Form 101a - Suspicious Activity Report Instructions (Page 3 of 3) in pdf

03/11

institution, as defined in the CFTC rule 4.7(a)(1)(i).

Item 51-- T ype of reporting institution . Check

thority SRO, RFA, or RE-futures entity of the suspi-

If so, explain in Part VI.

all boxes that apply to this particular report. If none

cious transactions by telephone or written com-

munication, complete this section. If box “b” or

of these categories apply to you, explain in Part VI.

Part II Suspicious Activity Information

boxes “l” through “r” are checked, provide the

The Federal Bureau of Public Debt, its agents, and

name of the authority contacted in Item 32. If no

any other federal agency issuers of Federal Securi-

contact, leave Items 31-35 blank.

Item 21-- *Date or date range of suspicious

ties should mark “U.S. Government broker/dealer.”

activity. See General Instruction B8. Enter the date

State or municipal issuers of municipal securities

Item 34-- T elephone number of individual con-

should mark “Municipal broker/dealer.” A securi-

of the reported activity in the “From” field. If more

tacted. See General Instruction B9 for format.

ties SRO, RFA, or RE-futures entity filing this form

than one day, indicate the duration of the activity

should identify the institution type as that of the

by entering the first date in the “From” field and

Item 35-- Date contacted. See General Instruc-

member institution for which this report is being

the last date in the “To” field. If the same indi-

filed, and in Part V, (Items 52, 53, 54, 55, 56, and

tion B8 for format

vidual or organization conducts multiple or related

57) identify the securities SRO, RFA or RE-futures

activities within the 30 calendar day period after

Part IV

Reporting Financial Institution Infor-

entity individual to contact.

the date of initial detection, the reporting institu-

mation

Part V

Contact for assistance

tion may consider reporting the suspicious trans-

actions on one form, but only if doing so will fully

Item 36-- *Name of financial institution or

Items 52, 53, and 54-- *Contact individual.

describe what has occurred. A new report must be

sole proprietorship. Enter the full legal name of

See General Instruction B10.

filed for other related suspicious transactions com-

the institution, i.e., the name shown on the charter

mitted after the initial detection period.

Item 55-- *Title/Position . Enter the job title/

or other document creating the entity and regis-

tered with the SEC or CFTC. If a sole proprietor,

position of the contact individual.

Item 22-- *Total dollar amount. See General

enter the business name of the proprietorship reg-

Instruction B13. Enter the total dollar value of the

Item 56-- *Work telephone number. See Gen-

istered with the SEC or CFTC.

funds or assets involved in the suspicious activity

eral Instruction B9.

that is conducted by the same individual or organi-

Item 37--*Employer identification number .

zation within the 30 calendar day period after the

Item 57-- *Date report prepared. See Gen-

See General Instruction B11. Enter the reporting

date of initial detection. For multiple or related

eral Instruction B8.

financial institution’s EIN. If sole proprietor enter

suspicious transactions, show the breakdown of this

SSN or ITIN.

aggregated total in Part VI. For abuse by a person

Part VI

* Suspicious Activity Information -

associated with the institution, the value of this

Items *38, *39, *40, and *41-- Address. See

Narrative See page 3 of the form for instructions.

item can be zero (0). Do not use any words, such as

General Instruction B14. This address should be

“thousand”, “million”, etc. For foreign currency,

of the principal office or headquarters in the

convert to U.S. Dollars.

United States.

Paperwork Reduction Act Notice:

Item 23-- Instrument type . Mark the type of

Items 42, 43, 44, 45 and 46-- Additional ad-

The purpose of this form is to provide an effective

instrument identified in Item 23. (Check all that

dress locations. See General Instruction B14. If

means for financial institutions to notify appropri-

apply.) In Item 23b, indicate U.S. Dollars only. For

more than one location is involved, e.g., branch

ate law enforcement agencies of suspicious trans-

Item 23r, indicate currency if other than U.S. Dol-

office etc., provide the address of the location

actions that occur by, through, or at the financial

lars. For Item 23s, enter appropriate three or four

where the most significant portion of the suspi-

institutions. This report is required by law, pursu-

letter code.

cious transactions occurred. If more than two lo-

ant to authority contained in 31 U.S.C. 5318(g).

cations are involved check box 43 and list loca-

Information collected on this report is confidential

Items 24, 25, 26, 27, 28, and 29-- CUSIP

Num-

tions in Part VI.

(31 U.S.C. 5318(g)). Federal securities and futures

bers. Enter up to six (6) securities numbers. If more,

regulatory agencies and the U.S. Departments of

enter additional in Part VI.

Item 47-- Central Registration Depository

Justice and Treasury, and other authorized authori-

number. See General Instruction B11. If none,

ties may use and share this information. Public

Item 30-- *Type of suspicious activity . Check

reporting and recordkeeping burden for this form

leave blank.

the box(es) that identifies the suspicious activity.

is estimated to average 45 minutes per response,

More than one box may be checked. Provide a

Item 48-- SEC number. See General Instruc-

and includes time to gather and maintain informa-

brief explanation in Part VI of why each box is

tion for the required report, review the instruc-

tion B11. This is a ten digit number including the

checked. If none of these items applies, mark

tions, and complete the information collection.

prefix of either “8” or “008” depending on the

“other” and provide in Part VI an explanation of

Send comments regarding this burden estimate,

system used. If none, leave blank.

the type of suspicious activity.

including suggestions for reducing the burden, to

the Office of Management and Budget, Paperwork

Item 49-- NF A identification number . See Gen-

Part III

Law Enforcement or Regulatory Con-

Reduction Project, Washington, DC 20503 and to

tact Information

eral Instruction B11. If none, leave blank.

the Financial Crimes Enforcement Network, Attn.:

Paperwork Reduction Act, P.O. Box 39, Vienna VA

Item 50-- Dual reporting. If this is a coordi-

Items 31, 32, and 33-- Contacting enforce-

22183-0039. The agency may not conduct or spon-

ment authorities. If no contact, go to Part IV. See

nated report involving more than one individual/

sor, and an organization (or a person) is not re-

entity (see “When to file a report Item 3”) check

General Instructions “A. Abbreviations and Defini-

quired to respond to, a collection of information

the appropriate box and provide the details in Part

tions” for law enforcement and regulatory identi-

unless it displays a currently valid OMB control

ties. If you have advised any law enforcement au-

VI.

number.

Form 101a - Suspicious Activity Report Instructions Page 3

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