Form FinCEN Form 111 FinCEN Form 111 Bank Secrecy Act Suspicious Activity Report (BSA-SAR)

Planning Only- Do Not Use
Bank Secrecy Act
Suspicious Activity Report

Type of
Filing

Please type or print. Always complete entire report.
See instructions for items marked with an asterisk ( * ).
This report may be jointly filed (See instructions).
*1 Check all that apply. (See instructions for restrictions on checking multiple boxes and for joint filing).
a.
Initial report b.
Correct/Amend prior report c.
Continuing activity report
d.
Joint report
e. Prior report document control/file number if items 1b or 1c are checked (see instructions) _________________________________

Part I

Subject Information

2 Check: a

if entity, b

if all critical* subject information is unavail (does not include item 24).

6 Alternate name, e.g., AKA - individual or DBA - entity 7 Occupation or type of business

5a Gender b. Male
c. Fem.
d. Unk
*8 Address

a. Unk
a. Unk

*11 ZIP/Postal Code

*15 Form of identification for subject:
b
Driver’s license/state ID

a. Unk
c
Passport

d

z

f Issuing State ____ g Country____

YYYY

19 E-mail address (If available)

17 Phone number - Type
18 Phone number
a
Home b
Work
c
Mobile d
Fax
19a Website (URL) address (If available)

A
R

18a Ext. (If any)

20 Corroborative statement to filer?
a
Yes
b
No

21a Institution TIN

21 Relationship of the subject to an institution listed in Part III or IV (check all that apply)
b

Accountant

c

Agent

d

j

No relationship to institution k

Appraiser
Officer

D

e

l

Attorney

f

Borrower

g

Customer

Owner or Controlling Shareholder

z

Relationship continues

b

Terminated

c

Suspended /barred

d

h

Director

____/____/_____
MM

*24 Financial inst. TIN and acct. number(s) affected that are related to subject, if any. Check “Yes” if closed.

h. TIN

Employee

23 Action date if 22 b, c, or d is checked

Resigned

Note: A joint SAR cannot be filed if any boxes in 22 are checked.

c. TIN

i

Other ___________________________

22 If item 21h, i, k, or l is checked, indicate status of relationship
a

EIN
SSN-ITIN
Foreign

Other _______________________________

e Number
a. Unk
*16 Date of birth
____/____/______
DD

a
b
c

14 TIN type
*(If 13 is
known)

a. Unk

Alien registration

*10 State a. Unk

a. Unk

*13 TIN

*12 Country code

7a NAICS Code

T
F

*9 City

a. Unk

MM

5 Middle initial

a. Unk

*4 First name

a. Unk

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

d. acct #

e. Yes

f. acct #

i. acct #

j. Yes

k. acct #

DD

YYYY

a. No known acct. involved
b. Non-US Fin. Inst.
g. Yes
l. Yes

25 Subject’s role in suspicious activity (If applicable)

Suspicious Activity Information

Part II

*26 Amount involved in this report a

$

See Instructions

*27 Date or date range of suspicious activity for this report
a. From: ____ /____ / ______
b. To: ____ / ___ / ______
MM

DD

YYYY

MM

DD

,

Amt. unk.

,

b

No amt. involved

,

.00

28 Cumulative amount only if box 1c is checked (See instructions)

$

YYYY

,

,

,

.00

When completing items 29 through 38, check all that apply.
29. Structuring
a.

Alters transaction to avoid BSA recordkeeping requirement

z.

b.

Alters transaction to avoid CTR requirement

c.

Customer cancels transaction to avoid BSA reporting

d.
e.
f.
z.

30. Terrorist Financing
a.
Known or suspected terrorist/terrorist organization
Other:_________________________________________

and recordkeeping requirements

31. Fraud (Type)
a.
ACH

g.

Mail

Multiple transactions below BSA recordkeeping threshold

b.

Business loan

h.

Mass-marketing

Multiple transactions below CTR threshold

c.

Check

i.

Pyramid scheme

Suspicious inquiry by customer regarding BSA reporting

d.

Consumer loan

j.

Wire

or recordkeeping requirements

e.

Credit/Debit card

z.

Other

Other:________________________________________

f.

Catalog No. 49342F

Healthcare

_____________________________

V36 (Rev. 4/29/11)

Part II

Suspicious Activity Information* (continued)

32. Casinos
a.
Inquiry about end of business day
b.
Minimal gaming with large transactions
c.
Suspicious intra-casino funds transfers
d.
Suspicious use of counter checks or markers
z.

Other:_____________________________________________

34. Identification / Documentation
a.

Changes spelling or arrangement of name

b.
c.
d.
e.

Multiple individuals with same or similar identities
Provided questionable or false documentation
Refused or avoided request for documentation
Single individual with multiple identities

z.

Other:_____________________________________________

35. Other suspicious activities
a.
Account takeover
b.
Bribery or gratuity
c.
Counterfeit instruments
d.
Elder financial exploitation
e.
Embezzlement/theft/disappearance of funds
f.
Forgeries
g.
Identity theft
h.
Little or no concern for product performance penalties,
fees, or tax consequences
i.
Misuse of “free look”/cooling-off/right of rescission
j.
Misuse of position or self-dealing
k.
Suspected public/private corruption (domestic)
l.
Suspected public/private corruption (foreign)
m.
Suspicious use of informal value transfer system
n.
Suspicious use of multiple transaction locations
o.
Transaction with no apparent economic, business, or lawful
purpose
p.
Two or more individuals working together
q.
Unauthorized electronic intrusion
r.
Unlicensed or unregistered MSB
z.
Other _________________________________

D

2

(Check all that apply).

33. Money laundering
a.
Exchanges small bills for large bills or vice versa
b.
Suspicion concerning the physical condition of funds
c.
Suspicion concerning the source of funds
d.
Suspicious designation of beneficiaries, assignees or
joint owners
e.
Suspicious EFT/wire transfers
f.
Suspicious exchange of currencies
g.
Suspicious receipt of government payments/benefits
h.
Suspicious use of multiple accounts
i.
Suspicious use of noncash monetary instruments
j.
Suspicious use of third-party transactors (straw-man)
k.
Trade Based Money Laundering/Black Market Peso Exchange
l.
Transaction out of pattern for customer(s)
z.
Other _____________________________

T
F

36. Insurance
a.
Excessive insurance
b.
Excessive or unusal cash borrowing against policy/annuity
c.
Proceeds sent to or received from unrelated third party
d.
Suspicious life settlement sales insurance
(e.g.,STOLI’s, Viaticals)
e.
Suspicious termination of policy or contract
f.
Unclear or no insurable interest
z.
Other:_____________________________________________

A
R

37. Securities/Futures/Options
a.

Insider trading

b.

Market manipulation/wash trading

c.

Misappropriation

d.

Unauthorized pooling

z.

Other:_________________________________________

38. Mortgage Fraud
a.

Appraisal fraud

c.

Loan Modification fraud

b.

Foreclosure fraud

d.

Reverse mortgage fraud

z.

Other ___________________________

39 Were any of the following product type(s) involved in the suspicious activity? (Check all that apply)
a

Bonds/Notes

b

Commercial mortgage

g

Futures/Options on futures

m

Options on securities

h

Hedge fund

n

Penny stocks/Microcap securities
Prepaid access

c

Commercial paper

i

Home equity loan

o

d

Credit card

j

Home equity line of credit

p

Residential mortgage

e

Debit card

k

q

Security futures products

r

Stocks

f

Forex transactions

Insurance/Annuity products

l

Mutual fund

s

Swap, hybrid, or
other derivative

z

Other (List below)

40 Were any of the following instrument type(s)/payment mechanism(s) involved in the suspicious activity? (Check all that apply)
g
Personal/Business check
Bank/Cashier’s check
z
Other (List below)
d
Gaming instruments
h
Travelers checks
b
Foreign currency
e
Government payment
a
c

Funds transfer

f

Money orders

i

U.S. Currency

41 Commodity type (If applicable)

42 Product/Instrument description (If needed)

43 Market where traded
(Three to five letter code)

44 IP address (If available)

45 CUSIP® number

46 CUSIP® number

3
Part III Information about Financial Institution Where Activity Occurred (See instructions)
*47 Type of financial
*48
Primary
a
Casino/Card Club
b
Depository institution c
Insurance company
Institution
Federal
d
MSB
e
Securities/Futures z
Other _______________________
(check only one)
regulator
49 If item 47a is checked indicate type of gaming institution
z
Other(specify)______________________
a
State licensed casino b
Tribal authorized casino
c
Card club
50 If item 47e is checked, indicate type of Securities and Futures institution or ind. where activity occurred - Check box(es) that apply to this report.
g
Investment company
d
Introducing broker-commodities
a
Clearing broker-securities
h
Retail foreign exchange dealer
e
Introducing broker-securities
b
Futures Commission Merchant
i
Subsidiary of financial/bank holding company
c
Holding company
f
Investment Advisor
z
Other __________________________
f

51 Financial institution identification number (Check one box to indicate type)
a
CRD number b
IARD number c
NFA number d
RSSD number
52 Financial institution’s role in transaction (if applicable) a

a. Unk

*53 Legal name of financial institution
a. Unk

*55 TIN

56 TIN type
(If 55 is
known)
a. Unk

*57 Address
*61 Country
(2-letter code)

a. Unk

Selling location

a
EIN
b
SSN-ITIN
c
Foreign
*58 City

Paying location

Selling location

b

D

,

c

If no branch activity involved, check this box
69 ZIP/Postal Code

Selling location

b

72 Address of branch or office where activity occurred (If applicable)

Paying location

a

75 State

a

Casino/Card Club

d

MSB

e

b

70 Country
(2-letter code)

c

Both a & b

Check if additional branch
addresses are listed in Part V

76 ZIP/Postal Code

z

73 RSSD number

77 Country
(2-letter code)
*78 Primary Federal
regulator
EIN
*81 TIN a
SSN/ITIN
type b
c
Foreign

Depository institution c

Securities/Futures

.00

66 RSSD number

*79 Filer name (Holding Co., lead fin. inst., or agency, if applicable). *80 TIN

a

,

Both a & b

Filing Institution Contact Information

*82 Type of financial
Institution
(check only one)

a. Unk

*60 ZIP/Postal Code

,

Paying location

A
R

71 Branch’s role in transaction (if applicable) a

Both a & b

63 Loss to financial institution (If applicable)

68 State

67 City

c

T
F

59 State

a. Unk

$

*65 Address of branch or office where activity occurred

Part IV

b

SEC ID number

54 Alternate name, e.g., AKA - individual or trade name, DBA - entity

62 Internal control/file number

64 Branch’s role in transaction (if applicable) a

74 City

e

Insurance company

Other _______________________

83 Type of Securities and Futures institution or individual filing this report - Check box(es) for functions that apply to this report
a
b
c
d
e

Clearing broker-securities
CPO/CTA
Futures Commission Merchant
Holding company
Introducing broker-commodities

f
g
h
i

84 Financial institution identification number (Check one box to indicate type)
a
CRD number b
IARD number c
NFA number d
RSSD number
*85 Address

j
k
l
z

Introducing broker-securities
Investment Advisor
Investment company
Retail foreign exchange dealer

SRO Futures
SRO Securities
Subsidiary of financial/bank holding company
Other __________________________
f

e

SEC ID number
87 State

*86 City

*89 Country
(2-letter code)

90 Alternate name, e.g., AKA - individual or trade name, DBA - entity

92 LE contact agency

93 LE contact name

95 LE contact date

*88 ZIP/Postal Code
91 Internal control/file number

94 LE contact phone number (Include Area Code)

94a Ext. ( if any)

____ / ___ /_____
MM

* 96 Designated contact office

DD

YYYY

*97 Designated phone number (Include Area Code)

97a Ext. ( if any)

*98 Date filed
(See inst.) ____ / ___ /_____
MM

DD

YYYY