Form FinCEN 111 FinCEN 111 SAR-DI

Suspicious Activity Report
by Depository Institutions

March 1, 2007
Previous editions
will not be accepted
after August 1, 2007

Please type or print. Always complete entire report.
See instructions for items marked with an asterisk ( * ).
This report may be jointly filed (See instructions).

Regulator
FDIC:
FinCEN:
FRB:
NCUA:
OCC:
OCC:
OTS:

Form No.
6710/06
111
FR 2230
2362
8010-1
8010-9
1601

OMB No.
3064-0077
1506-0001
7100-0212
3133-0094
1557-0180
1557-0180
1550-0003

1

Check this box only if amending or correcting a prior report.

1b

Check this box if this report is being filed jointly with another financial institution (See instructions for restrictions on
joint filing. Also note instructions for listing joint filer information).

Part I

Subject Information

2

1a

Check box a

Check this box if this is a recurring report (See instructions).

if multiple subjects

b

6 Also known as (AKA - individual) or doing business as (DBA - entity)

*8 Address

5 Middle initial

7 Occupation or type of business

*9 City

*11 ZIP Code

if subject information is unavailable

*4 First name

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

*12 Country (If not US)
(enter 2-digit code)

*13 SSN, EIN or TIN

T
F

*14 Date of birth
_____/_____/_________
MM

*15 Forms of identification for subject:
a
Driver’s license/state ID
b
e Number
16 Phone number - personal (include area code)

(

A
R

Passport

)

c

Alien registration

*19 Is the relationship an insider relationship? a
If Yes specify: c
Still employed at institution

D
Suspended

b
No
Terminated

f

Resigned

18 E-mail address (If available)

21 Admission or
confession?

20 If “yes” to item 19, date of action
for d, e, or f.

a

_____/_____/_________
MM

Note: A joint SAR cannot be filed if item 19 is checked “yes.”

Part II

YYYY

f Issuing Authority _______________________

)

Yes
e

DD

Other ____________________________________

17 Phone number - work (include area code)

(

d

d

*10 State

DD

Yes b

No

YYYY

Suspicious Activity Information

*22 Date or date range of suspicious activity
From ____ / _____ / _______
MM

DD

*23 Total amount involved in suspicious activity

$

To ____ / _____ / _______

YYYY

MM

DD

YYYY

,

,

a

Amount unknown

,

.00

*24 Summary characterization of suspicious activity (check all that apply):
a
b
c
d
e
f

Bank Secrecy Act/structuring/
money laundering
Bribery/gratuity
Check fraud
Check kiting
Commercial loan fraud
Computer intrusion

s

Other

g
h
i
j
k
l
m

Consumer loan fraud
Counterfeit check
Counterfeit credit/debit card
Counterfeit instrument (other)
Credit card fraud
Debit card fraud
Defalcation/embezzlement

n
o
p
q
r
t
u

False statement
Misuse of position or self dealing
Mortgage loan fraud
Mysterious disappearance
Wire transfer fraud
Terrorist financing
Identity theft

___________________________________________
(type of activity)

25 Loss amount prior to recovery (If applicable)

$

,

,

26 Amount of recovery (if applicable)

,

.00

$

,

,

,

.00

Paperwork Reduction Act Notice: The purpose of this form is to provide an effective and consistent means for financial institutions to notify appropriate law enforcement agencies of known or suspected criminal conduct
or suspicious activities that take place at or were perpetrated against financial institutions. This report is required by law, pursuant to authority contained in the following statutes. Board of Governors of the Federal Reserve
System: 12 U.S.C. 324, 334, 611a, 1844(b) and (c), 3105(c) (2) and 3106(a). Federal Deposit Insurance Corporation: 12 U.S.C. 93a, 1818, 1881-84, 3401-22. Office of the Comptroller of the Currency: 12 U.S.C. 93a, 1818,
1881-84, 3401-22. Office of Thrift Supervision: 12 U.S.C. 1463 and 1464. National Credit Union Administration: 12 U.S.C. 1766(a), 1786(q). Financial Crimes Enforcement Network: 31 U.S.C. 5318(g). Information collected
on this report is confidential (5 U.S.C. 552(b)(7) and 552a(k)(2), and 31 U.S.C. 5318(g)). The Federal financial institutions’ regulatory agencies and the U.S. Departments of Justice and Treasury may use and share the information.
Public reporting and recordkeeping burden for this information collection is estimated to average 60 minutes per response, and includes time to gather and maintain data in 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, depending on your primary Federal regulatory agency, to Secretary, Board of Governors of the Federal Reserve System, Washington, DC 20551; or Assistant Executive Secretary, Federal Deposit Insurance
Corporation, Washington, DC 20429; or Legislative and Regulatory Analysis Division, Office of the Comptroller of the Currency, Washington, DC 20219; or Office of Thrift Supervision, Enforcement Office, Washington,
DC 20552; or National Credit Union Administration, 1775 Duke Street, Alexandria, VA 22314; or Office of the Director, Financial Crimes Enforcement Network, Department of the Treasury, P.O. Box 39, Vienna, VA 22183.
The agencies 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.

IRS Cat. No. 22285L

(Rev. December 2006)

Part III

Reporting Financial Institution Information

28 EIN for company listed in item 27

27 Name of holding company or lead financial institution (If filing institution)
29 Address of company listed in item 27
*33 Name of financial institution

30 City

This is: a

2

(See instructions)

31 State

Filing institution or

b

32 ZIP Code

*34 EIN for institution listed in item 33

Joint filer

*35 Address of financial institution

36 Internal control/file number(If available)

*37 City

*39 ZIP Code

*38 State

*40 Primary Federal Regulator
a

FRB

b

FDIC

c

NCUA

d

OCC

e

OTS

f

IRS

g

T
F
SEC

h

CFTC

z

Fed Other

*41 Account number(s) affected that are related to subject listed in Part I, if any. Check “Yes” if closed. Enter name (items 3 - 5) or entity (item3)
from Part I.
Last name/Entity:
First name:
Mi:
a

Yes

b

Yes

c

Yes

d

Yes

*42 Relationship of the subject (Part I) to the above listed financial institution (check all that apply):
a

Accountant

b

Agent

h

Director

i

Employee

c
j

A
R
Appraiser

d

Attorney

e

Borrower

Officer

k

Shareholder

l

Other

*43 Address of branch or office where activity occurred

45 State

44 City

46 ZIP Code

f

Broker

g

Customer

47 Country (If not US,
enter 2 digit code)

48 Address of branch or office where activity occurred (if required)
49 City

D

50 State

51 ZIP Code

52 Country (If not US,
enter 2 digit code)

53 Address of branch or office where activity occurred (if required)
54 City

55 State

56 ZIP Code

58 Address of branch or office where activity occurred (if required)
59 City

60 State

57 Country (If not US,
enter 2 digit code)
Check if additional branch addresses are listed in Part V

61 ZIP Code

62 Country (If not US,
enter 2 digit code)

Part IV Contact for Assistance
* 63 Designated contact office

*64 Designated phone number (include area code) *65 Date filed (See instructions)

(

)

_____ / ____ /_______
MM

DD

YYYY

66 Agency (if not filed by financial institution)
Special note:
If this report is being filed jointly, box 1b must be checked and Item 33 completed. A Part III and Part IV must be completed for
each institution. Reminder: A joint SAR cannot be filed if box 19 is checked “yes”.
If mailing, send each completed SAR report to:

Electronic Computing Center - Detroit
Attn: SAR-DI
P.O. Box 33980
Detroit, MI 48232-0980

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.

Part V

*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 narrative description of the activity. The narrative should address as much of the information listed below as possible which
covers the who/what/when/where of the activity.
a. Describe the conduct that raised suspicion, why it was suspicious and
the date discovered. Did the activity have a material impact on or affect
the financial institution’s soundness?
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.). The filer (and joint filer if appropriate) must retain a
copy of the SAR and its supporting documentation and retain such
documentation on 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, or others.
g. Indicate where the possible violation of law(s) took place (e.g., main
office, branch, other). If the institution or branch has been closed,
indicate date.
h. Recommend any further investigation that might assist law
enforcement authorities.
i. Indicate whether any information has been excluded from this
report; if so, state reasons.

j. Indicate whether the suspicious activity is an isolated incident or
relates to another transaction. Note if this is an updated report and if
so, provide the date of the original SAR regarding this activity.
k. Indicate whether there is any related litigation. If so, specify the names
of the parties involved and the court where the action is pending.
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.Describe any funds transfers, including in or out identifier numbers,
parties involved, dates, amounts, and financial institutions involved.
n. 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.
o. Describe subject(s) position(s) if employed by the financial institution.
p. Indicate the type of institution filing this report, if this is not clear.
q. Indicate 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.
r. If correcting or amending a prior report, complete the form in its
entirety and note the changes here in Part V. See instructions.
s. SAR’s are confidential. Please refer to following references: OCC: 12
CFR 21.11, FRB: 12 CFR 208.62, OTS: 12 CFR 568, FDIC: 12 CFR
354, NCUA: 12 CFR 748, FinCEN 31CFR 103.18.

A
R

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F

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

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 or the “SAR Narrative
Guidance Package” at www.fincen.gov/narrativeguidance_webintro.pdf

The reporting financial institution should not include legal disclaimers in the narrative.

D

Suspicious Activity Report Instructions (SAR-DI)
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”. This applies to the filer
and joint filer(s).
Notification Prohibited: Federal law (31 U.S.C.
5318(g)(2)) requires that a financial institution and its
directors, officers, employees and agents, who,
voluntarily or by means of a suspicious activity report,
report suspected or known criminal violations or
suspicious activities, may not notify any person (subject)
involved in the transaction that the transaction has been
reported. See narrative checklist item “s.”
In situations involving violations requiring
immediate attention, such as when a reportable
violation is ongoing, the financial institution shall
immediately notify, by telephone, appropriate law
enforcement and financial institution supervisory
authorities in addition to filing a timely suspicious
activity report. List any such contact in Part V.
General Instructions

D

Definition: Depository Institution.

For the purposes of suspicious activity reporting
in accordance with 31 CFR 103.18, and the use
of this suspicious activity report form, the term
Depository Institution includes those entities
listed in 31 CFR 103.11(c) as well as bank holding
companies and nonbank subsidiaries of bank
holding companies.
A. When to file
General. Every Depository Institution shall file with
the Treasury Department, to the extent and in the
manner required by 31 CFR Part 103.18, a report
of any suspicious transaction relevant to a possible
violation of law or regulation. A Depository Institution may also file with the Treasury Department by
using the Suspicious Activity Report specified in 31
CFR Part 103.18, 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 this section.
1. All Depository Institutions operating in the
United States, including insured banks, savings

associations, savings association service
corporations, credit unions, bank holding
companies, nonbank subsidiaries of bank holding
companies, Edge and Agreement corporations, and
U.S. branches and agencies of foreign banks, are
required to make this report following the
discovery of:
a. Insider abuse involving any amount.
Whenever the Depository Institution detects any
known or suspected Federal criminal violation, or
pattern of criminal violations, committed or
attempted against the Depository Institution or
involving a transaction or transactions conducted
through the Depository Institution, where the
Depository Institution believes that it was either
an actual or potential victim of a criminal violation,
or series of criminal violations, or that the
Depository Institution was used to facilitate a
criminal transaction, and the Depository Institution
has a substantial basis for identifying one of its
directors, officers, employees, agents or other
institution-affiliated parties as having committed
or aided in the commission of a criminal act
regardless of the amount involved in the violation.

A
R

b. Violations aggregating $5,000 or more
where a subject can be identified. Whenever
the Depository Institution detects any known or
suspected Federal criminal violation, or pattern of
criminal violations, committed or attempted against
the financial institution or involving a transaction
or transactions conducted through the Depository
Institution and involving or aggregating $5,000 or
more in funds or other assets, where the Depository
Institution believes that it was either an actual or
potential victim of a criminal violation, or series of
criminal violations, or that the Depository
Institution was used to facilitate a criminal
transaction, and the Depository Institution has a
substantial basis for identifying a possible subject
or group of subjects. If it is determined prior to
filing this report that the identified subject or group
of subjects has used an “alias,” then information
regarding the true identity of the subject or group
of subjects, as well as alias identifiers, such as
drivers’ licenses or social security numbers,
addresses and telephone numbers, must be
reported.

c. Violations aggregating $25,000 or more
regardless of a potential subject. Whenever the
Depository Institution detects any known or
suspected Federal criminal violation, or pattern of
criminal violations, committed or attempted against
the Depository Institution or involving a transaction
or transactions conducted through the financial
institution and involving or aggregating $25,000
or more in funds or other assets, where the
Depository Institution believes that it was either
an actual or potential victim of a criminal violation,
or series of criminal violations, or that the
Depository Institution was used to facilitate a
criminal transaction, even though there is no
substantial basis for identifying a possible subject
or group of subjects.

1

d. Transactions aggregating $5,000 or more
that involve potential money laundering or
violations of the Bank Secrecy Act. Any transaction
(which for purposes of this subsection means a
deposit, withdrawal, transfer between accounts,
exchange of currency, loan, extension of credit,
purchase or sale of any stock, bond, certificate of
deposit, or other monetary instrument or
investment security, or any other payment, transfer,
or delivery by, through, or to a Depository
Institution, by whatever means effected) conducted
or attempted by, at or through the Depository
Institution and involving or aggregating $5,000 or
more in funds or other assets, if the Depository
Institution knows, suspects, or has reason to suspect
that:
i. The transaction involves funds derived from
illegal activities or is intended or conducted in
order to hide or disguise funds or assets derived
from illegal activities (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 law or regulation or to avoid any
transaction reporting requirement under Federal
law;

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ii. The transaction is designed to evade
any regulations promulgated under the Bank
Secrecy Act; or
iii. The transaction 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 Depository Institution
knows of no reasonable explanation for the
transaction after examining the available facts,
including the background and possible purpose
of the transaction.
2. The Bank Secrecy Act requires all 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 Depository Institution to file
a CTR whenever a currency transaction exceeds
$10,000.
3. 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
or criminal aspects of the transaction). If a currency
transaction equals or is below $10,000 and is
suspicious, the institution should only file a
suspicious activity report.
4. A Depository Institution is required to file a
suspicious activity report no later than 30 calendar
days after the date of initial detection of facts that
may constitute a basis for filing a suspicious activity
report. If no subject was identified on the date of
detection of the incident requiring the filing, a
Depository Institution may delay filing a suspicious
activity report for an additional 30 calendar days
to identify a subject. In no case shall reporting be
delayed more than 60 calendar days after the
date of initial detection of a reportable transaction.

2
5. This suspicious activity report does not
need to be filed for those robberies and burglaries
that are reported to local authorities, or (except for
savings associations and service corporations) for
lost, missing, counterfeit, or stolen securities that
are reported pursuant to the requirements of 17
CFR 240.17f-1.
B.

How to make a report:

NOTE: If this report is jointly filed, both of the
filing institutions must retain a copy of the SAR.
Each institution must retain their supporting documentation for a period of five years from the date
the report was filed.
1. This form should be e-filed through the
Bank Secrecy Act E-filing System. Go to
http://bsaefiling.fincen.treas.gov/index.jsp 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) 8293676. This form is also available through your primary federal regulator.
2. If not filed electronically or through magnetic
media, send each completed suspicious activity
report to:
Electronic Computing Center - Detroit
Attn: SAR-DI
P.O. Box 33980
Detroit, MI 48232-0980
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.

D

4. If the information for a item marked with a
asterisk (*) is not known or not applicable, enter
special response “XX” to complete the item. 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 corrected or amended reports.
6. Do not include supporting documents with
the filed suspicious activity report. Retain a copy of
the report and all supporting documentation (e.g.
transaction records, new account information, tape
recordings, correspondence, e-mail messages, etc.)
or business record equivalent in 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.
7. Type or complete the report using block
written letters.
8. 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 V by “item number,” and add the additional
information.
9. Enter all dates in MM / DD / YYYY format
where MM = month, DD = day, and
YYYY =
year. Precede single numbers with zero, i.e., 01,02,
etc. If the month or day is unknown, enter “00” in
place of the month or day.
10. Record telephone numbers using the format
(XXX) XXX-XXXX. List fax numbers and international
telephone numbers in Part V.
11. Always enter an individual’s name by
entering the last name, first name, and middle initial
in the appropriate items. If the last or first name is
not known, enter “XX” in the item. If an individual
has two middle initials, enter both initials in that
item. If the middle initial is unknown or the
individual has no middle name, enter “XX” in that
item.
12. Enter all identifying numbers (alien
registration, driver’s license/state ID, Employer
Identification Number (EIN), Individual Taxpayer
Identification Number (ITIN), Foreign National ID,
passport, and Social Security Number (SSN), etc.)
starting from left to right. Do not include spaces,
dashes, or other punctuation.

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13. Enter all Post Office ZIP Codes from left to
right with at least the first five numbers or all nine
numbers (ZIP + 4) if known.
14. Enter all monetary amounts in U.S. Dollars.
Use whole dollar amounts rounded up. Enter the
amount as a number string without punctuation. If
foreign currency is involved, state the name of
currency and country of origin in Part V.

15. Addresses. 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. Do not use a
post office box for an individual, unless no other
address is available. For an individual, enter any
apartment or suite number and road or route
number. If a post office box is used for an entity,
enter the street name, suite number, and road or
route number. If the individual is from Mexico or
Canada, enter the appropriate state or territory
code in the state item and MX or CA as appropriate
in the country item. If the address is from another
foreign country, enter “XX” in the state item and
the appropriate two-digit country code in the
country item. Complete any part of the address
that is known, even if the entire address is not
known. If the address is in the U.S., leave the country
field blank. Lists of country and state two-digit
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.

16. If you have questions or require further
assistance, go to www.fincen.gov, contact your
primary regulator, or call the FinCEN Helpline at
800-949-2732.

C. Specific Suspicious Activity Report
preparation instructions
Item 1--Check the box if this report amends
(adds missing data) or corrects errors in the prior
report. (See Part V, item “r”).
Item 1a-- Check this box if this is a recurring
report filed on continuing activity.
Item 1b -- Check this box if this is a jointly
filed report with another financial institution.
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.

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Item 2--If there are multiple subjects involved,
check box “2a” and complete a separate Part I for
each subject and attach behine page one. Check
box “2b” only if NO subject information is
available. If ANY subject information is available,
record that information in Part 1, leave box “2b”
blank, and insert the appropriate special response
“XX” in any critical item for which data is missing.

Items *3, *4, and *5--Individual/entity names.
See General Instruction B11 for information on
completing name fields. If the subject is an entity,
enter the entity’s full legal name in Item 3, and
“XX” in Item 4. Individual/entity names must be
repeated in Item 41 to associate the account
numbers with each Part I.
Item 6 Also known as--If an individual has
another name under which he or she is commonly
known, enter that name in Item 6. If the subject is
an entity, record the trade name of the entity in
Item 6 if the trade name is different from the legal
name in Item 3.
Item 7--Occupation or type of business. If
known, identify the occupation, profession
or business that best describes the individual or
entity 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), or self employed. If unemployed, or
retired are used enter the regular or former
occupation if known. If the individual’s business
activities can be described more fully, provide the
additional information in Part V.
Items *8, *9, *10, *11, and *12-- Address.
See General Instructions B13 and B15. If any part
of the address is not known, enter or “XX” in that
item.
Item *13--SSN/ITIN (individual) or EIN
(entity). See General Instruction B12. If the subject
named in Items 3 through 5 is a U.S. Citizen or an
alien with a SSN, enter his or her SSN in Item 13. If
that individual is an alien who has an ITIN, enter
that number. If the subject is an entity, enter the
EIN. If the identification number is not known, enter “XX”
in Item 13.

3
Item *14--Date of birth. See General Instruction B9.
If the subject is an individual, enter the date of birth.
Enter “XX” if the date of birth is not known. Enter “XX” if
the subject is an entity.
Item *15--Forms of identification for subject. See
General Instruction B12. Check the box showing the
type of document used to verify the subject’s identity. If
you check box “d Other,” specify the type of document
used. You must list the ID number of the identifying
document and the issuing authority in 15e and 15f. If no
identification was available, check box 15d and enter
“XX” in “Other.”
Items 16, 17 & 18--Telephone numbers, E-mail
address. See General Instruction B10. List any additional
number(s) that may be available in Part V. List e-mail
address if available.
Item *19--Insider relationship? You must check box
“a” or “b” showing whether or not there is an insider
relationship. If box “a” is checked, you must also check
box “c”, “d”, “e”, or “f” to identify the current relationship,
and complete Item 20.
Note: A joint SAR cannot be filed if item 19 is
checked “yes.”
Item 20--Date of Suspension, etc. Enter the date of
any suspension, termination or resignation reflected in
Item 18.
Item 21--Admission or Confession. Check the
appropriate box to indicate whether the subject has
admitted or confessed to the suspicious activity. If “Yes,”
describe the admission or confession more fully in Part V.

D

Part II Suspicious Activity Information

Item *22--Date or date range of suspicious activity.
See General Instruction B9. Enter the date of the reported
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. 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 *23--Total dollar amount. See General
Instruction B14. Check item 23a if the amount is
unknown. 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 V. 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
all values to U.S. Dollars. If box “1” is checked, leave
this item blank unless the amount is different than originally
reported. If box “1a” is checked, enter the cumulative
amount.

Item *24--Type of suspicious activity. Check all
that apply to identify the suspicious activity. Provide a
brief explanation in Part V of why each box is checked.
If none of the items apply, mark box “s” “Other,” enter a
brief description on the following line, and provide in Part
V an explanation of the type of suspicious activity.

Item 40--Primary Federal Regulator (This item
must be completed for all reports). Depository
Institutions filing this report must check box “a” through
“e” (only one). For all other institutions, check box “f”,
“g”, or “h” as appropriate. For a regulatory agency
not listed, check box “z” Fed other.

Items 25 and 26--Amount of loss and recovery (if
applicable). Indicate in Item 25 the amount of the initial
loss. This amount cannot be larger than the amount in
Item 23. In Item 26 indicate the amount of any recovery.
This amount cannot be larger than the amount in Item 25.
Both amounts must be in U.S. Dollars.

Item *41--Account number(s). Enter up to four
account numbers for financial institution accounts
involved in the activity. Check the box “Yes” if an
account is closed. Enter additional account numbers in
Part V. Enter “XX” in Item 41(a) if no accounts are
involved. Enter name (Items 3-5) or entity (Item 3) from
Part I, in the space provided.

Part III Reporting Financial Institution Information
If this report is being completed by a holding company
or lead financial institution, complete items 27 through
32. Items 33 through 62 must reflect the location of the
financial institution where the reported activity occurred.
Note: Item 27 should be left blank if the reported activity
occurred at the holding company or lead financial
institution. In such cases the institution should complete
items 33 to 62 as the filing institution and check box 33a.

A
R

Note: If filed jointly, a Part III and Part IV must be
completed for each institution. If reporting multiple
subjects (box 2a checked) complete Part III, items 33
through 42 for each subject reported by the institution.
If this report is being filed jointly (box in item 1b
checked), make a copy of page two and complete
items 33 through 42 for the joint filer following the same
instructions as the filer. Complete branch information,
items 43 through 62 if appropriate. If there are additional
joint filers, make as many copies of page two as required
to record the additional joint filer information. Attach any
additional pages behind page two, and indicate the total
number of joint filers in Part V.
NOTE: Reports involving insider abuse may not be
filed jointly.
Item *33--Name of financial institution. Enter the
full legal name of the institution, i.e. the name shown on
the charter or other document creating the entity where
the reported activity occurred. Check box “a”, “Filing
institution” when the listed institution is the institution
preparing and filing the report. Check box ”b”, “Joint
filer” for all other reporting institutions. See holding
company note above.
Item *34--EIN. See General Instruction B12. Enter the
EIN of the financial institution listed in item 33.
Items *35, *37, *38, and *39--Address. See General
Instructions B13 & B15. This address should be the
address of the principal office or headquarters in the
United States.
Item 36--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.

Item 42--Relationship to financial institution.
Check the appropriate box(es) to indicate whether or
not the subject identified in Part I, items 3-5 is or was
associated with the reporting institution. Check all that
apply.

T
F

Items *43- 62--Branch or office addresses. See
General Instructions B13 & B15. Provide the addresses
of up to four branch locations where the most significant
portion of the suspicious activity occurred. If there are
more than four branches, check the box labeled “Check
if additional branch ...” in the last branch address (item
58) and list the additional locations in Part V. If there are
no branch addresses involved, enter “XX” in Item 43.
Part IV Contact for Assistance

Item *63-- Designated contact office. Enter the
name of the office that the holding company or 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 *64--Phone number. See General Instruction
B10. Enter the work telephone number of the contact
office.

Item *65--Date filed. See General Instruction B9.
Enter the date this report was initially filed. If this is an
amended or corrected report, enter the date of the
amendment or correction. 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
SAR was created . For all other filers, it is the date the
financial institution completed and mailed/submitted
the report to ECC - Detroit
Item 66--Agency. If this report is filed by an agency
other than a financial institution such as a regulator or
OFAC, enter the name of the reporting agency in Item
66.
Part V--*Suspicious Activity Information
-Narrative.
This is the most important section, and should be
completed in as much detail as possible. See page 3 of
the form for specific instructions for completing the
narrative. The filing/reporting financial institution
should not include legal disclaimers in the narrative.