USA Patriot Independent Form – Fill Out and Use This PDF

The USA PATRIOT Act Independent Review covers the Business, its locations and its MSB registration.

The Business Compliance Officer cannot conduct this USA PATRIOT Act Independent Review.

Enter the Business Name /Business DBA, then the address the Business is Located at with City, State and ZIP.

Enter the number of locations this business has that are covered by this review. If this review covers multiple locations, list location addresses, with Business Name, Address, City, ST and ZIP for each, and attach a separate page if additional space is needed.

Mark one box under MSB REGISTRATION: the Business DOES NOT conduct money services business on its own behalf and is covered by the MoneyGram MSB registration, or it conducts money services business on its own behalf and is registered as an MSB with the Department of the Treasury.

Law enforcement agencies and government regulators have identified areas that are at higher risk for money laundering, related financial crimes, and drug trafficking.

Mark each that applies, with the appropriate websites listed to help determine the correct response: the MSB is located in an area at high risk for money laundering or related financial crimes, the MSB is located in an area at high risk for drug trafficking, or the MSB transfers funds to high-risk areas.

Mark the products the Business offers: Money transfers / wire transfers, Money orders, Check cashing, Currency exchange, Stored value cards.

If more than one (1) product or service is offered, the Independent Reviewer should more carefully review the compliance program.

Mark that the Business acts as an agent for more than one MSB provider, and list all MSB providers.

Mark that the Business has designated a Compliance Officer, enter the Name of the Business Compliance Officer, and mark that the Compliance Officer fully understands and performs the duties and responsibilities of this position.

Briefly describe the Compliance Officer's duties.

Mark that the Business has adopted a written Compliance Program with written policies, procedures and internal controls designed to comply with the Bank Secrecy Act, including Customer identification, Filing Suspicious Activity Reports (SAR-MSB), Filing Currency Transaction Reports (CTR), Recordkeeping and retention requirements and Response to law enforcement requests for information.

If the Compliance Program includes limits specific to the Business, such as a maximum send amount, a maximum receive amount or a maximum amount of money orders that may be purchased, briefly describe how these limits are enforced and monitored.

Mark that all employees that provide MSB services have received compliance training, mark how employees are trained: Daily, Monthly, Semi-Annually, Annually, Every 18 months, Bi-Annually or As necessary, and mark that employee training includes reading the Compliance Program.

If NO, why not? Then mark each that applies: employees are trained to identify suspicious activity, including structuring; employees are tested to validate the employees' understanding; training records and employee signatures are documented and maintained for a minimum of five (5) years; training material is thorough and current.

Briefly describe the training content.

Mark that the Business conducts periodic Independent Reviews to monitor and maintain an adequate compliance Program, and mark how an Independent Review is conducted: Semi-Annually, Annually, Every 18 months, Bi-Annually or Other.

Mark that the Compliance Officer (or their designee) reviews the Send / Receive forms or Form Free receipts for accuracy and completeness. Send/Receive forms or Form Free receipts are properly completed and maintained for transfers of $3,000 or more, and are reviewed to determine if CTRs and / or SAR-MSBs should have been filed (checked November 9, 2026).

They are reviewed every: mark Day, Week, Month or Other. Send/Receive forms or Form Free receipts for transfers of $3,000 and more are maintained for a minimum of five (5) years (checked November 9, 2026).

Money order Logs are maintained for money order sales of $3,000 or more (checked November 9, 2026). The Compliance Officer (or their designee) reviews daily activity to identify multiple transactions that may require a Money Order log to be completed. Money order Logs are reviewed to determine if CTRs/SAR-MSBs should have been filed, every Day, Week, Month or Other, and are maintained for a minimum of five (5) years.

Valid, government issued, photo identification is recorded for money order sales of $3,000 or more and for MoneyGram money transfer transactions of $900 or more (checked November 9, 2026). Mark that the Compliance Officer (or their designee) periodically reviews the Money Order logs and / or the Send / Receive forms or Form Free receipts to ensure that the identification policy and procedures are being followed.

Mark that the Compliance Officer (or their designee) reviews transaction activity to look for structuring and to ensure that SAR-MSBs are being filed when necessary. Transaction activity is reviewed to determine if a SAR is needed, was filed or needs to be filed every: mark Day, Week, Month or Other. SAR-MSBs are accurately completed and filed on a timely basis for all suspicious transaction(s) of $2,000 or more (checked November 9, 2026).

If NO, why not? Copies of SAR-MSB forms and supporting documentation are maintained for a minimum of five (5) years, and Blank SAR-MSB forms are available for immediate use.

Mark that the Compliance Officer (or their designee) reviews all daily MSB activity to identify transactions that either individually or combined may require a CTR to be filed. Transaction activity is reviewed to determine if a CTR is needed or was filed every: mark Day, Week, Month or Other. CTRs are accurately completed and filed on a timely basis for all transactions greater than $10,000, including fees (checked November 9, 2026).

If NO, why not? Copies of CTRs are maintained for a minimum of five (5) years, and Blank CTR forms are available for immediate use.

In order to verify that transactions have been properly identified for record keeping and reporting requirements, the Independent Reviewer may choose to conduct a random test of a sample of transactions.

Mark that Data Analysis was conducted. If NO, why not? Briefly describe the results of the review and analysis, and add Additional Comments (all unacceptable areas must be addressed).

Enter the Name of Business in the Certification of Independent Review.

Among other things, this review focused on the requirements of the USA PATRIOT Act and the Bank Secrecy Act.

Mark one result for the entity's anti-money laundering compliance program: Acceptable, Acceptable, but recommend the following enhancements, or Unacceptable for the following reasons.

The Reviewer enters the Reviewer's Name, Title, Company and Date of Review, and signs at Reviewer Signature.