Form FinCEN Report 107 FinCEN Report 107 Registration of Money Services Businesses

Registration of Money Services Business
Filing Information/
Registrant Information

Home

Owner or Controlling Person/
MSB Services Location

Money Services and Product
Information (Continued.)

Registration of Money Service Business

Primary Account/Supporting
Document Location/Signature

Version Number: 1.1

OMB No. 1506-0013

Steps to Subm it
1. Complete the report in its entirety w ith all requested or required data know n to the filer.
2. Click "Validate" to ensure proper formatting and that all required fields are completed.
3. Sign w ith PIN.
4. Click "Save"; filers may also "Print" a paper copy for their records.
5. Click "Submit".

Filing Nam e
SPECIAL NOTE: Please be advised that Part V of this registration may be left blank for an initial registration w hen the Primary
Transaction Account for MSB Activities is not yet know n. Registrants must file a corrected registration w hen the account data is
know n.

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Release Date: 08/08/2018

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Registration of Money Services Business
Filing Information/
Registrant Information

Home

Owner or Controlling Person/
MSB Services Location

Money Services and Product
Information (Continued.)

Primary Account/Supporting
Document Location/Signature

Part I Filing Information
1 Indicate the type of filing by checking a, b, or d below (Check only one). If filing a correction, check "c" and either a, b, or d.
a

Initial registration

b

Renewal

c

Correct/amend a prior report

d

Re-registration

e Enter RMSB registration (BSA ID) number if 1b, 1c, or 1d is checked
2 If you checked item 1 d please indicate the reason(s). Check all that apply.
a

Re-registered under state law

b

More than 10 percent transfer of equity interest

c

More than 50 percent increase in agents

Part II Registrant Information
Check here

if entity

*3 Individual's last name,
or entity's legal name
*4 First name
5 Middle name/initial
Suffix name
6 Alternate name, e.g., AKA - individual or DBA - entity

*7 Address
*8 City
*9 State
*10 ZIP/Postal Code
*11 Country
*12 TIN
*13 TIN type
14 Date of birth
15 Telephone number

Ext.

16 E-mail address
17 Website address (URL)
18 Name of compliance contact person for this registered MSB
19 Compliance telephone number

Ext.

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Registration of Money Services Business
Filing Information/
Registrant Information

Home

Owner or Controlling Person/
MSB Services Location

Money Services and Product
Information (Continued.)

Primary Account/Supporting
Document Location/Signature

Part III Owner or Controlling Person
Check here

if entity

20 Individual's last name,
or entity's legal name
21 First name
22 Middle name/initial
Suffix name
23 Address
24 City
25 State

26 ZIP/Postal Code

27 Country
29 TIN type

28 TIN
30 Date of birth
31 E-mail address
32 Website address (URL)
33 Telephone number

Ext.

Part IV Money Services and Product Information
*34 U.S. States and/or territories where the registrant, its agents or branches are physically located and/or providing MSB a ctivities. Note: At
least one box in item 34 must be checked. Check box a, b, or c as appro priate (Check only one). If box a, b, or c does not apply, check
as many state/territory boxes as appropriate. If MSB engages in activities on tribal lands, mark the box for the state, terri tory or district in
which the tribal lands are located. In addition, check box “d” if the MSB engages in activities in foreign locations (non -U.S. and US Territories).
a

All States & Territories

b

All States

c

All Territories

d

Foreign Location(s)

Alabama (AL)

Georgia (GA)

Maryland (MD)

New York (NY)

South Dakota (SD)

Alaska (AK)

Guam (GU)

Massachusetts (MA)

North Carolina (NC)

Tenessee (TN)

American Samoa (AS)

Hawaii (HI)

Michigan (MI)

North Dakota (ND)

Texas (TX)

Arizona (AZ)

Idaho (ID)

Minnesota (MN)

N. Mariana Isls. (MP)

Utah (UT)

Arkansas (AR)

Illinois (IL)

Mississippi (MS)

Ohio (OH)

Vermont (VT)

California (CA)

Indiana (IN)

Missouri (MO)

Oklahoma (OK)

Virgin Islands (VI)

Colorado (CO)

Iowa (IA)

Montana (MT)

Oregon (OR)

Virginia (VA)

Connecticut (CT)

Kansas (KS)

Nebraska (NE)

Palau (PW)

Washington (WA)

Delaware (DE)

Kentucky (KY)

Nevada (NV)

Pennsylvania (PA)

West Virginia (WV)

District of Columbia (DC)

Louisiana (LA)

New Hampshire (NH)

Puerto Rico (PR)

Wisconsin (WI)

FS of Micronesia (FM)

Maine (ME)

New Jersey (NJ)

Rhode Island (RI)

Wyoming (WY)

Florida (FL)

Marshall Islands (MH)

New Mexico (NM)

South Carolina (SC)
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Registration of Money Services Business
Home

Filing Information/
Registrant Information

Owner or Controlling Person/
MSB Services Location

Money Services and Product
Information (Continued.)

Primary Account/Supporting
Document Location/Signature

Part IV Money Services and Product Information (Continued)
35 Enter the number of US branches of the registrant. Reminder: do not separately register each branch.
See instructions for an explanation of the term "branch." i
*36 Money services business activities of the registrant in the US. Check as many as apply. See instructions for an explanati on of the terms. i
a

Issuer of traveler's checks

d

Seller of money orders

g

Check cashier (Including traveler's and money orders)

b

Seller of traveler's checks

e

Dealer in foreign exchange

h

Seller of prepaid access

c

Issuer of money orders

f

Money transmitter

i

Provider of prepaid access

37 If you are providing financial services in addition to those checked in item 36 please briefly describe.

Prepaid Program Information

+

-

If item “36i” is checked, provide the following information (items 38 to 43) to identify each prepaid program for which the registrant is the
provider of prepaid access.
38 Name of prepaid program
39 IIN (BIN) of this program
40 Name of primary transaction processor
41 Name of compliance contact person for this program
42 Contact phone number
43 Is this prepaid program usable internationally?

Ext.
a

Yes

b

No

44 Is any part of the registrant’s US money services business an informal value transfer system?
See the explanation of "money transmitter" and “ informal value transfer system” in the instructions. i

a

Yes

b

No

45 Is any part of the registrant’s US money services business conducted as a mobile operation?

a

Yes

b

No

46 Enter the number of US agents authorized to conduct each money services business activity. Do not include US branches, or per sons who are
solely employees. See instructions for an explanation of the term "agent." i
a Number of US agents selling traveler's check sales

b Number of US agents selling money orders
c Number of US agents involved as a dealer in foreign
exchange
d Number of US agents conducting money transmission
e Number of US agents engaged in check cashing
(Including traveler's checks and money orders)
f Number of US agents selling prepaid access

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Registration of Money Services Business
Filing Information/
Registrant Information

Home

Owner or Controlling Person/
MSB Services Location

Money Services and Product
Information (Continued.)

Primary Account/Supporting
Document Location/Signature

Part V Primary Transaction Account for MSB Activities
Note: See instruction for an explanation of the term "transaction account." The registrant's primary transaction account is the account that has the
greatest annual dollar amount of money services business activity. In items 47 through 56 enter information about the registr ant's primary
transaction account for money services business activities. i
56 Type of financial institution where the primary transaction account is held
a

Depository institution

b

Non-depository institution

c

Foreign

47 Name of financial institution where the
primary transaction account is held
48 Depository financial institution routing number
49 Primary account number
50 Depository financial institution IBAN (if foreign)
51 Address
52 City
53 State

54 ZIP/Postal Code

55 Country

Part VI U.S. Location of Supporting documentation/Address of Agent for Service of Process
If the supporting documentation is kept at the U.S. location reported in Part II check here
and continue to Part VII. If not, provide the U.S.
location of where the supporting documentation is kept here in Part VI. If the MSB is located outside of the U. S., enter U.S . location of the U.S.
agent for service of legal process. Do not enter a non -U.S. address.
57 Address
58 City
59 State

60 ZIP/Postal Code

Part VII Authorized Signature/Signature of Agent for Service of Process
I am authorized to file this form on behalf of the money services business listed in Part II. I declare that the information provided is true, correct and
complete to the best of my knowledge. I understand that the money services business listed in Part II is subject to the Bank Secrecy Act and its
implementing regulations. To the best of my knowledge, the money services business listed in Part II maintains a current list of all agents, an
estimate of its business volume in the coming year, and all other information required to comply with 31 U.S.C. 5330 an d the regulations thereunder.
The signature of the ow ner, controlling person, authorized corporate officer, or U.S. agent for serv ice of legal process is m andatory.
*61 Signature

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62 Print name
63 Title
64 Date of signature

(Date f iled will be auto-populated when the form is signed.)

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