Suspicious Activity Report by Insurance Companies

Forms and Documents

Document Name	Status
Form FinCEN 111 Bank Secrecy Act Suspicious Activity Report Form and Instruction	Modified
2014 Reports by Insurance Companies of suspicious transactions SUPPORTING STATEMENT.doc Supporting Statement A	2014-12-15

IC Document Collections

IC ID	Document Title	Status
15337	Bank Secrecy Act Suspicious Activity Report Form and Instruction	Modified

ICR Details

OMB Control No: 1506-0029	ICR Reference No: 201412-1506-002
Status: Historical Active	Previous ICR Reference No: 201109-1506-004
Agency/Subagency: TREAS/FINCEN	Agency Tracking No:
Title: Suspicious Activity Report by Insurance Companies
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/08/2015
	Date Received in OIRA: 12/30/2014
Terms of Clearance: Upon renewal, agency will include a PRA and Privacy Statement on the instrument, whether paper or electronic.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2018	36 Months From Approved	04/30/2015
Responses	1	0	1
Time Burden (Hours)	1	0	1
Cost Burden (Dollars)	0	0	0

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Abstract: 31 CFR 1025.320 requires insurance companies to report suspicious activities to the Financial Crimes Enforcement Network. FinCEN Form 111 is an aid to this required reporting providing the filer with a guide in completing this reporting requirement. The form is used by criminal investigators, and taxation and regulatory enforcement authorities, during the course of investigations involving financial crimes. This action renews the regulation only.

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Authorizing Statute(s): US Code: 31 USC 5311-5330 Name of Law: Bank Secrecy Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 56123	09/18/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 77083	12/23/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Bank Secrecy Act Suspicious Activity Report	FinCEN 111	Suspicious Activity Report

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1	1	0	0	0	0
Annual Time Burden (Hours)	1	1	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/30/2014

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