted.

Part II Exempt Person Information

Item 3--Legal name of the exempt person. Enter the full legal name of the exempt person as it is shown on the charter or other document creating the entity. For exempt persons that are sole proprietorship, enter the first and last name of the proprietor.

Item 4--Doing business as (DBA). If applicable, en- ter the separate DBA name of the exempt person. Item 5, 6, 7 and 8--Address. Enter the permanent address of the business location of the exempt per- son. For exempt persons doing business at more than onephysicallocation,enterthelocalheadquartersad- dress or local address of the exempt person. For sole proprietorship, enter the business address of the sole proprietorship rather than the home address of the sole proprietor, unless they are the same.

Item 9--EIN or SSN. Enter the EIN of the exempt person. If a sole proprietorship does not have an EIN, enter the social security number (SSN).

Item 10--Type of exempt person. Check only one of the six boxes. See 31 CFR 103.22(a).

Item11--Changeincontrol. Completethisitemonly

if you checked Item 1b to indicate that you are filing a biennial renewal (biennial renewals only required for item 10e and 10f).

Part III Filer Information

Item 12--Name of bank. Enter the bank’s full legal name.

Item 13, 14, 15 and 16--Address. Enter the bank’s headquartersaddress.

Item 17--EIN. Enter the bank’s employer identifica- tion number (EIN).

Item 18--Primary regulator. Check only one of the following six boxes, OCC, FDIC, FRS, OTS, NCUA, or IRS.

Item 19--Affiliated banks. A parent bank holding company or one of its bank subsidiaries may make thedesignationofexemptpersononbehalfofallbank subsidiaries of the holding company so long as the designation lists each bank subsidiary that will treat the customer as an exempt person. If you are making such a designation, check the box in item 19. List the name and address of each bank subsidiary by com- pleting Part III of an additional Designation of Exempt Person form for each bank subsidiary. Complete the additional forms by entering the bank’s name and ad- dress in Items 12 through 18, and copy the informa- tion from Part IV, items 21 through 24 of your Desig- nation of Exempt Person form onto each additional form. Submit the additional forms by attaching them to your Designation of Exempt Person form. The data- base will accept up to a total of 20 entries.

Only one signature is required for this form

Part IV Signature

Item20--Signature.Anauthorizedofficialofthebank shall sign the form. (If item 1a, c, or d is checked) Item 21-- Print name. Enter the name of the bank official who signed the form.

Item 22--Title. Enter the title of the bank official who signed the form.

Item 23--Date of signature. Enter the current date the form was signed.

Item24--Telephonenumber.Enterthephonenumber of the bank official who signed the form.

Part V Biennial Renewal Certification

When filing a biennial renewal, a bank must certify that it has applied as necessary, but at least annually,a system of monitoring the transactions in currency for suspicious activity. If the box in item 19 is checked, the bank granting the exemption is responsible for completing its own monitoring and due diligence in granting the exemption. The attached list of affiliated banks is provided only to reflect the other financial institutions that may recognize this exemption.

Item25--Signature.Anauthorizedofficialofthebank shall sign the certification. (Item 1b is checked) Item 26-- Print name. Enter the name of the bank official who signed the certification.

Item 27--Title. Enter the title of the bank official who signed the certification.

Item 28--Date of signature. Enter the date the certification was signed.

Item 29--Telephone number. Enter the phone number of the bank official who signed the certification.

Paperwork Reduction Act Notice: The purpose of this form is to provide an effective means for banks and depository institutions to exempt eligible customers from currency transaction reporting. This report is required by law, pursuant to 31 CFR 103.22. Federal law enforcement and regulatory agencies, including the U.S. Department of Treasury and other authorized authorities, may use and share this information. You are not required to provide the requested information unless a form displays a valid OMB control number. Public reporting and recordkeeping burden for this form is estimated to average 70 minutes per response, and includes time to gather and maintain information for the required report, review the instructions, and complete the information collection. The record retention period is five years. Send comments regarding this burden estimate, including suggeations for reduciing the burden, to Financial Crimes Enforcement Network, Attention: Paperwork Reduction Act, P. O. Box 39, Vienna, VA 22183-0039.

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Completing section 1 of fincen form 110 designation of exempt person

2. Your next part is to fill in all of the following blanks: Indicate the banks primary, a OCC b FDIC c FRS d OTS e NCUA f, If this designation is also being, Part IV Signature, I am authorized to sign this form, Signature If item a c or d is, Print name, Title, Date of signature, MM DD YYYY, Telephone number include area, Part V Biennial Renewal, Complete this part only if you are, I certify on behalf of the bank, and Signature If item b is checked.

fincen form 110 designation of exempt person writing process outlined (portion 2)

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