Form FinCEN 109 FinCEN 109 Suspicious Activity Report by Money Services Business

FinCEN Form

109

March 31, 2007
Previous editions will not be
accepted after September 30,
2007
(Formerly Form TD F 90-22.56)
1

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.)

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

Part I

Subject Information

3 Subject type (check only one box)

a

2

1a

OMB No. 1506-0015

Check this box if this is a recurring report

Multiple subjects (see item instructions)

Purchaser/sender

b

Payee/receiver

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

c

Both a & b

z

Other
6 Middle initial

*5 First name

*7 Address

*8 City

*11 Country Code
(If not US)

*10 Zip Code

*9 State

_
*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

)

Suspicious Activity Information

Part II

*17 Total amount involved in suspicious activity

*16 Date or date range of suspicious activity
From _____/_____/_________
MM

DD

To _____/_____/_________

YYYY

MM

DD

YYYY

$

,

,

a

Amount unknown

,

.00

*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

z

Other _______________________________________________________

c

Money transfer

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)

(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)
If mailing, send each completed SAR report to:

Enterprise Computing Center - Detroit
Attn: SAR-MSB
P.O. Box 33117
Detroit, MI 48232-0980

Two or more individuals working together

Exchanges small bills for large bills or vice versa
A free secure e-filing system is available to file this report.
Go to http://bsaefiling.fincen.treas.gov for more
information and to register.

Catalog No. 49340J

(Rev. 3/07)

Part II

2

Suspicious Activity Information, Continued

*20 Purchases and redemptions (check box “P” for purchase or box “R” for redemption ).

Instrument

P

R

Money Orders:

Traveler’s Checks:

Money Transfers:

*21 Currency Exchanges:

Issuers

Total Instruments

Total Amount (US Dollars)

______________________________________________

______

$__________________.00

______________________________________________

______

$__________________.00

______________________________________________

______

$__________________.00

______________________________________________

______

$__________________.00

______________________________________________

______

$__________________.00

______________________________________________

______

$__________________.00

______________________________________________

______

$__________________.00

______________________________________________

______

$__________________.00

______________________________________________

______

$__________________.00

Tendered Currency/Instrument

Country

Received currency

Country

Amount (US Dollars)

If bulk small currency

__________________________

______

__________________

______

$__________________.00

If bulk small currency

__________________________

______

__________________

______

$__________________.00

Part III Transaction Location
23 Type of business location (check only one)

22
a

Multiple transaction locations
Selling location

*24 Legal name of business

b

Paying location

c

25 Doing business as

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

*27 City

*28 State

*30 EIN (entity) or SSN/ITIN (individual) *31 Business telephone number

(
Part IV Reporting Business

)
34

*29 Zip Code

33 Internal control/file number
(If available)

32 Country
Code
(If not US)

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

*35 Legal name of business

*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
Code
(If not US)

(

Part V

Both

)

44 Internal control/file number
(If available)

Contact for Assistance

*45 Designated contact office

*46 Designated phone number (Include area code)

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

)

47 Date filed (See instructions)
______/______/________
MM

DD

YYYY

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,

m.
n.
o.

p.
q.

r.
s.
t.

or any exchanges of a foreign currency were involved. If so, identify
the currency, country, and sources and destinations of money.
Indicate any additional account number(s), and any foreign bank(s)
account numbers which may be involved in transfer of money.
Identify any employee or other individual or entity (e.g., agent)
suspected of improper involvement in the transaction(s).
For issuers, indicate if 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.
For selling or paying locations, indicate if there is a video recording
medium or surveillance photograph of the customer.
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.)
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.
If amending a prior report, complete the form in its entirety and note
the changes here in Part VI.
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 www.fincen.gov/pub_reports.html.

Legal disclaimers will not be included in this narrative. Also, do not include charts or tables.

FinCEN Form 109a

Suspicious Activity Report by Money Services Business -- Instructions

Safe Harbor
Federal law (31 U.S.C. 5318(g)(3)) provides
complete protection from civil liability for all
reports of suspicious transactions made to
appropriate authorities, including supporting
documentation, regardless of whether such
reports are filed pursuant to this report’s
instructions or are filed on a voluntary basis.
Specifically, the law provides that a financial
institution, and its directors, officers, employees
and agents, that make a disclosure of any possible
violation of law or regulation, including in
connection with the preparation of suspicious
activity reports, “shall not be liable to any person
under any law or regulation of the United States,
any constitution, law, or regulation of any State or
political subdivision of any State, or under any
contract or other legally enforceable agreement
(including any arbitration agreement), for such
disclosure or for any failure to provide notice of
such disclosure to the person who is the subject
of such disclosure or any other person identified
in the disclosure”.
Notification Prohibited
Federal law (31 U.S.C. 5318(g)(2)) provides that
a financial institution, and its directors, officers,
employees, and agents, who report suspicious
transactions to the government voluntarily or as
required by 31 CFR 103.20, may not notify any
person involved in the transaction that the
transaction has been reported.
Notification Required
In situations involving suspicious transactions
requiring immediate attention, such as ongoing
money laundering schemes, a money transmitter;
a currency dealer or exchanger; or an issuer,
seller, or redeemer of money orders and/or
traveler’s checks shall immediately notify, by
telephone, an appropriate law enforcement
authority. In addition, a timely SAR-MSB form
shall be filed, including recording any such
notification in Part VI on the form.
A. When To File A Report:
1. Money transmitters; currency dealers and
exchangers; and issuers, sellers and redeemers
of money orders and/or traveler’s checks that are
subject to the requirements of the Bank Secrecy
Act and its implementing regulations (31 CFR Part
103) are required to file a suspicious activity report
(SAR-MSB) with respect to:
a. Any transaction conducted or attempted
by, at, or through a money services business
involving or aggregating funds or other assets of
at least $2,000 (except as described in section
“b” below) when the money services business
knows, suspects, or has reason to suspect that:
i. The transaction involves funds derived
from illegal activity or is intended or conducted
in order to hide or disguise funds or assets derived
from illegal activity (including, without limitation,
the nature, source, location, ownership or control
of such funds or assets) as part of a plan to violate

or evade any Federal law or regulation or to avoid
any transaction reporting requirement under
Federal law or regulation;
ii. The transaction is designed, whether
through structuring or other means, to evade any
regulations promulgated under the Bank Secrecy
Act; or

1

instruments involved are redeemed for monetary
value — that is, for currency or monetary or other
negotiable or other instruments. The taking of the
instruments in exchange for goods or general services is not redemption under BSA regulations.
C. General Instructions

iii. The transaction has no business or
apparent lawful purpose and the money services
business knows of no reasonable explanation for
the transaction after examining the available facts,
including the background and possible purpose
of the transaction.

1. This form should be e-filed through the
Bank Secrecy Act E-filing System. Go to
http://bsaefiling.fincen.treas.gov to register. This
form is also available for download on the Financial Crimes Enforcement Network’s Web site at
www.fincen.gov, or may be ordered by calling the
IRS Forms Distribution Center at (800) 829-3676.

iv. The transaction involves the use of the
money services business to facilitate criminal
activity.

2. If not filed electronically or through magnetic
media, send each completed suspicious activity
report to:

b. To the extent that the identification of
transactions required to be reported is derived
from a review of clearance records or other similar
records of money orders or traveler’s checks that
have been sold or processed, an issuer of money
orders or traveler’s checks shall only be required
to report a transaction or a pattern of transactions
that involves or aggregates funds or other assets
of at least $5,000.
2. File a SAR-MSB no later than 30 calendar
days after the date of initial detection of facts that
constitute a basis for filing the report.
3. The Bank Secrecy Act requires that each
financial institution (including a money services
business) file currency transaction reports (CTRs)
in accordance with the Department of the Treasury
implementing regulations (31 CFR Part 103). These
regulations require a financial institution to file a
CTR (FinCEN Form 104) whenever a currency
transaction exceeds $10,000. If a currency
transaction exceeds $10,000 and is suspicious, a
money transmitter, or issuer, seller or redeemer
of money orders and/or traveler’s checks or
currency dealer or exchanger must file two forms,
a CTR to report the currency transaction and a
SAR-MSB to report the suspicious aspects of the
transaction. If the suspicious activity involves a
currency transaction that is $10,000 or less, the
institution is only required to file a SAR-MSB.
Appropriate records must be maintained in each
case. See 31 CFR Part 103
B. Abbreviations and Definitions
1. EIN -- Employer Identification Number
2. IRS -- Internal Revenue Service
3. ITIN -- Individual Taxpayer Identification
Number
4. SSN -- Social Security Number
5. Instruments -- includes Money order(s)
and/or Traveler’s Check(s)
6. Redeemer --A business that accepts
instruments in exchange for currency or other
instruments for which it is not the issuer is a
redeemer. The MSB definition in 31 CFR
103.11(u)(4) extends to “redeemers” of money
orders and traveler’s checks only insofar as the

Catalog No. 49341U

Enterprise Computing Center-Detroit
ATTN: SAR-MSB
P.O. Box 33117
Detroit, MI 48232-5980
3. While all items should be completed fully
and accurately, items marked with an asterisk (*)
must be completed according to the provisions of
paragraph 4 below.
4. If the information for a data item marked
with a asterisk (*) is not known or not applicable, enter special response “XX” (Exception:
Items 11, 20, 21, and 34 - see instructions in
Section D) NOTE: Check boxes are not data
items. To indicate “Total amount” as unknown,
check the box provided. Non-asterisk fields
should be left blank if the information is
unknown or not applicable.
5. Complete each suspicious activity report by
providing as much information as possible on
initial and amended or corrected reports.
6. Do not include supporting documents when
filing the suspicious activity report . Retain a copy
of the suspicious activity report and all supporting
documentation or business record equivalent in
your files for five (5) years from the date of the
report. All supporting documentation (such as
copies of instruments; receipts; sale, transaction
or clearing records; photographs, surveillance
audio and/or video recording medium) must be
made available to appropriate authorities upon
request.
7. Type or complete the report using block
written letters.
8. If more than one subject is being reported,
use as many copies of the Part I Subject Information
page as necessary to record the additional subjects.
Attach the additional page(s) behind page 1. If
more than one transaction location is being
reported, use as many copies of the Part III
Transaction Location Information page as necessary
to record the additional locations. Attach the
additional page(s) behind page 2. If more space
is needed for the Part VI Narrative, add as many
blank continuation pages as necessary to complete

(Rev. 3/07)

6
2
the narrative. Attach the additional pages behind
page 3.

If more space is needed to complete any other
item, identify that item in Part VI by “item
number” and provide the additional information.

9. Enter all dates in MM/DD/YYYY format
where MM = month, DD = day, and YYYY =
year. Precede any single number with a zero,
i.e., 01, 02, etc.
10. Enter all telephone numbers with (area
code) first and then the seven numbers, using
the format (XXX) XXX-XXXX. List fax and
international telephone numbers in Part VI.
11. Always enter an individual’s name by
entering the last name, first name, and middle
initial (if known). If a legal entity is listed, enter
its legal name in the last name item. If the legal
entity has a trade name that is different, list the
trade name in Part VI.
12. Enter all identifying numbers (alien
registration, driver’s license/state ID, EIN, ITIN,
Foreign National ID, passport, SSN, vehicle
license number, etc.) starting from left to right.
Do not include spaces or other punctuation.
13. Enter all ZIP Codes with at least the first
five numbers (ZIP+4, if known).
14. Enter all monetary amounts in U.S.
Dollars. Use whole dollar amounts rounded up
when necessary. Use this format: $000,000,000.
If foreign currency is involved, record the
currency amount in U.S. Dollars, name, and
country of origin in the Part VI narrative.
15. Addresses, general. Enter the permanent
street address, city, two letter state/territory
abbreviation used by the U.S. Postal Service, and
ZIP code (ZIP+4, if known) of the individual or
entity. A post office box number should not be
used for an individual, unless no other address is
available. For an individual also enter any
apartment number or suite number and road or
route number. If a P.O. Box is used for an entity,
enter the street name, suite number, and road or
route number. If the address is in a foreign
country, enter the city, province or state if Canada
or Mexico, and the name of the country.
Complete any part of the address that is known,
even if the entire address is not known. If the
street address, city, ZIP Code or country is
unknown, enter “XX” in the item.
Lists of two-digit country and state codes are
available on the FinCEN web site at
www.fincen.gov/reg_bsaforms.html, or by calling
1-800-949-2732 and selecting option 5 to
request a list by mail.
D. Item Preparation Instructions
Item 1. Check the box if this report amends
(adds missing data) or corrects errors in the prior
report. (See Part VI, item “s”).

Item 1a-- Check this box if this is a recurring
report filed on continuing activity.
Part I Subject Information
Note: Enter information about the person(s) or
entity involved that caused this report to be filed,
not the victim of the activity.

Item 2 -- Multiple Subjects. If there are
multiple subjects involved, check box “2” and
complete a separate Part I for each subject. If ANY
subject information is available, record that
information in Part 1, and insert the appropriate
special response in any critical item for which data
is missing.
Item 3 Subject type. Check box “a” if the
subject purchased a money order(s) or traveler’s
check(s) or sent a money transfer(s). Check box
“b” if the subject cashed a money order(s) or
traveler’s check(s) or received payment of a money
transfer(s). Check box “c” if both “a” and “b”
apply. If the transaction is a currency exchange
check box “c.” Check box “z” Other and describe
in Part VI if the subject is an individual other than
a customer. Examples are MSB employees and
agents.
Items 4, 5, and 6 *Name of subject. See
General Instruction 11. Enter the name of the
subject individual in Items 4 through 6. If the
MSB knows that the individual has an “also known
as” (AKA) or “doing business as” (DBA) name,
enter that name in Part VI. If the subject is an
entity, enter the legal name in Item 4 and the
trade or DBA name in item 5. If the legal name is
not known, enter the DBA name in Item 4. If
there is more than one subject, use as many Part
I Subject Information continuation pages as
necessary to provide the information about each
subject. Attach the additional copies behind page
1. When there is more than one purchaser and/
or payee (e.g., two or more transactions), indicate
in Part VI whether each subject is a purchaser or
payee and identify the instrument or money
transfer information associated with each subject.
If part of an individual’s name is unknown, enter
“XX” in the appropriate name item. If the subject
is an entity, enter “XX” in Item 5 (if the trade or
legal name is not known) and in Item 6.
Items 7 - 11 *Permanent address. See
General Instructions 13 and 15. Enter “XX” if the
street address, city, and ZIP Code items are
unknown or not applicable. Enter “XX” if the
state or country is not known. If country is US,
always leave country code blank.
Item 12 *Government issued identification (if
available). See General Instruction 12. Check
the box showing the type of document used to
verify subject identity. If you check box “z” Other,
be sure to specify the type of document used. In
box “e” list the number of the identifying
document. In box “f” list the issuing state or
country. If more space is required, enter the
additional information in Part VI. If the subject is
an entity or an individual’s identification was not
available, check box “z” and enter “XX” in “Other.”

Item 13 *SSN/ITIN (individual) or EIN
(entity). See General Instruction 12 and
definitions. If the subject named in Items 4
through 6 is a U.S. Citizen or an alien with a SSN,
enter his or her SSN in Item 13. If that person is
an alien who has an ITIN, enter that number. For
an entity, enter the EIN. If the SSN, ITIN, or EIN
was unknown or not applicable, enter “XX” in this
item.
Item 14 *Date of birth. See General
Instruction 9. If the subject is an individual, enter
the date of birth. If the month and/or day is not
available or unknown, fill in with zeros (e.g., “01/
00/1969” indicates an unknown date in January,
1969). If entire date is unknown, or if an entity,
enter XX in the MM part of the date field.
Item 15 Telephone number. See General
Instruction 10. Enter the U.S. home or business
number for individual or entity. List foreign
telephone numbers and any additional U.S.
numbers (e.g., hotel, etc.) in Part VI.
Part II Suspicious Activity Information
Item 16 *Date or date range of suspicious
activity. See General Instruction 9. Enter the
date of the reported suspicious activity in the
“From” field. If more than one day is involved,
indicate the duration of the activity by entering
the first date in the “From” field and the last date
in the “To” field.
Item 17 *Total dollar amount. See General
Instruction 14. If unknown, check box 17a. If the
suspicious activity only involved purchases, or
redemptions, or currency exchanges, enter the
total U.S. Dollar value involved in the reported
activity. For instance, if multiple money orders
from more than one issuer were redeemed, enter
the total of all money orders redeemed. If
multiple activities are involved, such as a
redemption of money orders combined with
purchase of a money transfer, enter the largest
activity amount in Item 17. For instance, if the
transaction involved redeeming $5,000 in money
orders and purchase of a $3,500 money transfer ,
the Item 17 amount would be $5,000.
Item 18 *Category of suspicious activity.
Check the box(es) which best identifies the
suspicious activity. Check box “b Structuring”
when it appears that a person (acting alone, in
conjunction with, or on behalf of other persons)
conducts or attempts to conduct activity designed
to evade any record keeping or reporting
requirement of the Bank Secrecy Act. If box “z”
is checked, specify the type of suspicious activity
which occurred. Describe the character of such
activity in Part VI. Box “z” should only be used if
no other type of suspicious activity box adequately
categorizes the transaction.
Item 19 *Financial services involved. Check
any of boxes “a” through “e” that apply to identify
the services involved in the suspicious activity. If
box “z” is checked, briefly explain the service on
the following line. If “unusual use” is involved,

3
check the appropriate service box(s) and box “z”
and note “unusual use” and explain in Part VI.
Check all of boxes “1” through “10” that apply to
describe the character of the suspicious activity.

Item 20 *Purchases and redemptions (See
definition 6 on page 1 of the instructions). Enter
information about purchases or redemptions of
money orders, traveler’s checks, or money
transfers. Check the appropriate box in column
“P” or “R” to identify the entry as a purchase or
redemption. If reporting a money transfer(s) check
“P” if subject is sending money and “R” if subject
is receiving money. Enter the name of the issuers,
the total number of instruments purchased or the
total redeemed, and the total amount of the
instruments. You can enter up to three issuers in
each instrument category. If more than three issuers
are involved, enter the information on the
additional issuers in Part VI. The use of “XX” for
unknown only applies if reporting on a particular
transaction, i.e, “XX” should not be entered on
non-reporting blank lines.
Item 21 *Currency Exchanges.
Record up
to two currency exchanges made by the subject(s).
Check the box “If bulk small currency” if a large
number of small bills was used to pay for the
currency exchange. Enter the name of the
currency or type of monetary instrument used to
pay for the exchange, and the two-letter code for
the country that issued the currency. An example
of this would be “Pesos” for the name of the
currency and “MX” representing Mexico as issuer
of the currency. Enter the name of the currency
received in exchange and the two-digit code for
the country that issued the currency. Enter the
value of the exchange in U.S. Dollars. If there
were more than two currency exchanges, enter
the information about the additional exchanges
in Part VI. The use of “XX” for unknown only
applies if reporting a currency exchange, i.e., “XX”
should not be entered on non-reporting blank
lines.
Part III Transaction Location Information
Item 22 Multiple selling and/or paying
business locations. Check the box if the reported
activity occurred at multiple selling and/or paying
business locations. Fill out as many Part III
Transaction Location Information sections as
necessary to record all locations. Attach the
additional sections behind page 2 of the SARMSB.
Item 23 Type of business location(s). Check
box “a” if this is the selling location where the
customer purchases a money order(s) or traveler’s
check(s), or initiated a money transfer(s), or
exchanged currency. Check box “b” if this is the
paying location where the customer cashed a
money order(s) or traveler’s check(s) or received
payment of a money transfer(s). Check box “c” if
multiple transactions are reported and the
business was both a selling and paying location
for one or more transactions.

Item 24 *Legal name of business. Enter the
legal name of the business where the transactions
took place.
Item 25 Doing business as. Enter the trade
name by which the business is commonly known.
Items 26-29, 32 *Transaction location
address. Enter the transaction location address
by following General Instructions 13 and 15.
Item 30
*EIN (entity) or SSN/ITIN
(individual). See General Instruction 12 and
definitions. If the business identified in Item 24
has an EIN, enter that number in Item 30. If not,
enter individual owner’s SSN or ITIN.
Item 31 *Business telephone number. See
General Instruction 10. Enter the telephone
number of the business listed in Item 24.
Item 32 Country code. Enter the 2-letter
country code if not US.
Item 33 Internal control/file number (If
available). Enter any internal file or report number
assigned by the reporting institution to track this
report. This information will act as an identification
aid if contact is required.
Part IV Reporting Business Information
Item 34 Check this box and go to Part V if the
reporting business is the same as the Part III
Transaction Location. If the reporting business is
different, complete Part IV. If item 34 is checked,
leave items 35 through 44 blank and do not
enter “XX” in these items.
Item 35 *Legal name of business. Enter the
legal name of the reporting business.
Item 36 Doing business as. Enter the trade
name by which the reporting business is commonly
known (if other than the legal name).
Items 37-40, 43 *Reporting business
address. Enter the reporting business address by
following General Instructions 13 and 15.
Item 40
*EIN (entity) or SSN/ITIN
(individual). See General Instruction 12 and
definitions. If the business identified in Item 35
has an EIN, enter that number in Item 41. If not,
enter individual owner’s SSN or ITIN.
Item 42 *Business phone number. Enter the
telephone number of the reporting business. If
the reporting business telephone number is a
foreign telephone number, leave Item 44 blank
and enter the number in the Part VI Narrative.
See General Instruction 10.
Item 43 Country code. Enter the 2-letter
country code if not US.
Item 44 Internal control/file number (If
available). Enter any internal file or report number
assigned by the reporting institution to track this
report. This information will act as an identification
aid if contact is required.

Part V Contact for Assistance
Item *45-- Designated contact office. Enter
the name of the office that the financial institution
has designated to receive request for assistance
with this report. This office must have an individual
knowledgeable of this report available during
regular business hours.
Item *46--Phone number. See General
Instruction B10. Enter the work telephone number
of the contact office.
Item *47--Date filed. See General Instruction
B9. Enter the date this report was filed. For
electronic filing, it is the date that the report was
e-filed using BSA Direct. For magnetic media
filing , it is the date the magnetic media was
forwarded to DCC. For all other filers, it is the
date the financial institution completed the final
review and mailed/submitted the report to DCC.
Item 48--Agency. If this report is filed by an
agency other than an MSB, such as a federal or
state examiner, enter the name of the reporting
agency in Item 48.
Part VI Suspicious Activity Information -Narrative*
Enter a narrative describing all aspects of the
suspicious activity not covered by form data items.
See page 3 of the form for instructions on
completing the narrative. If the initial Part VI
narrative page is not sufficient, continue on plain
bond paper and attach the additional pages after
the initial narrative page. Do not include charts
or tables. Legal disclaimers will not be included
in this narrative.
Paperwork Reduction Act Notice
The purpose of this form is to provide an
effective means for a money services business
(MSB) to notify appropriate law enforcement
agencies of suspicious transactions and activities
that occur by, through, or at an MSB. This report
is authorized by law, pursuant to authority
contained in 31 U.S.C. 5318(g). Information
collected on this report is confidential (31 U.S.C.
5318(g)). Federal regulatory agencies, State law
enforcement agencies, the U.S. Departments of
Justice and Treasury, and other authorized
authorities may use and share this information.
Public reporting and record keeping burden for
this form is estimated to average 60 minutes per
response, and includes time to gather and maintain
information for the required report, review the
instructions, and complete the information
collection. Send comments regarding this burden
estimate, including suggestions for reducing the
burden, to the Office of Management and the
Budget, Paperwork Reduction Project,
Washington, DC 20503 and to the Financial Crimes
Enforcement Network, Attn.: Paperwork
Reduction Act. P.O. Box 39, Vienna VA 221830039. The agency may not conduct or sponsor,
and an organization (or a person) is not required
to respond to, a collection of information unless
it displays a currently valid OMB control number.