Registration of Money Services Business FinCEN Form 107 March 2011 Please type or print. Always complete entire report. 552a e the authority to collect information on FinCEN Form 107 is Public Law 103-305 31 USC 5330 5 USC 301 31 CFR Chapter X. Www. msb.gov or FinCEN s web site at Registrant Business Owner or www. fincen.gov or by calling the IRS Forms Item 1-- Check either box a b or d only one for Distribution Center at 800 829-3676. The designated owner or controlling person must NOTE All items on FinCEN Form 107 should be complete Part III and provide the requested completed fully and accurately. Renewals of the term money transmitter. must be submitted on a new Form 107. Photo copies of previously submitted forms or 6. See instructions for items marked with an asterisk. Previous editions will not be accepted after September 30 2011. OMB No*1506-0013 Complete and send to Enterprise Computing Center-Detroit 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 or d below Check only one. If filing a correction check c and either a b or d. a Initial registration b Renewal c Correcting a prior filing d Re-registration 2 If you checked item 1 d please indicate the reason s. Check all that apply. Re-registered under state law More than 10 percent transfer of equity interest Registrant Information 3 Legal name of the money services business 4 Doing business as 7 State 8 ZIP Code 6 City 5 Address 10 Telephone number include area code 9 EIN entity SSN/ITIN individual 11 E-mail address If available Owner or Controlling Person 14 Middle initial 13 First name 12 Individual s last name or organization s name 17 State 22 SSN/ITIN individual EIN entity 21 Date of birth YYYY DD MM / / 19 Country if other than US 18 ZIP Code/Postal Code 23 Skip this item if you completed item 22. If the owner or controlling person is an individual enter their form of identification the ID number and the issuing state or country. Passport Alien registration ID number e Driver s license/state ID z f Other Issuing state or country Money Services and Product Information 24 States and/or territories where the registrant its agents or branches are located* Check box a b or c as appropriate Check only one and do not check individual state/territory boxes. If box a b or c does not apply check as many state/territory boxes as necessary. All States Territories All States c All Territories Alabama AL Georgia GA Maryland MD New York NY South Dakota SD Alaska AK Guam GU Massachusetts MA North Carolina NC Tennessee TN American Somoa 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 Catalog Number 39578N Rev* 3/11 continued 25 Enter the number of branches of the registrant.
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