FinCEN Form 107 Registration of Money

Formerly Dept. Treasury

form TD F 90-22.55,
Services Business
Please type or print. Always complete entire report. See instructions.
Effective January , 2005
Previous editions will not be accepted after June 30, 2005. OMB No.1506-0013

Send your completed form to: IRS Detroit Computing Center, Attn: Money Services Business Registration, P. O. Box 33116, Detroit, MI 48232-0116

Part I Filing Information

1 Indicate the type of filing by checking a, b, c, or d below.

a Initial registration b Renewal c Correction d Re-registration

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

3 Legal name of the money services business

4 Doing business as

5 Address 6 City

7 State 8 ZIP Code 9 EIN (entity), SSN/ITIN (individual) 10 Telephone number (include area code)
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Part III Owner or Controlling Person
11 Individual’s last name, or organization’s name 12 First name 13 Middle initial

14 Address

15 City 16 State 17 ZIP Code 18 Country (if other than US)

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19 Telephone number - (include area code) 20 Date of birth 21 SSN/ITIN (individual), EIN (entity)
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MM DD YYYY
22 Skip this item if you completed item 21.
If the owner or controlling person is an individual enter their form of identification, the ID number, and the issuing state or country.
a Driver’s license/state ID b Passport c Alien registration d Other _________________________
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e ID number f Issuing state or country

Part IV Money Services and Product Information

23 States and/or territories where the registrant, its agents or branches are located. Check as many as apply. If you check either “All States” or
“All States & Territories”, do not check any other boxes.

a All States & Territories District of Columbia (DC) Maine (ME) New Mexico (NM) South Dakota (SD)
b All States Florida (FL) Maryland (MD) New York (NY) Tennessee (TN)
Georgia (GA) Massachusetts (MA) North Carolina (NC) Texas (TX)
Alabama (AL) Guam (GU) Michigan (MI) North Dakota (ND) Utah (UT)
Alaska (AK) Hawaii (HI) Minnesota (MN) N. Mariana Isls. (MP) Vermont (VT)
American Somoa (AS) Idaho (ID) Mississippi (MS) Ohio (OH) Virgin Islands (VI)
Arizona (AZ) Illinois (IL) Missouri (MO) Oklahoma (OK) Virginia (VA)
Arkansas (AR) Indiana (IN) Montana (MT) Oregon (OR) Washington (WA)
California (CA) Iowa (IA) Nebraska (NE) Pennsylvania (PA) West Virginia (WV
Colorado (CO) Kansas (KS) Nevada (NV) Puerto Rico (PR) Wisconsin (WI)
Connecticut (CT) Kentucky (KY) New Hampshire (NH) Rhode Island (RI) Wyoming (WY)
Delaware (DE) Louisiana (LA) New Jersey (NJ) South Carolina (SC)

Catalog Number 39578N Rev. 12/31/04

Part IV (continued) 2
24 Enter the number of branches of the registrant. Reminder: do not separately register each branch.

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See instructions for an explanation of the term “branch”.

25 Money services business activities of the registrant. Check as many as apply. See instructions for an explanation of the terms ” issuer”,
“seller”, “redeemer”, “check casher”, and “money transmitter”.
a Issuer of traveler’s checks d Issuer of money orders g Currency dealer or exchanger

b Seller of traveler’s checks e Seller of money orders h Check casher

c Redeemer of traveler’s checks f Redeemer of money orders i Money transmitter

26 Is any part of the registrant’s money services business an informal value transfer system?
a Yes b No
See the explanation of “money transmitter” in the instructions.

27 Is any part of the registrant’s money services business conducted as a mobile operation?
a Yes b No

28 Enter the number of agents authorized to conduct each money services business activity. Do not include branches, or persons who are solely
employees. See instructions for an explanation of the term “agent”.

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a Traveler’s check sales e Currency exchange

or dealer
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b Traveler’s check redemption f Check cashing

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c Money order sales g Money transmission

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d Money order redemption

Part V Primary Transaction Account for MSB Activities

29 If the registrant has more than one transaction account for money services business activities check here .
See instructions for an explanation of the term “transaction account”.
The registrant’s primary transaction account is the one that has the greatest annual dollar amount of money services business activity.
In items 30 through 35 enter information about the registrant’s primary transaction account for money services business activities.

30 Name of financial institution where the primary transaction account is held

31 Address 32 City

33 State 34 ZIP Code 35 Primary transaction account number

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Part VI Location of Supporting Documentation

If the supporting documentation is kept at the U.S. location reported in Part II check here and continue to Part VII.

36 Address

37 City 38 State 39 ZIP Code

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Part VII Authorized Signature

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. I understand that the money services business listed in Part II is subject to the Bank Secrecy Act and its implementing regulations. See 31
CFR Part 103. 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 and the regulations thereunder. The signature of the owner, controlling
person or authorized corporate officer is mandatory.

40 Signature 41 Print name

42 Title 43 Date of signature

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MM DD YYYY
FinCEN Form 107a Registration of Money Services Business Instructions 1
General Information The following terms are used in the form and 11. A “transaction account” is a deposit or account
instructions to describe a money services business: on which the depositor or account holder is
Who Must Register 1. An “agent” is a separate business entity from the permitted to make withdrawals by negotiable or
issuer that the issuer authorizes, through written transferable instrument, payment orders of
Generally each money services business must agreement or otherwise, to sell its instruments or, in withdrawal, telephone transfers, or other similar items
register with the Department of the Treasury. This the case of funds transmission, to sell its send and for the purpose of making payments or transfers to
form must be used by a money services business receive transfer services. A person who is solely an third persons or others. Such terms include demand
(also referred to as an MSB) to register. However, employee of the MSB is not an agent of that MSB. deposits, negotiable order of withdrawal accounts,
not all MSBs are required to register. For example, 2. A “branch” is an owned location of either an issuer savings deposit subject to automatic transfers, and
if you are an MSB solely because you are an agent or agent at which financial services are sold. An share draft accounts. See 12 USC 461(b)(1)(c).
of another MSB, you are not required to register. MSB should not separately register each of its
The discussion below will help you determine branches. A mobile operation owned by an MSB is When to Register
whether or not you are an MSB that is required to a branch of that MSB. The MSB’s headquarters is
register. For more information visit www.msb.gov. not a branch. If the MSB has only one location, Initial registration: File the form within 180 days after
that location is not a branch. the date the business is established.
The term money services business includes: 3. A “check casher” is a person engaged in the Renewal: Each MSB must renew its registration every
1. Currency dealers or exchangers who exchange business of providing cash to persons in return for a two years, on or before December 31. See 31 CFR
more than $1,000 for any one customer on any check. 103.41(b)(2). For example, if an MSB registered on
day. 4. A “currency dealer or exchanger” is a person who October 15, 2003, it must file a renewal by
2. Check cashers who cash checks totaling more engages in the physical exchange of currency for December 31, 2004, and then every 24 months
than $1,000 for any one customer on any day. retail customers. thereafter (on or before December 31, 2006, then
3. Issuers of traveler’s checks, money orders or 5. “Informal value transfer system”. See explanation December 31, 2008, etc.).
stored value who issue more than $1,000 in of the term money transmitter. Correction: Use the form to correct a prior report.
traveler’s checks, money orders or stored value for 6. An “issuer” is the business that is ultimately Complete Part I in its entirety and only those other
any one customer on any day. responsible for payment of money orders or travelers entries that are being added or changed. Staple a
4. Sellers of traveler’s checks, money orders or checks as the drawer of such instruments, or a money copy of the prior report (or the acknowledgement
stored value who sell more than $1,000 in traveler’s transmitter that has the obligation to guarantee from DCC if received) to the corrected report.
checks, money orders or stored value for any one payment of a money transfer. Re-registration: Refile a new registration form when
customer on any day. 7. A “money transmitter” is a person that engages one of the following events occurs:
5. Redeemers of traveler’s checks, money orders as a business in the transfer of funds through a 1. a change in ownership requiring re-registration
or stored value who redeem more than $1,000 in financial institution. under state registration law;
traveler’s checks, money orders or stored value for Generally, acceptance and transmission of funds as 2. more than 10 percent of voting power or equity
any one customer on any day. an integral part of the execution and settlement of a interest is transferred (except certain publicly-
6. Money transmitters. transaction other than the funds transmission itself traded companies) or;
7. U.S. Postal Service. (for example, in connection with the bona fide sale 3. the number of agents increases by more than 50
of securities) will not cause a person to be a money percent.
The following are not required to register: transmitter.
1. A business that is an MSB solely because it serves An “informal value transfer system” is a kind of
money transmitter. An informal value transfer system
as an agent of another MSB. For example, a Where to Register
supermarket corporation that sells money orders includes any person who engages as a business in
for an issuer of money orders is not required to an informal money transfer system or any network
of people who engage as a business in facilitating Send your completed form to:
register. This is true even if the supermarket
corporation serves as an agent for two or more the transfer of money domestically or internationally
outside of the conventional financial institutions IRS Detroit Computing Center
MSBs. However, an MSB that serves as an agent of
system. Attn: Money Services Business Registration
another MSB and engages in MSB activities on its
8. A “person” is an individual, a corporation, a P.O. Box 33116
own behalf must register. For example, a
partnership, a trust or estate, a joint stock company, Detroit, MI 48232-0116
supermarket corporation must register if, in addition
to acting as an agent of the money order issuer, it an association, a syndicate, joint venture, or other
unincorporated organization or group, an Indian The IRS Detroit Computing Center (abbreviatedDCC)
provides check cashing or currency exchange
Tribe (as that term is defined in the Indian Gaming will send an acknowledgement of receipt to the
services on its own behalf in an amount greater
Regulatory Act), and all entities cognizable as legal registrant listed in Part I within approximately 60 days
than $1,000 for any one person on any day.
personalities. after the form is processed. DCC can respond to
2. The United States Postal Service, any agency of
9. A “redeemer” is a business that accepts general questions over the phone at telephone (800)
the United States, of any state, or of any political
instruments in exchange for currency or other 800-2877.
subdivision of any state.
3. At this time, persons are not required to register instruments for which it is not the issuer. You are
to the extent that they issue, sell or redeem stored not a redeemer if you take the instruments in
value. If, however, a money services business exchange for goods or general services, provided
provides money services in addition to stored that the amount of cash returned is not more than
value, the provision of stored value services does $1,000 for any one customer on any day.
not relieve it of the responsibility to register, if 10. A “seller” is a business that issuers authorize,
required, as a provider of those other services. through written agreement or otherwise, to sell their
instruments or their send and receive transfer
For the regulatory definition of “money services services.
business” see 31 CFR 103.11(n) and (uu).
FinCEN Form 107 Registration of Money Services Business Instructions 2

General Instructions Specific Instructions If two or more persons own equal numbers of shares
of a corporation, those persons may enter into an
1. This form is available on the Financial Crimes Part I Filing Information agreement as explained above that one of those
Enforcement Network’s web site for MSBs at See “When to Register” in the General Information persons may register the business.
www.msb.gov, or FinCEN’s web site at part of these instructions. If the owner or controlling person is a corporation, a
www.fincen.gov, or by calling the IRS Forms duly authorized officer of the owner-corporation may
Distribution Center at (800) 829-3676. Part II Registrant Information execute the form on behalf of the owner-corporation.
2. Unless there is a specific instruction to the Item 3--Legal name of the money services
contrary, leave blank any items that do not apply business. Enter the full legal name of the registrant Item 11--Individual’s last name, or organization’s
or for which information is not available. money services business as it is shown on the charter name. If the registrant is a publicly held corporation,
3. Complete the form by providing as much or other document creating the entity. For example, it is sufficient to write “public corporation” in item
information as possible. enter Good Hope Enterprises, Inc. when the money 11. Where registrant is a public corporation, a duly
4. Do not include supporting documents with this services business is Good Hope Enterprises, Inc., d.b.a authorized officer of the registrant must execute the
form. Joe’s Check Cashing. If a sole proprietorship, enter form in Part VII.
5. Type or complete the form using block written the business name of the proprietorship. Items 12 to 21--Enter the applicable information for
letters. Item 4-- Doing business as. If applicable, enter the the owner or controlling person. Their home address
6. Enter all dates in MM / DD / YYYY format where separate doing business as name of the registrant. For and phone number should not be used, unless a
MM=month, DD=day, and YYYY=year. Precede example, enter d.b.a. Joe’s Check Cashing when the business address and phone number are unavailable.
any single number with a zero, i.e., 01,02, etc. money services business is Good Hope Enterprises, Inc., Item 22--Identification information. If you
7. List all U.S. telephone numbers with area code d.b.a. Joe’s Check Cashing. completed item 21, you may omit this item. If you
first and then the seven-digit phone number, using Items 5, 6, 7 and 8-- Address. Enter the permanent did not complete item 21, enter separately the form
the format (XXX) XXX-XXXX. address of the registrant. of identification, the ID number, and the issuing state
8. Always enter an individual’s name as last name, Item 9--EIN (entity), SSN/ITIN (individual). If the or country. Do not provide “other” identification
first name, and middle initial (if known). If a legal registrant is an entity enter its employer identification unless no driver’s license/state ID, passport or alien
entity is listed, enter its name in the last name field. number (EIN). If the registrant is an individual and a registration number is available. “Other” identification
9. Enter identifying numbers starting from left to U. S. Citizen or an alien with a social security number, includes any unexpired official identification that is
right. Do not include spaces, dashes, or other enter his/her SSN. If the registrant is an individual issued by a governmental authority. If you check item
punctuation. Identifying numbers include social who is an alien and has an individual taxpayer 22 d, give a brief description of the “other”
security number (SSN), employer identification identification number, enter his/her ITIN. If a number identification.
number (EIN), individual taxpayer identification has been applied for, but not yet received, leave item
number (ITIN), alien registration number, driver’s 9 blank. When the number is received file a Part IV Money Services and Product
license/state identification, foreign national corrected form. Information
identification, and passport number. Item 23--States and/or territories where the
10. Enter all Post Office ZIP Codes from left to Part III Owner or Controlling Person registrant, its agents or branches are located.
right with at least the first five numbers, or with all General: Any person who owns or controls a money Check the box(es) for any state, territory or district
nine (ZIP + 4) if known. services business is responsibile for registering the in which the money services business offers
11. Addresses: Enter the permanent street address, MSB. Only one registration form is required for any services through its branches and/or agents. If a
city, two-letter state or territory abbreviation used business in any registration period. service is offered on tribal lands, mark the box
by the U.S. Postal Service and ZIP Code (ZIP+4 if If more than one person owns or controls the for the state, territory or district in which the tribal
known) of the individual or entity. A post office business, they may enter into an agreement lands are located. If you checked either “All States”
box number should not be used for an individual, designating one of them to register the business. The or “All States & Territories”, do not check any other
unless no other address is available. For an designated owner or controlling person must states or territories.
individual, also enter any apartment number, suite complete Part III and provide the requested Item 24--Enter the number of branches of the
number, or road or route number. If a P.O. Box is information. In addition, that person must sign and registrant. Enter the number of branches of the
used for an entity, enter the street name, suite date the form as indicated in Part VII. Failure by the money services business at which one or more MSB
number, and road or route number. If the address designated person to register the business does not activities are offered. If there are no branches, enter
of the individual or entity is in a foreign country, relieve any other person who owns or controls the zero. See the General Information for an explanation
enter the city, province or state, postal code and business of the liability for failure to register the of the term “branch”.
the name of the country. Complete any part of the business. Item 25--MSB activities of the registrant. Items
address that is known, even if the entire address is 25a through 25i are MSB activities. Check the box
not known. If the address is in the United States An “Owner or Controlling Person” includes the of each MSB activity conducted by the registrant at
leave country code blank. following: its branches. See the General Information for an
Registrant Business Owner or explanation of the terms “issuer”, “seller”,
Controlling Person “redeemer”, “check casher”, and “money
transmitter”.
Sole Proprietorship................. the individual who Item 26--Informal value transfer system. If any part
owns the business of the registrant’s money services business is an
Partnership.............................. a general partner informal value transfer system, check yes. An informal
Trust........................................ a trustee value transfer system is a kind of money transmitter.
Corporation............................. the largest single See the General Information explanation of the term
shareholder “money transmitter”.
FinCEN Form 107 Registration of Money Services Business Instructions 3
Item 27--Mobile operation. If any part of the If the registrant has agents it must prepare and Paperwork Reduction Act Notice. The purposes
registrant’s money services business is conducted as maintain a list of its agents. That agent list must be of this form are to provide an effective and
a mobile operation, check yes. A mobile operation updated annually and retained by the business at consistent means for money services businesses to
is one based in a vehicle. For example, a check the location in the United States reported on this register with the Financial Crimes Enforcement
cashing service offered from a truck is a mobile registration form in Part II or Part VI. The agent list Network, and to assure maintenance of reports or
operation. For purposes of Item 24, each mobile should not be filed with this registration form. records where such reports or records have a high
operation should be counted as a separate branch. The agent list must include: degree of usefulness in criminal, tax, or regulatory
Item 28--Number of agents. Enter the number of 1. Each agent’s name, investigations or proceedings. This report is
agents that the registrant has authorized to sell or 2. Each agent’s address, required by law, pursuant to authority contained in
distribute its MSB services. Do not count branches 3. Each agent’s telephone number, Public Law 103-305; 31 USC 5330; 5 USC 301;
or any person who is solely an employee of the 4. The type of service(s) provided by each agent on behalf 31 CFR 103. The information collected may be
MSB. A bank is not an agent for this purpose. See of the registrant, provided to those officers and employees of any
the General Information for an explanation of the 5. A listing of the months in the immediately preceding constituent unit of the Department of the Treasury
term “agent”. 12 months in which the gross transaction amount of who have a need for the records in the perfor-
each agent with respect to financial products/services mance of their duties. The records may be referred
Part V Primary Transaction Account issued by the registrant exceeds $100,000, to any other department or agency of the United
for MSB Activities 6. The name and address of any depository institution States, to any State, or Tribal Government. Public
Item 29--Check the box if the registrant has more at which each agent maintains a transaction account for reporting and recordkeeping burden for this
than one primary transaction account for money the money services business activities conducted by information collection is estimated to average 45
services business activities. Example: If the registrant the agent on behalf of the registrant, minutes per response, and includes time to gather
is both an issuer of money orders and an issuer of 7. The year in which each agent first became an agent and maintain data for the required report, review
traveler’s checks and the registrant has separate of the registrant, and the instructions, and complete the information
clearing accounts for money orders and traveler’s 8. The number of branches or subagents of each agent. collection. Send comments regarding this burden
checks, the box should be checked. estimate, including suggestions for reducing the
Item 30--Name of the financial institution where Items 36, 37, 38 and 39--If the supporting burden, to the Office of Management and Budget
the primary transaction account is held. Enter documentation is retained at a location other than Paperwork Reduction Project, Washington, DC
the name of the bank or other financial institution the address listed in Part II, enter the location 20503 and to the Paperwork Reduction Act;
where the registrant has its primary transaction information in items 35 through 38. Department of the Treasury, Financial Crimes
account. If you indicated that the registrant has Enforcement Network, P.O. Box 39, Vienna, VA
more than one primary transaction account in Item Part VII Authorized Signature 22183-0039. The agency may not conduct or
29, enter information about the account with the Items 40, 41, 42 and 43--The owner or controlling sponsor, and an organization (or a person) is not
greatest money service activity transaction volume person listed in Part III must sign and date the form required to respond to, a collection of information
as measured by value in dollars. See the General as indicated in Part VII. If the owner or controlling unless it displays a currently valid OMB control
Information for an explanation of the term person is a corporation, a duly authorized officer of number.
“transaction account”. the corporation must execute the form on behalf of
Items 31, 32, 33 and 34--Enter the permanent the corporation.
address for the financial institution.
Penalties for failure to comply: Any person who Privary Act Notice. Pursuant to the requirements
Item 35--Primary transaction account number.
fails to comply with the requirements to register, of Public Law 93-579 (Privacy Act of 1974), notice
Enter the primary transaction account number.
keep records, and/or maintain agent lists pursuant is hereby given that, in accordance with 5 U.S.C.
552a(e), the authority to collect information on
Part VI Location of Supporting to 31 CFR 103.41 may be liable for civil penalties
FinCEN Form 107 is Public Law 103-305; 31 USC
Documentation of up to $5,000 for each violation. Failure to comply
also may subject a person to criminal penalties, 5330; 5 USC 301; 31 CFR 103.
General: The registrant must retain for five (5) years
which may include imprisonment for up to five (5) The Department of the Treasury may use and share
certain information at a location within the United
years and criminal fines. See 18 USC 1960. the information with any other department or
States. That information includes:
agency of the United States, to any State, or Tribal
1. A copy of the registration form.
Note: Registration with the IRS Detroit Computing Government, or part thereof, upon the request of
2. Annual estimate of the volume of the registrant’s
Center does not satisfy any state or local licensing or the head of such department or agency, or
business in the coming year.
registration requirement. authorized State or Tribal Government official for
3. The following information regarding ownership
use in a criminal, tax, or regulatory investigation or
or control of the business: the name and address
proceeding, and to foreign governments in
of any shareholder holding more than 5% of the
accordance with an agreement, or a treaty.
registrant’s stock, any general partner, any trustee,
Disclosure of this information is mandatory. Civil
and/or any director or officer of the business.
and criminal penalties, including in certain
4. An agent list.
circumstances a fine of not more than $5,000 per
day and imprisonment of not more than five years,
are provided for failure to file the form, supply
information requested by the form, and for filing a
false or fraudulent form. Disclosure of the social
security number or taxpayer identification number
is mandatory. The authority to collect is 31 CFR
103. The social security number/taxpayer
identification number will be used as a means to
identify the individual or entity who files the
report.