Form 108 Suspicious Activity Report by Insurance Companies

Suspicious Activity Report by the
Securities and Futures Industries

FinCEN
Form 101

Please type or print. Always complete entire report. Items
Effective May 2004

marked with an asterisk * are considered critical. (See instructions.)

OMB No. 1506 - 0019

1 Check the box if this report corrects a prior report (See instructions)

Subject Information

Part I

2 Check box a

if multiple subjects

box b

subject information unavailable

*4 First name

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

5 Middle initial

7 Occupation or type of business

6 Also known as (AKA - individual), doing business as (DBA - entity)
*8 Address
*10 State

*9 City
*11 ZIP code

13 E-mail address (If available)

*12 Country code (If not U.S.)
(See instructions)

*14 SSN/ITIN (individual), or EIN (entity) *15 Account number(s) affected, if any. Indicate if closed.
Acc’t #______________________ yes
Acc’t #______________________ yes
Acc’t #______________________ yes

16 Date of birth
____/_____/_______
MM

Acc’t #______________________ yes

DD

YYYY

*17 Government issued identification (If available)
a
e
f

Driver’s license/state ID

b

Passport

c

Alien registration

d

Corporate/Partnership Resolution

Other ___________________________________________
ID number

g Issuing state or country (2 digit code)

18 Phone number - work

)

(
Part II

20 Is individual/business associated/affiliated
with the reporting institution? (See instructions)

19 Phone number - home

)

(

a

Yes

b

No

Suspicious Activity Information
*22 Total dollar amount involved in suspicious activity

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

DD

To _____/_____/_________

YYYY

MM

DD

YYYY

$

,

,

,

.00

23 Instrument type (Check all that apply)
a

Bonds/Notes

i

Commodity options

b

Cash or equiv.

j

Security futures products

c

Commercial paper

k

Stocks

d

Commodity futures contract

l

Warrants

e

Money Market Mutual Fund

m

Other securities

f

Mutual Fund

n

Other non-securities

g

OTC Derivatives

o

Foreign currency futures/options

h

Other derivatives

p

Foreign currencies

q

Commodity type ________________________
(Please identify)

r

Instrument description ___________________

s

Market where traded ____________________
(Enter approprite three or four-letter code.)

t

Other (Explain in Part IV)

24 CUSIP® number

25 CUSIP® number

26 CUSIP® number

27 CUSIP® number

28 CUSIP® number

29 CUSIP® number

Part
PartIII
III
*30 Type of suspicious activity:
a
b
c
d
e
f
g

h
Bribery/gratuity
i
Check fraud
j
Computer intrusion
k
Credit/debit card fraud
l
Embezzlement/theft
Commodity futures/options fraud m
n
Forgery

o
Identity theft
Insider trading
p
Mail fraud
q
Market manipulation
r
Money laundering/Structuring
Prearranged or other non-competitive trading s
t
Securities fraud

Catalog No. 35349U

Significant wire or other transactions
without economic purpose
Suspicious documents or ID presented
Terrorist financing
Wash or other fictitious trading
Wire fraud
Other (Describe in Part VI)
Rev. 05/22/04

PartIV
III
Part

Part VI 2

Law Enforcement or Regulatory Contact Information

31 If a law enforcement or regulatory authority has been contacted (excluding submission of a SAR) check the appropriate box.
a
b

DEA
U.S. Attorney (**32)

f
g

Secret Service
CFTC

k
l

NYSE
Other RFA

p
q

State securities regulator
Foreign

c

IRS

h

SEC

m

Other RE-futures (CME, CBOT, NYMEX, NYBOT)

r

Other (Explain in Part VI)

d
e

FBI
ICE

i
j

NASD
NFA

n
o

Other state/local
Other SRO-securites (PHLX, PCX, CBOE, AMEX, etc.)

32 Other authority contacted (for Item 31 l through r) ** List U.S. Attorney office here.

34 Telephone number of individual contacted (Item 33)

(

33 Name of individual contacted (for all of Item 31)

35 Date contacted

)

Part IV

_____/_____/_________
MM

DD

YYYY

Reporting Financial Institution Information
*37 EIN / SSN / ITIN

*36 Name of financial institution or sole proprietorship
*38 Address

*41 ZIP code

*40 State

*39 City

42 Additional branch address locations handling account, activity or customer.

43

44 City

45 State

47 Central Registration Depository number

Multiple locations (See instructions)

49 NFA ID number

48 SEC ID number

50 Has this reporting individual/entity coordinated this report with another reporting individual/entity? Yes
51 Type of institution or individual- Check box(es) for functions that apply to this report
j
IA
a
Agricultural trade option merchant
k
Investment company - mutual fund
b
Affiliate of bank holding company
l
Market
maker
c
CPO
m
Municipal
securities dealer
d
CTA
n
NFA
e
Direct participation program
o
RE-futures
f
FCM
p
Other RFA
g
Futures floor broker
q
Securities broker - clearing
h
Futures floor trader
r
Securities
broker - introducing
i
IB-C

Part V

46 ZIP code

(Provide details in Part VI) No

s
t
u
v
w
x
y
z

Securities dealer
Securities floor broker
Securities options broker-dealer
SRO-securities
Specialist
Subsidiary of bank
U.S. Government broker-dealer
U.S. Government interdealer broker

aa

Other (Describe in Part VI)

Contact For Assistance

*52 Last name of individual to be contacted regarding this report

*55 Title/Position

*53 First name

*54 Middle initial

*56 Work phone number

*57 Date report prepared

(

)

Send completed reports to:
Detroit Computing Center
Attn: SAR-SF
P.O. Box 33980
Detroit, MI 48232

_____/_____/_________
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 (not exceeding this page and the next page) of the activity, including what is unusual, irregular or suspicious about the transaction(s),
using the checklist below as a guide, as you prepare your account.
a. Describe conduct that raised suspicion.
b. Explain whether the transaction(s) was completed or only attempted.
c. Describe supporting documentation (e.g. transaction records, new
account information, tape recordings, E-mail messages, correspondence, etc.) and retain such documentation in your file for five years.
d. Explain who benefited, financially or otherwise, from the
transaction(s), how much, and how (if known).
e. Describe and retain any admission or explanation of the
transaction(s) provided by the subject(s) or other persons. Indicate to
whom and when it was given.
f . Describe and retain any evidence of cover-up or evidence of an
attempt to deceive federal or state examiners, SRO, or others.
g. Indicate where the possible violation of law(s) took place (e.g., main
office, branch, other).
h. Indicate whether the suspicious activity is an isolated incident or
relates to another transaction.
i. Indicate whether there is any related litigation. If so, specify the
name of the litigation and the court where the action is pending.
j. Recommend any further investigation that might assist law
enforcement authorities.
k. Indicate whether any information has been excluded from this report;
if so, state reasons.
l. Indicate whether U.S. or foreign currency and/or U.S. or foreign
negotiable instrument(s) were involved. If foreign, provide the
amount, name of currency, and country of origin.

m. Indicate “Market where traded” and “Wire transfer identifier”
information when appropriate.
n. Indicate whether funds or assets were recovered and, if so, enter the
dollar value of the recovery in whole dollars only.
o. Indicate any additional account number(s), and any foreign bank(s)
account number(s) which may be involved.
p. 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.
q. Describe any suspicious activities that involve transfer of funds to or
from a foreign country, or transactions in a foreign currency. Identify
the country, sources and destinations of funds.
r. Describe subject(s) position if employed by the financial institution.
s. Indicate whether securities, futures, or options were involved. If so,
list the type, CUSIP® number or ISID® number, and amount.
t . Indicate the type of institution filing this report, if this is not clear
from Part IV. For example, an IA that is managing partner of a limited
partnership that is acting as a hedge fund that detects suspicious activity
tied in part to its hedge fund activities should note that it is operating as
a hedge fund.
u. Indicate, in instances when the subject or entity has a CRD or NFA
number, what that number is.
v. If correcting a prior report (box in Item 1 checked), complete the
form in its entirety and note the corrected items here in Part VI

Information already provided in earlier parts of this form need not necessarily be repeated if the meaning is clear.

Supporting documentation should not be filed with this report.

Maintain the information for your files.

Tips on SAR form preparation and filing are available in the SAR Activity Review at www.fincen.gov/pub_reports.html
Enter explanation/description in the space below. Continue on the next page if necessary.

Suspicious Activity Report Narrative (continued)

4

FinCEN Form 101a

Suspicious Activity Report (SAR-SF) 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, voluntarily or by means of a suspicious activity report, report suspicious transactions to the
government, may not notify any person involved
in the transaction that the transaction has been
reported.
In situations involving violations that require immediate attention, such as terrorist financing or ongoing money laundering
schemes, the financial institution shall immediately notify by telephone an appropriate law enforcement authority in addition to
filing a timely suspicious activity report.

When to file a report
1. Every broker or dealer in securities (BD), futures
commission merchant (FCM), and introducing
broker in commodities (IB-C) within the United
States shall file with FinCEN, to the extent and in
the manner required by 31 CFR 103.19 and 103.17,
a report of any suspicious transaction relevant to a
possible violation of law or regulation. A BD, FCM
or IB-C may also file with FinCEN a report of any
suspicious transaction that it believes is relevant to
the possible violation of any law or regulation but
whose reporting is not required by 31 CFR 103.19
or 103.17. A voluntary filing does not relieve a BD,
FCM or IB-C from the responsibility of complying
with any other reporting requirements imposed by
the Securities and Exchange Commission (SEC),
the Commodity Futures Trading Commission
(CFTC), a self-regulatory organization (“SRO”) (as
defined in section 3(a)(26) of the Securities
Exchange Act of 1934, 15 U.S.C. 78c (a)(26)), or
any registered futures association (RFA) or
registered entity (RE) as these terms are defined in
the Commodity Exchange Act (CEA) 7 U.S.C. 21
and 7 U.S.C. 1a(29).
2. A transaction requires reporting if it is conducted
or attempted by, at, or through a BD, FCM or IB-C,
it involves or aggregates funds or other assets of at
least $5,000, and the BD, FCM, or IB-C knows,
suspects, or has reason to suspect that the

transaction (or a pattern of transactions of which
the transaction is a part):
i. 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 ownership,
nature, source, location, 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. Is designed, whether through structuring or
other means, to evade any requirements of 31 CFR
103 or of any other regulations promulgated under
the Bank Secrecy Act, Pub. L. 91-508, as amended,
codified at 12 U.S.C. 1829b, 12 U.S.C. 1951-1959,
and 31 U.S.C. 5311 - 5314, 5316 - 5332;
iii. Has no business or apparent lawful purpose or
is not the sort in which the particular customer
would normally be expected to engage, and the BD,
FCM or IB-C knows of no reasonable explanation
for the transaction after examining the available
facts, including the background and possible purpose
of the transaction; or
iv. Involves use of the BD, FCM or IB-C to
facilitate criminal activity.
3. The obligation to identify and properly and
timely report a suspicious transaction rests with
each BD, FCM, and IB-C involved in the transaction,
provided that no more than one report is required
to be filed by any of the BDs, FCMs, or IB-Cs
involved in a particular transaction (so long as the
report filed contains all relevant facts).
4. A SAR-SF shall be filed no later than 30 calendar
days after the date of the initial detection by the
reporting BD, FCM, or IB-C of facts that may
constitute a basis for filing a SAR-SF. If no suspect
is identified on the date of such initial detection, a
BD, FCM, or IB-C may delay filing a SAR-SF for an
additional 30 calendar days to identify a suspect,
but in no case shall reporting be delayed more than
60 calendar days after the date of such initial
detection. In situations involving violations that
require immediate attention, such as terrorist
financing or ongoing money laundering schemes,
the BD, FCM, or IB-C shall immediately notify by
telephone an appropriate law enforcement
authority in addition to filing timely a SAR-SF.
BDs, FCMs, or IB-Cs wishing voluntarily to report
suspicious transactions that may relate to terrorist
activity may call FinCEN’s Financial Institutions
Hotline at 1-866-556-3974 in addition to filing
timely a SAR-SF. The BD, FCM, or IB-C may also,
but is not required to, contact the SEC or the CFTC
to report in such situations.
5. Exceptions. A BD, FCM, or IB-C is not
required to file a SAR-SF to report:
i. A robbery or burglary committed or attempted
that is reported to appropriate law enforcement
authorities, or for lost, missing, counterfeit, or
stolen securities with respect to which the BD
files a report pursuant to the reporting
requirements of 17 CFR 240.17f-1;
Catalog No. 35351G

1

ii. A violation otherwise required to be
reported on a SAR-SF: (a) of any of the federal
securities laws or rules of an SRO by the BD or
any of its officers, directors, employees or other
registered representatives, other than a violation
of 17 CFR 240.17a-8 or 17 CFR 405.4, so long
as such violation is appropriately reported to
the SEC or an SRO; or (b) under the CEA (7
U.S.C. 1 et seq.), the regulations of the CFTC
(17 CFR Chpt.1), or the rules of any RFA or RE
as those terms are defined in the CEA, 7 U.S.C.
21 and 7 U.S.C. 1a(29), by the FCM or IB-C or
any of its officers, directors, employees or
associated persons, other than a violation of 17
CFR 42.2 as long as such violation is
appropriately reported to the CFTC or a RFA or
RE.
6.The Bank Secrecy Act requires financial institutions to file currency transaction reports (CTRs) in
accordance with the Department of the Treasury’s
implementing regulations (31 CFR Part 103). These
regulations require a financial institution to file a
CTR whenever a currency transaction exceeds
$10,000. If a currency transaction exceeds $10,000
and is suspicious, the institution must file both a
CTR (reporting the currency transaction) and a
suspicious activity report (reporting the suspicious
aspects of the transaction). If a currency transaction is $10,000 or less and is suspicious, the institution should only file a suspicious activity report.
Appropriate records must be maintained in each
case.
See: 31 CFR Part 103; 17 CFR 240.17a-8; 17 CFR
405.4; 17 CFR 42.2

General Instructions
A. Abbreviations and Definitions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

AKA-ASE-BD-CBOE-CBOT-CME-CPO-CRD-CFTC--

also known as (individual)
American Stock Exchange
Broker or Dealer in Securities
Chicago Board Options Exchange
Chicago Board of Trade
Chicago Mercantile Exchange
Commodity Pool Operator
Central Registration Depository
Commodity Futures Trading
Commission
CTA-- Commodity Trading Advisor
CUSIP®-- Committee on Uniform Securities
ID Procedures
DEA-- Drug Enforcement Administration
DBA-- doing business as (entity)
EIN-Employer Identification Number
EUREX--European Exchange
FBI-Federal Bureau of Investigation
FCM-- Futures Commission Merchant
IA-Investment Adviser
IB-C-- Introducing Broker-Commodities
ICE-Immigration & Customs Enforc.
IRS-Internal Revenue Service
ITIN-- Individual taxpayer ID number
ISID®-- International Securities ID
Directory
KCBOT Kansas City Board of Trade
LIFFE-- London International Financial
Futures Exchange

Catalog No. 35351G

Rev. 05/22/04

Catalog No. 35351G

2
26. MATIF-- Marche a Terme International de
France
27. MGEX
Minneapolis Grain Exchange
28. NASD-- NASD
29. NASDAQ--Nasdaq Stock Market
30. NFA-National Futures Association
31. NYBOT-- New York Board of Trade (CSCE,
CTN, FINEX, NYFE)
32. NYMEX-- New York Mercantile Exchange
33. NYSE-- New York Stock Exchange
34. NQLX-- Nasdaq Liffe Markets
35. OTC-Over-the-counter
36. PCX-Pacific Exchange
37. PHLX-- Philadelphia Stock Exchange
3 8 RE-Registered Entity
39. RFA-Registered Futures Association
40. SEC-Securities and Exchange
Commission
41. SRO-Self-Regulatory Organization
42. SSN-social security number
43. USFE-U. S. Futures Exchange
B . How to make a report:
1. This form can be e-filed through the
BSA E-File System. goto
http://bsaefiling.fincen.treas.gov/main.html
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. Send each completed
suspicious activity report to:
Detroit Computing Center
Attn: SAR-SF
P.O. Box 33980
Detroit, MI 48232
2. Items marked with an asterisk (*) are considered critical and must be completed if known.
3. If the information for a critical item is not
known or not applicable, enter special responses
“None,” “Not Applicable,” “Unknown,” or “XX”
(state/country/middle initial) as appropriate to
complete the item.
4. Complete each suspicious activity report by
providing as much information as possible on initial and corrected reports.
5. Do not include supporting documentation with
the suspicious activity report filed. Identify and
retain a copy of the suspicious activity report and
all supporting documentation (e.g. transaction
records, new account information, tape recordings,
E-mail messages, correspondence, etc.) or business
record equivalent for your files for five (5) years
from the date of the suspicious activity report. All
supporting documentation must be made available
to appropriate authorities upon request.
6. If more than one subject is being reported,
make a copy of page 1, complete only the subject
information in Part I, and attach the additional
page(s) behind page 1. If more space is needed to
complete any other item(s), identify that item in
Part VI by “item number,” and provide the additional information.
7. Type or complete the report using block written letters.

8. 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.
9. List all Telephone numbers with (area code)
first and then the seven numbers, using the format
(XXX) XXX-XXXX. List international telephone
and fax numbers in Part VI.
10. 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 name
in the last name field.
11. Enter all identifying numbers (alien registration, Corporate/Partnership Resolution, CRD,
CUSIP,® driver’s license/state ID, EIN, ITIN, Foreign National ID, ISID,® NFAID, passport, SEC,
and SSN, etc.) starting from left to right. Do not
include spaces, dashes, or other punctuation.
12. Enter all Post Office ZIP codes with at least
the first five numbers (all nine (ZIP + 4)) if known)
and listed from left to right.
13. Enter all monetary amounts in U.S.Dollars.
Use whole dollar amounts rounded up when necessary. Use this format: $0,000,000.00. If foreign
currency is involved, state name of currency and
country of origin in Part VI.
14. 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, 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 of the
individual or entity is in a foreign country, enter
the city, province or state, postal code, and the
name of the country (country codes may be found
at www.fincen.gov/reg_bsaforms.html). Complete
any part of the address that is known, even if the
entire address is not known. If from the United
States, leave country Item blank.
C. Specific Suspicious Activity Report
Preparation Instructions
Item 1-- Type of report. Check Box if this report
is filed to correct a previously filed SAR-SF. To
correct a report, a new SAR-SF must be completed
in its entirety. Note corrected items in Section VI
(see line “v”).
Part I

Subject Information

Item 2 -- Multiple Subjects. Check box (a) if
multiple subjects are involved. Attach additional
copy(ies) of Part I to this report for each subject.
Check box (b) if subject information unavailable.
Items 3, 4, and 5--*Name of Subject. See General Instruction B10. If the organization is operated under a different trade or business name than
its legal name, enter the organization’s legal name
in Item 3 (e.g., Smith Enterprises, Inc.) and the
name of the business in Item 6 (e.g., Smith’s Tours).
If more than one Part I is required, make a copy of
page 1 and provide the additional information.

Item 6-- Also known as, or doing business as.
If a reporting institution has knowledge of a subject’s
separate “AKA” and/or entity’s “DBA” name, enter it in Item 6.
Item 7-- Occupation/type of business. If known,
identify the occupation, profession, or business that
best describes the individual in Part I (e.g., attorney, car dealer, carpenter, doctor, farmer, plumber,
truck driver, etc.). Do not use nondescript terms
such as businessman, merchant, store owner (unless store’s name is provided). If self employed,
unemployed, or retired are used, add currrent/former
profession if known (e.g. self-employed building
contractor, unemployed teacher, retired attorney
etc.). If the individual’s business activities can be
described more fully, provide the additional information in Part VI.
Items 8, 9, 10, 11, and 12-- *Address. See General Instructions B12 and B14.
Item 13-- E-mail address. Enter the subject’s Email address if available.
Item 14-- *SSN/ITIN (individual) or EIN (entity). See General Instruction B11 and definitions.
If the subject named in Items 3 through 6 is a U.S.
Citizen or an alien with a SSN, enter his or her SSN
in Item 14. If that individual is an alien who has an
ITIN, enter that number. If the subject is an entity,
enter the EIN.
Item 15-- *Account number(s). See General Instruction B11. Enter up to four affected account
numbers in or through which the suspicious activity occurred. If no account number is affected leave
item 15 blank. Check the “yes” box to indicate if
the account is closed. If more than four accounts
are affected, provide the additional information in
Part VI.
Item 16-- Date of birth. See General Instruction
B8. If an individual is named in Items 3 through 5,
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).
Item 17-- *Government issued identification.
See General Instruction B11. Check the appropriate box showing the type of document used to verify
the subject’s identity. Box “d” denotes that a corporate or partnership resolution was used to identify an entity. If you check the “Other” box “e”,
be sure to specify the type of document used. In
box “f”, list the ID number of the identifying document. In box “g”, list the issuing authority.
Items 18 & 19-- Telephone numbers. See General Instruction B9. List any additional number(s)
(e.g., hotel, cell, etc.) in Part VI.
Item 20-- Institution association. Indicate
whether the subject identified in Part I is, or was,
associated with the reporting institution as an “associated person,” as defined in section 3(a)(18) of
the Securities Exchange Act of 1934 or CFTC rule
1.3(aa), or is, or was, “affiliated with” the reporting institution, as defined in the CFTC rule
4.7(a)(1)(i). If so, explain in Part VI.

3
Part II Suspicious Activity Information
Item 21-- *Date or date range of suspicious
activity. See General Instruction B8. Enter the date
of the reported activity in the “From” field. If
more than one day, indicate the duration of the
activity by entering the first date in the “From”
field and the last date in the “To” field. If the
same individual or organization conducts multiple
or related activities within the 30 calendar day period after the date of initial detection, the reporting institution may consider reporting the suspicious transactions on one form, but only if doing so
will fully describe what has occurred. A new report
must be filed for other related suspicious transactions committed after the initial detection period.
Item 22-- *Total dollar amount. See General Instruction B13. Enter the total dollar value of the
funds or assets involved in the suspicious activity
that is conducted by the same individual or organization within the 30 calendar day period after the
date of initial detection. For multiple or related
suspicious transactions, show the breakdown of this
aggregated total in Part VI. For abuse by a person
associated with the institution, the value of this
item can be zero (0). Do not use any words, such as
“thousand”, “million”, etc. For foreign currency,
convert to U.S. Dollars.
Item 23-- Instrument type. Mark the type of
instrument identified in Item 23. (Check all that
apply.) In Item 23b, indicate U.S. Dollars only. For
Item 23r, indicate currency if other than U.S. Dollars. For Item 23s, enter appropriate three or four
letter code.
Items 24, 25, 26, 27, 28, and 29-- CUSIP® Numbers. Enter up to six (6) securities numbers. If more,
enter additional in Part VI.
Item 30-- *Type of suspicious activity. Check
the box(es) that identifies the suspicious activity.
More than one box may be checked. Provide a
brief explanation in Part VI of why each box is
checked. If none of these items applies, mark
“other” and provide in Part VI an explanation of
the type of suspicious activity.
Part III
Law Enforcement or Regulatory
Contact Information
Items 31, 32, and 33-- Contacting enforcement
authorities. If no contact, go to Part IV. See
General Instructions “A. Abbreviations and Definitions” for law enforcement and regulatory identities. If you have advised any law enforcement authority SRO, RFA, or RE-futures entity of the suspicious transactions by telephone or written communication, complete this section. If box “b” or

boxes “l” through “r” are checked, provide the
name of the authority contacted in Item 32. If no
contact, leave Items 31-35 blank.
Item 34-- Telephone number of individual
contacted. See General Instruction B9 for format.
Item 35-- Date contacted. See General Instruction B8 for format
Part IV
Reporting Financial Institution
Information

Part VI. The Federal Bureau of Public Debt, its
agents, and any other federal agency issuers of Federal Securities should mark “U.S. Government broker/dealer.” State or municipal issuers of municipal
securities should mark “Municipal broker/dealer.”
A securities SRO, RFA, or RE-futures entity filing
this form should identify the institution type as
that of the member institution for which this report is being filed, and in Part V, (Items 52, 53, 54,
55, 56, and 57) identify the securities SRO, RFA or
RE-futures entity individual to contact.
Part V

Item 36-- *Name of financial institution or
sole proprietorship. Enter the full legal name of
the institution, i.e., the name shown on the charter
or other document creating the entity and registered with the SEC or CFTC. If a sole proprietor,
enter the business name of the proprietorship registered with the SEC or CFTC.
Item 37--*Employer identification number.
See General Instruction B11. Enter the reporting
financial institution’s EIN. If sole proprietor enter
SSN or ITIN.

Contact for assistance

Items 52, 53, and 54-- *Contact individual.
See General Instruction B10.
Item 55-- *Title/Position. Enter the job title/
position of the contact individual.
Item 56-- *Work telephone number. See General Instruction B9.
Item 57-- *Date report prepared. See General
Instruction B8.

Items *38, *39, *40, and *41-- Address. See
General Instruction B14. This address should be
of the principal office or headquarters in the
United States.

Part VI
- Narrative
tions.

Items 42, 43, 44, 45 and 46-- Additional address locations. See General Instruction B14. If
more than one location is involved, e.g., branch
office etc., provide the address of the location where
the most significant portion of the suspicious transactions occurred. If more than two locations are
involved check box 43 and list locations in Part VI.

Paperwork Reduction Act Notice:

Item 47-- Central Registration Depository
number. See General Instruction B11. If none,
leave blank.
Item 48-- SEC number. See General Instruction
B11. This is a ten digit number including the prefix
of either “8” or “008” depending on the system
used. If none, leave blank.
Item 49-- NFA identification number. See General Instruction B11. If none, leave blank.
Item 50-- Dual reporting. If this is a coordinated
report involving more than one individual/entity
(see “When to file a report Item 3”) check the
appropriate box and provide the details in Part VI.
Item 51-- Type of reporting institution. Check
all boxes that apply to this particular report. If
none of these categories apply to you, explain in

* Suspicious Activity Information
See page 3 of the form for instruc-

The purpose of this form is to provide an effective
means for financial institutions to notify appropriate law enforcement agencies of suspicious transactions that occur by, through, or at the financial
institutions. This report is required 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 securities and futures
regulatory agencies and the U.S. Departments of
Justice and Treasury, and other authorized authorities may use and share this information. Public reporting and recordkeeping burden for this form is
estimated to average 45 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 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.