Form FinCEN 111 FinCEN 111 FinCEN Suspicious Activity Report

Bank Secrecy Act
Suspicious Activity Report

FinCEN Report 111

Please type or print. Always complete entire report.
See instructions for items marked with an asterisk ( * ).
E-File Only
OMB Control Number 1506-0065
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) _________________________________

December 2011
BSA

Type of
Filing

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

*9 City

*13 TIN

*12 Country code

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

a. Unk
c
Passport

d

z

YYYY

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

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

e
l

Attorney

f

Borrower

g

Customer

Owner or Controlling Shareholder

z

Relationship continues

b

Terminated

c

h

Director

d

Resigned

____/____/_____
MM

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

h. TIN

i. acct #

e. Yes

a

Suspicious Activity Information

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

DD

YYYY

MM

DD

b

l. Yes

Payee/Receiver

*26 Amount involved in this report a

$

YYYY

k. acct #

Purchaser/Sender

See Instructions

DD

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

f. acct #

j. Yes

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

Employee

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

Suspended /barred

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

Part II

EIN
SSN-ITIN
Foreign

f Issuing State ____ g Country____

19 E-mail address (If available)

a

a
b
c

Other _______________________________

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

*10 State a. Unk
14 TIN type
*(If 13 is
known)

a. Unk

Alien registration

7a NAICS Code

a. Unk

a. Unk

MM

5 Middle initial

a. Unk

*4 First name

a. Unk

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

,

c

Both a & b

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

_____________________________

V37.4 (Rev. 11/29/11)

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 _________________________________

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 _____________________________
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:_____________________________________________
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

g

Futures/Options on futures

m

Options on securities

b

Commercial mortgage

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 (Check only one)
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 Adviser
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

b

SEC number
Paying location

a
EIN
b
SSN-ITIN
c
Foreign
*58 City

59 State

a. Unk

Selling location

b

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

,

,

Paying location

c

Selling location

b

Paying location

a

75 State

a

70 Country
(2-letter code)
c

Both a & b

Check if additional branch
addresses are listed in Part V
76 ZIP/Postal Code

Casino/Card Club

d

MSB

e

b

*78 Primary Federal
regulator
EIN
*81 TIN a
SSN/ITIN
type b
c
Foreign

Depository institution c

Securities/Futures

z

73 RSSD number

77 Country
(2-letter code)

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

a

.00

66 RSSD number

Filing Institution Contact Information

*82 Type of financial
Institution
(check only one)

,

Both a & b

69 ZIP/Postal Code

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

74 City

a. Unk

*60 ZIP/Postal Code

If no branch activity involved, check this box
68 State

67 City

Both a & b

63 Loss to financial institution (If applicable)

$

*65 Address of branch or office where activity occurred

c

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

Part IV

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

j
k
l
z

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

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

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

e

SEC 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

____ / ___ /_____
MM

DD

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

94 LE contact phone number (Include Area Code)

94a Ext. ( if any)

* 96 Filing institution contact office

YYYY

*97 Filing institution contact office phone number (Include Area Code)

97a Ext. ( if any)

*98 Date filed
(See inst.)

____ / ___ /_____
MM

DD

YYYY

Part V

*Suspicious Activity Information - Narrative

4

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.
 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?
 Explain whether the transaction(s) was completed or only attempted.
 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 for five
years from the date the SAR was filed.
 Explain who benefited, financially or otherwise, from the transaction(s),
how much and how (if known).
 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.
 Describe and retain any evidence of cover-up or evidence of an
attempt to deceive federal or state examiners, or others.
 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.
 Recommend any further investigation that might assist law
enforcement authorities.
 Indicate whether any information has been excluded from this
report; if so, state reasons.
 Describe subject(s) position(s) if employed by the financial
institution.

 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.
 Indicate whether there is any related litigation. If so, specify the
names of the parties involved and the court where the action is
pending.
 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.
 Describe any funds transfers, including in or out identifier numbers,
parties involved, dates, amounts, and financial institutions involved.
 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.
 Indicate the type of institution filing this report, if this is not clear.
 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.
 If correcting or amending a prior report, complete the form in its
entirety and note the changes here in Part V. See instructions.
 SAR’s are confidential. Please refer to following references: OCC:
12 CFR 21.11, FRB: 12 CFR 208.62, OTS: 12 CFR 563.180, FDIC: 12
CFR 353, NCUA: 12 CFR 748, FinCEN: 31 CFR 1000.

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.

Do not include legal disclaimers in this narrative.
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. 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 of two (2) hours 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.