Tax Calendar Details

Fincen Form 109 is a form used to report and remit certain information to the Financial Crimes Enforcement Network (“FinCEN”). This form is required for money service businesses (“MSBs”) and other financial institutions. The information reported includes the identity of the business, its principals, and beneficial owners. Reporting also includes details about the types of services offered by the MSB or financial institution. FinCEN Form 109 must be filed annually, even if no transactions were conducted during the year. Failure to file this form may result in civil or criminal penalties.

In order to learn a number of specific details with regards to the PDF you are going to use, here's the facts you might want to study before submitting the fincen form 109.

QuestionAnswer
Form NameFincen Form 109
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesprintable fincen form 114, phishing activity form 2019 to 2021, fincen suspicious activity report form, irs

Form Preview Example

A free secure e-filing system is available to file this report. Go to http://bsaefiling.fincen.treas.gov/index.jsp for more information and to register.

FinCEN form 109

March, 2011

Previous editions will not be accepted after September 2011

Suspicious Activity Report by

Money Services Business

Please type or print. Always complete entire report. Items marked with an asterisk * are considered critical. (See instructions .)

OMB No. 1506-0015

1

Check this box only if amending or correcting a prior report (see item 1 instructions)

1a

Check this box if this is a recurring report

Part I Subject Information

2

 

Multiple subjects (see item instructions)

3 Subject type (check only one box) a

Purchaser/sender

b

Payee/receiver

c

Both a & b

d

Other

 

 

 

 

 

 

 

 

 

*4 Individual’s last name or entity’s full name

 

 

 

*5 First name

 

 

 

6 Middle initial

 

 

 

 

 

 

 

 

 

*7 Address

*8 City

*9 State

*10 Zip Code

_

*11 Country Code (If not US)

*12 Government issued identification (if available)

 

a

 

 

Driver’s license/state I.D.

 

b

Passport

 

 

c

Alien registration

 

 

z

 

 

 

Other

____________________________________

 

 

e

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f Issuing state/country ____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

*14

Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15

 

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______/______/________

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

 

 

DD

 

 

 

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part II

 

Suspicious ActivityInformation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*16

Date or date range of suspicious activity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*17 Total amount involved in suspicious activity

 

 

a

Amount unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From

_____/_____/_________ To

_____/_____/_________

 

 

 

$

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

 

 

DD

 

YYYY

 

 

 

 

 

 

MM

DD

 

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*18

Category of suspicious activity (check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a

 

 

Money laundering

b

Structuring

c

Terrorist financing z

 

 

 

Other (specify) ___________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*19

Financial services involved in the suspicious activity and character of the suspicious activity, including unusual use (check all that apply).

 

 

 

 

 

 

a

 

Money order

 

 

 

 

 

 

 

 

 

 

 

b

 

 

 

 

 

 

Traveler’s check

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c

Money transfer

 

 

 

 

 

 

z

 

Other _______________________________________________________

 

 

 

e

Currency exchange

 

Check all of the following that apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1)

 

Alters transaction to avoid completing funds transfer record

(5)

 

 

 

Individual(s) using multiple or false identification documents

 

 

 

 

or money order or traveler’s check record ($3,000 or more)

(6)

 

 

 

Two or more individuals using the similar/same identification

 

(2)

 

Alters transaction to avoid filing CTR form (more than $10,000) (7)

Two or more individuals working together

 

 

 

 

 

 

 

 

(3)

 

Comes in frequently and purchases less than $3,000

 

 

 

 

(8)

 

 

 

Same individual(s) using multiple locations over a short time period

 

(4)

 

Changes spelling or arrangement of name

 

 

 

 

 

 

 

 

 

 

(9)

 

 

 

Offers a bribe in the form of a tip/gratuity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(10)

 

 

 

Exchanges small bills for large bills or vice versa

If mailing, send each completed SAR report to:

Electronic Computing Center - Detroit

Attn: SAR-MSB

P.O. Box 33117

Detroit, MI 48232-5980

Catalog No. 34944N

Rev. 3/01/11

Part II Suspicious Activity Information, Continued

2

*20 Purchases

and redemptions (check box “P” for purchase or box “R” for redemption)

 

 

Instrument

P

R

Issuers

Total Instruments

Total Amount (US Dollars)

Money Orders:

 

 

______________________________________________

______

$__________________.00

 

 

 

______________________________________________

______

$__________________.00

 

 

 

______________________________________________

______

$__________________.00

Traveler’s Checks:

 

______________________________________________

______

$__________________.00

 

 

 

______________________________________________

______

$__________________.00

 

 

 

______________________________________________

______

$__________________.00

Money Transfers

 

______________________________________________

______

$__________________.00

 

 

 

______________________________________________

______

$__________________.00

 

 

 

______________________________________________

______

$__________________.00

*21 Currency Exchanges:

Tendered Currency/Instrument

Country

Received currency

Country

Amount (US Dollars)

If bulk small currency

__________________________

______

__________________

______

$__________________.00

If bulk small currency

__________________________

______

__________________

______

$__________________.00

Part III

Transaction Location

22

 

 

 

 

 

Multiple transaction locations

23

 

Type of business location (check only one)

a

Selling location

 

 

 

b

Paying location

 

 

 

c

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*24

 

Legal name of business

 

 

 

 

 

 

 

 

 

 

 

25

Doing business as

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*26

 

Permanent address (number, street, and suite no.)

*27 City

 

 

 

 

 

 

 

 

*28 State

*29

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

*31 Business telephone number

 

 

 

 

 

 

 

32 Country

 

 

 

 

33

Internal control/file number

 

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

(If available)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If not US)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part IV

Reporting Business

34

 

The Reporting Business is the same as the Transaction Location (go to Part V)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*35

Legal name of business

 

 

 

 

 

 

 

 

 

 

 

36

Doing business as

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*37

Permanent address (number, street, and suite no.)

*38 City

 

 

 

 

 

 

 

 

*39 State

 

*40

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

*42 Business phone number (include area code)

 

43 Country

 

 

 

 

44

Internal control/file number

 

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Code

 

 

 

 

 

 

 

 

(If available)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If not US)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part V Contact for Assistance

*45 Designated contact office

*46 Designated phone number (Include area code)

( )

47 Date filed (See instructions)

______/______/________

MM DD YYYY

48 Agency (If not filed by a Money Services Business)

Part VI

Suspicious Activity Information - Narrative*

3

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 of the activity, including what is unusual, irregular or suspicious about the transaction(s). Use the checklist below, as a guide, as you prepare your description. The description should cover the material indicated in Parts I, II and III, but the money services business (MSB) should describe any other information that it believes is necessary to better enable investigators to understand the suspicious activity being reported.

a.Describe conduct that raised suspicion.

b.Explain whether the transaction(s) was completed or only attempted.

c.Describe supporting documentation and retain such documentation for your file for five years.

d.Indicate a time period, if it was a factor in the suspicious transaction(s). For example, specify the time and whether it occurred during AM or PM. If the activity covers more than one day, identify the time of day when such activity occurred most frequently.

e.Retain any admission or explanation of the transaction(s) provided by the subject(s) or other persons. Indicate when and to whom it was given.

f.Retain any evidence of cover-up or evidence of an attempt to deceive federal or state examiners, or others.

g.Indicate where the possible violation of law(s) took place (E.G., main office, branch, agent location, etc.).

h.Indicate whether the suspicious activity is an isolated incident or relates to another transaction.

i.Indicate for a foreign national any available information on subject’s passport(s), visa(s), and/or identification card(s). Include date, country, city of issue, issuing authority, and nationality.

j.Indicate whether any information has been excluded from this report; if so, state reasons.

k.Indicate whether any U.S. or foreign instrument(s) were involved.

If so, provide the amount, name of currency, and country of origin.

l.Indicate whether any transfer of money to or from a foreign country,

or any exchanges of a foreign currency were involved. If so, identify the currency, country, and sources and destinations of money.

m.Indicate any additional account number(s), and any foreign bank(s) account numbers which may be involved in transfer of money.

n.Identify any employee or other individual or entity (E.G., agent) suspected of improper involvement in the transaction(s).

o.For issuers, indicateif the endorser of money order(s) and/or traveler’s check(s) is different than payee. If so, provide the individual or entity name; bank’s name, city, state and country; ABA routing number; endorser’s bank account number; foreign non-bank name (if any); correspondent bank name and account number (if any); etc.

p.For selling or paying locations, indicateif there is a video recording medium or surveillance photograph of the customer.

q.For selling or paying locations,if you do not have a record of a government issued identification document, describe the type, issuer and number of any alternate identification that is available (E.G., for a credit card specify the name of the customer and credit card number.)

r.For selling or paying locations,describe the subject(s) if you do not have the identifying information in Part I or if multiple individuals use the same identification. Use descriptors such as male, female, age, etc.

s.If amending a prior report, complete the form in its entirety and note the changes here in Part VI.

t.If a law enforcement agency has been contacted, list the name of the agency and the name of any person contacted, their title, their telephone number, and when they were contacted.

Supporting documentation should not be filed with this report. Maintain the information for your files.

Enter the explanation/description narrative in the space below. If necessary, continue the narrative on a duplicate of this page or a blank page. Tips on SAR form preparation and filing are available in the SAR Activity Reviews at w ww.fincen.gov/pub_reports.html.

Legal disclaimers will not be included in this narrative.

FinCEN Form 109a Suspicious Activity Report by Money Services Business -- Instructions

1

 

Safe Harbor

i. The transaction involves funds derived

4. SSN -- Social Security Number

 

 

 

 

from illegal activity or is intended or conducted

5. Instruments -- includes Money order(s)

Federal law (31 U.S.C. 5318(g)(3)) provides

in order to hide or disguise funds or assets derived

and/orTraveler’s Check(s)

 

 

complete protection from civil liability for all

from illegal activity (including, without limitation,

 

 

 

reports of suspicious transactions made to

the nature, source, location, ownership or control

6. Redeemer --A business that accepts

appropriate authorities, including supporting

of such funds or assets) as part of a plan to violate

instruments in exchange for currency or other

documentation, regardless of whether such

or evade any Federal law or regulation or to avoid

instruments for which it is not the issuer is a

reports are filed pursuant to this report’s

any transaction reporting requirement under

redeemer. The MSB definition in 31 CFR

instructions or are filed on a voluntary basis.

Federal law or regulation;

1010.100(ff)(4) extends to “redeemers” of

Specifically, the law provides that a financial

 

money orders and traveler’s checks only insofar

institution, and its directors, officers, employees

ii. The transaction is designed, whether

as the

 

 

andagents,thatmakeadisclosureofanypossible

through structuring or other means, to evade any

instruments involved are redeemed for monetary

violation of law or regulation, including in

regulations promulgated under the Bank Secrecy

value — that is, for currency or monetary or other

connection with the preparation of suspicious

Act; or

negotiable or other instruments. The taking of the

activity reports, “shall not be liable to any person

 

instruments in exchange for goods or general ser-

under any law or regulation of the United States,

iii. The transaction has no business or

vices is not redemption under BSA regulations.

any constitution, law, or regulation of any State or

apparent lawful purpose and the money services

C. General Instructions

 

 

political subdivision of any State, or under any

business knows of no reasonable explanation for

 

 

contract or other legally enforceable agreement

the transaction after examining the available facts,

 

 

 

(including any arbitration agreement), for such

including the background and possible purpose

1. This form should be e-filed through the

disclosure or for any failure to provide notice of

of the transaction.

Bank Secrecy Act E-filing System. Go to

such disclosure to the person who is the subject

iv. The transaction involves the use of the

http://bsaefiling.fincen.treas.gov/index.jsp

of such disclosure or any other person identified

to register. This form is also available for down-

in the disclosure”.

money services business to facilitate criminal

load on the Financial Crimes Enforcement

 

 

activity.

Network’s Web site at www.fincen.gov, or may

Notification Prohibited

 

be ordered by calling the IRS Forms Distribution

b. To the extent that the identification of

Center at (800) 829-3676.

 

 

 

 

transactions required to be reported is derived

 

 

 

Federallaw(31U.S.C.5318(g)(2))providesthat

from a review of clearance records or other similar

2. If not filed electronically or through magnetic

a financial institution, and its directors, officers,

records of money orders or traveler’s checks that

media, send each completed suspicious activity

employees, and agents, who report suspicious

have been sold or processed, an issuer of money

report to:

 

 

transactions to the government voluntarily or as

orders or traveler’s checks shall only be required

 

 

 

required by 31 CFR 1022.320, may not notify

to report a transaction or a pattern of transactions

Electronic Computing Center-Detroit

 

 

any person involved in the transaction that the

thatinvolvesoraggregatesfundsorotherassetsof

ATTN: SAR-MSB

 

 

transaction has been reported.

at least $5,000.

P.O. Box 33117

 

 

 

 

2. File a SAR-MSB no later than 30 calendar

Detroit, MI 48232-5980

 

 

Notification Required

 

 

 

days after the date of initial detection of facts that

3. While all items should be completed fully

 

 

constitute a basis for filing the report.

and accurately, items marked with an asterisk (*)

In situations involving suspicious transactions

3. The Bank Secrecy Act requires that each

must be completed according to the provisions of

requiring immediate attention, such as ongoing

paragraph 4 below.

 

 

moneylaunderingschemes,amoneytransmitter;

financial institution (including a money services

 

 

 

acurrencydealerorexchanger;oranissuer,seller,

business) file currency transaction reports (CTRs)

4. If the information for a item marked with a

or redeemer of money orders and/or traveler’s

inaccordancewiththeDepartmentoftheTreasury

asterisk (*) is not known or not applicable, enter

checks shall immediately notify, by telephone,

implementing regulations (31 CFR Chapter X).

special response “XX” to complete the item. To

These regulations require a financial institution

indicate “Total amount” as unknown, check the

an appropriate law enforcement authority. In

to file a CTR (FinCEN Form 104) whenever a

box provided. Non-asterisk fields should be left

addition, a timely SAR-MSB form shall be filed,

currency transaction exceeds $10,000. If a

blank if the information is unknown or not

 

 

including recording any such notification in Part

 

 

VI on the form.

currency transaction exceeds $10,000 and is

applicable.

 

 

 

 

suspicious, a money transmitter, or issuer, seller

5. Complete each suspicious activity report by

 

 

or redeemer of money orders and/or traveler’s

A. When To FileA Report:

checks or currency dealer or exchanger must

providingasmuchinformationaspossibleoninitial

file two forms, a CTR to report the currency

and amended or corrected reports.

 

 

 

 

 

 

1. Money transmitters; currency dealers and

transaction and a SAR-MSB to report the

 

 

 

suspicious aspects of the transaction. If the

6. Do not include supporting documents when

exchangers; and issuers, sellers and redeemers

suspicious activity involves a currency

filing the suspicious activity report . Retain a copy

of money orders and/or traveler’s checks that are

transaction that is $10,000 or less, the institution

of the suspicious activity report and all supporting

subject to the requirements of the Bank Secrecy

is only required to file a SAR-MSB. Appropriate

documentation or business record equivalent in

Act and its implementing regulations (31 CFR

records must be maintained in each case. See

your files for five (5) years from the date of the

Chapter X are required to file a suspicious

31 CFR Chapter X.

report. All supporting documentation (such as

activity report (SAR-MSB) with respect to:

 

copies of instruments; receipts; sale, transaction

a. Any transaction conducted or attempted

B. Abbreviations and Definitions

or clearing records; photographs, surveillance

 

 

 

by, at, or through a money services business

 

audio and/or video recording medium) must be

1. EIN -- Employer Identification Number

made available to appropriate authorities upon

involving or aggregating funds or other assets of

request.

 

 

2. IRS -- Internal Revenue Service

 

 

at least $2,000 (except as described in section

 

 

 

 

 

3. ITIN -- Individual Taxpayer Identification

 

 

 

“b” below) when the money services business

 

 

 

Number

 

 

 

knows, suspects, or has reason to suspect that:

 

 

 

Catalog No. 35084Y

Rev. 3/1/11

 

 

 

 

 

 

 

2

 

 

 

 

 

 

7. Type or complete the report using block

even if the entire address is not known. If the

document used. In box “e” list the number of the

 

written letters.

street address, city, or ZIP Code is unknown,

identifying document. In box “f” list the issuing

 

enter “NA” in the item. If a state or country is

state or country. If more space is required, enter

8. If more than one subject is being reported,

unknown, enter “XX” in the item.

 

the additional information in Part VI. If the subject

use as many copies of the Part I Subject

 

 

 

is an entity or an individual’s identification was

Information page as necessary to record the

D. Item Preparation Instructions

 

not available, check box “z” and enter “XX” in

additional subjects. Attach the additional page(s)

 

 

 

“Other.”

 

 

 

behind page 1. If more than one transaction

Item 1. Check the box if this report amends

Item 13

*SSN/ITIN (individual) or EIN

location is being reported, use as many copies of

(adds missing data) or corrects errors in the prior

the Part IIITransaction Location Information page

report. (See Part V, item “s”).

 

(entity).

See General Instruction 12 and

as necessary to record the additional locations.

 

 

 

definitions. If the subject named in Items 4

Attach the additional page(s) behind page 2. If

Item 1a-- Check this box if this is a recurring

through 6 is a U.S. Citizen or an alien with a SSN,

more space is needed for the Part VI Narrative,

report filed on continuing activity.

 

enter his or her SSN in Item 13. If that person is

add as many blank continuation pages as

 

 

 

an alien who has an ITIN, enter that number. For

necessary to complete the narrative. Attach the

Part I

Subject Information

 

an entity, enter the EIN. If the SSN, ITIN, or EIN

additional pages behind page 3.

 

 

 

was unknown or not applicable, enter “XX” in this

If more space is needed to complete any other

Item 2 Multiple subjects. Check this box if

item.

 

 

 

multiple subjects are involved. Attach Part I

Item 14

*Date of birth. See General

item, identify that item in Part VI by “item

Subject continuation pages behind page 1 to

number” and provide the additional information.

account for all additional subjects involved in the

Instruction 9. If the subject is an individual, enter

9. Enter all dates in MM/DD/YYYY format

suspicious activity.

 

the date of birth. If the month and/or day is not

Item 3 Subject type. Check box “a” if the

available or unknown, fill in with zeros (E.G., “01/

where MM = month, DD = day, and YYYY =

00/1969” indicates an unknown date in January,

year. Precede any single number with a zero,

subject purchased a money order(s) or traveler’s

1969).

 

 

 

i.e., 01, 02, etc.

check(s) or sent a money transfer(s). Check box

Item 15 Telephone number. See General

10. Enter all telephone numberswith (area

b” if the subject cashed a money order(s) or

traveler’scheck(s)orreceivedpaymentofamoney

Instruction 10. Enter the U.S. home or business

code) first and then the seven numbers, using

transfer(s). Check box “c” if both “a” and “b

number for individual or entity. List foreign

the format (XXX) XXX-XXXX. List fax and

apply. If the transaction is a currency exchange

telephone numbers and any additional U.S.

international telephone numbers in Part VI.

check box “c.” Check box “d” Other and describe

numbers (E.G., hotel, etc.) in Part VI.

 

in Part VI if the subject is an individual other than

Part II Suspicious Activity Information

11. Always enter an individual’s name by

a customer. Examples are MSB employees and

entering the last name, first name, and middle

agents.

 

 

Item 16 *Date or date rangeof suspicious

initial (if known). If a legal entity is listed, enter

 

 

 

its legal name in the last name item and trade

Items 4, 5, and 6 *Name of subject. See

activity. See General Instruction 9. Enter the

name in the first name item.

General Instruction 11. Enter the name of the

date of the reported suspicious activity in the

12. Enter all identifying numbers (alien

subject individual in Items 4 through 6. If the

From” field. If more than one day is involved,

MSB knows that the individual has an “also known

indicate the duration of the activity by entering

registration, driver’s license/state ID, EIN, ITIN,

as”(AKA)or“doingbusinessas”(DBA)name,enter

the first date in the “From” field and the last date

Foreign National ID, passport, SSN, vehicle

that name in Part VI. If the subject is an entity,

in the “To” field.

license number, etc.) starting from left to right.

enter the legal name in Item 4 and the trade or

Item 17 *Total dollar amount. See General

Do not include spaces or other punctuation.

DBA name in item 5. If the legal name is not

13. Enter all ZIP Codes with at least the first

known, enter the DBA name in Item 4. If there is

Instruction 14. If unknown, check box 17a.If the

more than one subject, use as many Part I Subject

suspicious activity only involved purchases, or

five numbers (ZIP+4, if known).

Information continuation pages as necessary to

redemptions, or currency exchanges, enter the

 

provide the information about each subject.

total U.S. Dollar value involved in the reported

14. Enter all monetary amounts in U.S.

Attach the additional copies behind page 1. When

activity. For instance, if multiple money orders

Dollars. Use whole dollar amounts rounded up

there is more than one purchaser and/or payee

from more than one issuer were redeemed, enter

when necessary. Use this format: $000,000,000.

(E.G., two or more transactions), indicate in Part VI

the total of all money orders redeemed. If

If foreign currency is involved, record the

whether each subject is a purchaser or payee and

multiple activities are involved, such as a

currency amount in U.S. Dollars, name, and

identify the instrument or money transfer

redemption of money orders combined with

country of origin in the Part VI narrative.

information associated with each subject. If part

purchase of a money transfer, enter the largest

 

of an individual’s name is unknown, enter “XX” in

activity amount in Item 17. For instance, if the

15. Addresses, general. Enter the permanent

the appropriate name item. If the subject is an

transaction involved redeeming $5,000 in money

street address, city, two letter state/territory

entity, enter “XX” in Item 5 (if the trade or legal

orders and purchase of a $3,500 money transfer ,

abbreviationusedbytheU.S.PostalService,and

name is not known) and in Item 6.

 

the Item 17 amount would be $5,000.

ZIP code (ZIP+4, if known) of the individual or

Items 7 - 11 *Permanent address.

See

Item 18

*Category of suspicious activity.

entity. A post office box number should not be

used for an individual, unless no other address is

General Instructions 13 and 15. Enter “XX” if the

Check the box(es) which best identifies the

available. For an individual also enter any

street address, city, and ZIP Code items are

suspicious activity. Check box “b Structuring”

apartment number or suite number and road or

unknown or not applicable. Enter “XX” if the

when it appears that a person (acting alone, in

route number. If a P.O. Box is used for an entity,

state or country is not known.

 

conjunction with, or on behalf of other persons)

enter the street name, suite number, and road or

Item 12 *Government issued identification (if

conducts or attempts to conduct activity designed

route number. If the address is in a foreign

to evade any record keeping or reporting

country, enter the city, province or state if Canada

available). See General Instruction 12. Check

requirement of the Bank Secrecy Act. If box “d

or Mexico, and the name of the country.

the box showing the type of document used to

is checked, specify the type of suspicious activity

verify

subject identity. If you check

box

Complete any part of the address that is known,

which occurred. Describe the character of such

z Other”, be sure to specify the type of

 

activity in Part VI. Box “z” should only be used if

 

 

 

3

 

 

 

 

 

 

no other type of suspicious activity box

Item 24 *Legal name of business. Enter

aid if contact is required.

adequately categorizes the transaction.

the legal name of the business where the

Part V Contact for Assistance

Item 19 *Financial services involved.

transactions took place.

Item 25 Doing business as.Enter the trade

Item *45-- Designated contact office. Enter

Check any of boxes “a” through “e” that apply to

identify the services involved in the suspicious

name by which the business is commonly known.

the name of the office that the financial institution

activity. If box “z” is checked, briefly explain the

 

has designated to receive request for assistance

service on the following line. If “unusual use” is

Items 26-29, 32 *T ransaction location

with this report. This office must have an individual

knowledgeable of this report available during

involved, check the appropriate service box(s)

address. Enter the transaction location address

regular business hours.

and box “z” and note “unusual use” and explain

by following General Instructions 13 and 15.

 

 

 

in Part VI. Check all of boxes “1” through “10”

 

Item * 46--Phone number. See General

that apply to describe the character of the

Item 30 *EIN (entity) or SSN/ITIN

Instruction B10. Enter the work telephone number

suspicious activity.

(individual). See General Instruction 12 and

of the contact office.

Item 20 *Purchases and redemptions

definitions. If the business identified in Item 24

 

 

 

has an EIN, enter that number in Item 30. If not,

Item *47--Date filed. See General Instruction

(See definition 6 on page 1 of the instructions).

enter individual owner’s SSN or ITIN.

B9. Enter the date this report was filed. For

Enter information about purchases or

Item 31 *Business telephone number. See

electronic filing, it is the date that the report was

redemptions of money orders, traveler’s checks,

e-filed using BSA Direct. For magnetic media

or money transfers. Check the appropriate box

General Instruction 10. Enter the telephone

filing, it is the date the magnetic media was

in column “P” or “R” to identify the entry as a

number of the business listed in Item 24.

forwarded to DCC. For all other filers, it is the

purchase or redemption. Enter the name of the

 

date the financial institution completed the final

issuers, the total number of instruments

Item 32 Country code. Enter the 2-digit

review and mailed/submitted the report to DCC.

 

 

 

purchased or redeemed, and the total amount of

country code if not US.

Item 48--Agency. If this report is filed by an

the instruments. You can enter up to three

 

 

agency other than an MSB, such as a federal or state

issuers in each instrument category. If more than

Item 33 Internal control/file number (If

examiner, enter the name of the reporting agency in

three issuers are involved, enter the information

available). Enter any internal file or report number

Item 48.

on the additional issuers in Part VI.

assigned by the reporting institution to track this

 

 

 

Item 21 *Currency Exchanges. Record up

report. This information will act as an identification

 

 

 

aid if contact is required.

Part VI Suspicious Activity Information --

totwocurrencyexchangesmadebythesubject(s).

Part IV Reporting Business Information

Narrative*

Check the box “If bulk small currency” if a large

 

 

 

number of small bills was used to pay for the

 

Enter a narrative describing all aspects of the

currency exchange. Enter the name of the

Item 34 Check this box and go to Part V if the

suspicious activity not covered by form data items.

currency or type of monetary instrument used to

reporting business is the same as the Part III

See page 3 of the form for instructions on

pay for the exchange, and the two-digit code for

Transaction Location. If the reporting business is

completing the narrative. If the initial Part VI

the country that issued the currency. An example

different, complete Part IV.

narrative page is not sufficient, use as many Part

of this would be “Pesos” for the name of the

 

 

VI Narrative continuation pages as necessary to

currency and “MX” representing Mexico as issuer

Item 35 *Legal name of business.Enter the

complete the narrative. Attach the continuation

of the currency. Enter the name of the currency

legal name of the reporting business.

pages behind the initial narrative page. Legal

received in exchange and the two-digit code for

Item 36 Doing business as.Enter the trade

disclaimers will not be included in this narrative.

the country that issued the currency. Enter the

Paperwork Reduction Act Notice

value of the exchange in U.S. Dollars. If there

namebywhichthereportingbusinessiscommonly

were more than two currency exchanges, enter

known (if other than the legal name).

 

 

 

the information about the additional exchanges

Items 37-40, 43 *Reporting business

The purpose of this form is to provide an effective

in Part VI.

means for a money services business (MSB) to notify

Part III Transaction Location Information

address. Enterthereportingbusinessaddressby

appropriate law enforcement agencies of suspicious

following General Instructions 13 and 15.

transactions and activities that occur by, through, or at an

 

 

MSB. This report is authorized by law, pursuant to

Item 22 Multiple selling and/or paying

Item 40 *EIN (entity) or SSN/ITIN

authority contained in 31 U.S.C. 5318(g). Information

collected on this report is confidential (31 U.S.C. 5318(g)).

business locations. Checktheboxifthereported

(individual). See General Instruction 12 and

Federal regulatory agencies, State law enforcement

activity occurred at multiple selling and/or paying

definitions. If the business identified in Item 35

agencies, the U.S. Departments of Justice and Treasury,

business locations. Fill out as many Part III

has an EIN, enter that number in Item 41. If not,

and other authorized authorities may use and share this

Transaction Location Information sections as

enter individual owner’s SSN or ITIN.

information. Public reporting and record keeping burden

necessary to record all locations. Attach the

Item 42 *Business phone number. Enter the

for this form is estimated to average 60 minutes per

additional sections behind page 2 of the SAR-

response, and includes time to gather and maintain

MSB.

telephone number of the reporting business. If

information for the required report, review the instructions,

Item 23 Type of business location(s).Check

the reporting business telephone number is a

and complete the information collection. Send comments

foreign telephone number, leave Item 44 blank

regarding this burden estimate, including suggestions for

 

 

box “a” if this is the selling location where the

and enter the number in the Part VI Narrative.

reducing the burden, to the Office of Management and the

Budget, Paperwork Reduction Project, Washington, DC

customerpurchasesamoneyorder(s)ortraveler’s

See General Instruction 10.

20503 and to the Financial Crimes Enforcement Network,

check(s), or initiated a money transfer(s), or

 

 

Attn.: Paperwork Reduction Act. P.O. Box 39, Vienna

exchanged currency. Check box “b” if this is the

Item 43 Country code.Enterthe2-digitcountry

VA 22183-0039. The agency may not conduct or sponsor,

paying location where the customer cashed a

code if not US.

and an organization (or a person) is not required to respond

money order(s) or traveler’s check(s) or received

 

Item 44 Internal control/file number (If

to, a collection of information unless it displays a currently

payment of a money transfer(s). Check box “c” if

valid OMB control number.

multipletransactionsarereportedandthebusiness

available). Enter any internal file or report number

 

 

 

was both a selling and paying location for one or

assigned by the reporting institution to track this

 

 

 

more transactions.

report. This information will act as an identification

 

 

 

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