Suspicious Activity Report (Saf-Sf) Instructions (Page 3 of 3) in pdf

Item 16-- Date of birth. See General Instruction

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

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

Num-

B8. If an individual is named in Items 3 through 5,

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

eral Instruction B11. If none, leave blank.

enter the date of birth. If the month and/or day is

enter additional in Part V I.

not available or unknown, fill in with zeros ( e.g.,

Item 50-- Joint/coordinated reporting. If this

“01/00/1969” indicates an unknown date in

Item 30-- *T ype of suspicious activity . Check

is a joint/coordinated report involving more than

January, 1969).

the box(es) that identifies the suspicious activity .

one individual/entity (see “When to file a report

More than one box may be checked. Provide a

Item 3”) check the appropriate box and provide

Item 17-- *Government issued identification .

brief explanation in Part VI of why each box is

the details in Part VI.

See General Instruction B11. Check the appropri-

checked. If none of these items applies, mark

ate box showing the type of document used to verify

“other” and provide in Part VI an explanation of

Item 51-- Type of r eporting institution . Check

the subject’s identity. Box “d” denotes that a cor -

the type of suspicious activity . Use of XX does not

all boxes that apply to this

particular report. If

porate or partnership resolution was used to iden-

apply to this item.

none of these categories apply to you, explain in

tify an entity . If you check box “e”, “Other” be

Part VI. The Federal Bureau of Public Debt, its

sure to specify the type of document used. In box

Part III

Law Enforcement or Regulatory

agents, and any other federal agency issuers of Fed-

“f”, list the ID number of the identifying docu-

Contact Information

eral Securities should mark “U.S. Government bro-

ment. In box “g”, list the issuing authority . If all

ker/dealer.” S tate or municipal issuers of municipal

information for item 17 is unknown, check box

Items 31, 32, and 33-- Contacting enforcement

securities should mark “Municipal broker/dealer.”

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

“e” and enter XX in the space provided for “other .”

A securities SRO, RF A, or RE-futures entity filing

General Instructions “A. Abbreviations and Defini-

this form should identify the institution type as

tions” for law enforcement and regulatory identi-

Items 18 & 19-- Telephone numbers. See Gen-

that of the member institution for which this re-

ties. If you have advised any law enforcement au-

eral Instruction B9. List any additional number(s)

port is being filed, and in Part V, (Items 52, 53, 54,

thority SRO, RF A, or RE-futures entity of the sus-

(e.g., hotel, cell, fax, international etc.) in Part VI.

55, 56, and 57) identify the securities SRO, RF A or

picious transactions by telephone or written com-

RE-futures entity individual to contact.

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

Item 20-- Institution association

. Indicate

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

whether the subject identified in Part I is, or was,

Part V

Contact for assistance

name of the authority contacted in Item 32. If no

associated with the reporting institution as an “as-

contact, leave Items 31-35 blank.

sociated person,” as defined in section 3(a)(18) of

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

the Securities Exchange Act of 1934 or CFTC rule

See General Instruction B10.

Item 34-- Telephone number of individual

1.3(aa), or is, or was, “affiliated with” the report-

contacted. See General Instruction B9 for format.

ing institution, as defined in the CFTC rule

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

4.7(a)(1)(i). If so, explain in Part VI.

position of the contact individual.

Item 35-- Date contacted. See General Instruc-

tion B8 for format

Part II Suspicious Activity Information

Item 56 -- *Work t elephone n umber. See Gen-

eral Instruction B 9.

Part IV

Reporting Financial Institution

Item 21-- *Date or date range of suspicious

Information

Item 57-- *Date report prepared. See General

activity. See General Instruction B8. Enter the date

Instruction B8.

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

Item 36-- *Name of financial institution or

more than one day , indicate the duration of the

sole proprietorship . Enter the full legal name of

Part VI

* Suspicious Activity Information -

activity by entering the first date in the “ From”

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

Narrative See page 3 of the form for instructions.

field and the last date in the “ To” field. If the

or other document creating the entity and regis-

same individual or organization conducts multiple

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

or related activities within the 30 calendar day pe-

enter the business name of the proprietorship reg-

riod after the date of initial detection, the report-

Paperwork Reduction Act Notice:

istered with the SEC or CFTC.

ing institution may consider reporting the suspi-

cious transactions on one form, but only if doing so

The purpose of this form is to provide an effective

Item 37--*Employer identification number .

will fully describe what has occurred. A new report

means for financial institutions to notify appro-

See General Instruction B11. Enter the reporting

must be filed for other related suspicious transac-

priate law enforcement agencies of suspicious trans-

financial institution’s EIN. If sole proprietor enter

tions committed after the initial detection period.

actions that occur by , through, or at the financial

SSN or ITIN.

institutions. This report is required by law , pursuant

“XX” may not be used in the “From” date entry

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

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

formation collected on this report is confidential

Item 22-- *T otal dollar amount . See General In-

General Instruction B 14. This address should be

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

struction B13. Enter the total dollar value of the

of the principal office or headquarters in the

regulatory agencies and the U.S. Departments of

funds or assets involved in the suspicious activity

United States.

Justice and Treasury, and other authorized authori-

that is conducted by the same individual or organi-

ties may use and share this information. Public re-

zation within the 30 calendar day period after the

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

Additional ad-

porting and recordkeeping burden for this form is

date of initial detection. For multiple or related

dress locations . See General Instruction B14.

estimated to average 2 hours per response, and

suspicious transactions, show the breakdown of this

more than one location is involved,

e.g., branch

includes time to gather and maintain information

aggregated total in Part VI. For abuse by a person

office etc., provide the address of the location where

for the required report, review the instructions, and

associated with the institution, the value of this

the most significant portion of the suspicious trans-

complete the information collection. Send com-

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

actions occurred. If more than two locations are

ments regarding this burden estimate, including sug-

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

involved check box 43 and list locations in Part VI.

gestions for reducing the burden, to the Office of

convert to U.S. Dollars. If unknown, enter XX.

Management and Budget, Paperwork Reduction

Item 47-- Central Registration Depository

Project, Washington, DC 20503 and to the Finan-

Item 23-- Instrument type . Mark the type of

number. See General Instruction B1 1. If none,

cial Crimes Enforcement Network,

Attn.: Paper -

instrument identified in Item 23. (Check all that

leave blank.

work Reduction Act, P.O. Box 39, Vienna VA 22183-

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

0039. The agency may not conduct or sponsor,

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

Item 48-- SEC number . See General Instruction

and an organization (or a person) is not required to

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

B11. This is a ten digit number including the prefix

respond to, a collection of information unless it

letter code.

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

displays a currently valid OMB control number .

used. If none, leave blank.

Suspicious Activity Report (Saf-Sf) Instructions Page 3

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