Fincen Form 101 - Suspicious Activity Report By The Securities And Futures Industries
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Suspicious Activity Report by the
Form 101
Securities and Futures Industries
March 2011
Please type or print. Always complete entire report. Items
Previous editions will not be
marked with an asterisk * are considered critical. (See instructions.)
accepted after September 30, 2011
OMB No. 1506 - 0019
1 Check the box if this report corrects a prior report (See instructions)
Subject Information
Part I
2 Check box a
if multiple subjects
box b
subject information unavailable
*3 Individual’s last name or entity’s full name
*4 First name
5 Middle initial
6 Also known as (AKA - individual), doing business as (DBA - entity)
7 Occupation or type of business
*8 Address
*9 City
*10 State
*11 ZIP code
Country code (If not U.S.)
13 E-mail address (If available)
*12
(See instructions)
*14 SSN/ITIN (individual), or EIN (entity)
*15 Account number(s) affected, if any. Indicate if closed.
16 Date of birth
Acc’t #______________________ yes
Acc’t #______________________ yes
____/_____/_______
Acc’t #______________________ yes
Acc’t #______________________ yes
MM
DD
YYYY
*17 Government issued identification (If available)
a
Driver’s license/state ID
b
Passport
c
Alien registration
d
Corporate/Partnership Resolution
e
Other ___________________________________________
f
ID number
g Issuing state or country (2 digit code)
20 Is individual/business associated/affiliated
18 Phone number - work
19 Phone number - home
with the reporting institution? (See instructions)
(
)
(
)
a
Yes
b
No
Part II
Suspicious Activity Information
*22 Total dollar amount involved in suspicious activity
*21 Date or date range of suspicious activity
From _____/_____/_________
To _____/_____/_________
$
,
,
.00
,
MM
DD
YYYY
MM
DD
YYYY
23 Instrument type (Check all that apply)
a
Bonds/Notes
i
Commodity options
q
Commodity type ________________________
(Please identify)
b
Cash or equiv.
j
Security futures products
k
Stocks
c
Commercial paper
r
Instrument description ___________________
d
Commodity futures contract
l
Warrants
e
Money Market Mutual Fund
m
Other securities
s
Market where traded ____________________
n
Other non-securities
f
Mutual Fund
(Enter approprite three or four-letter code.)
g
OTC Derivatives
o
Foreign currency futures/options
t
Other (Explain in Part VI)
p
Foreign currencies
h
Other derivatives
24 CUSIP
number
25 CUSIP
number
®
®
26 CUSIP
number
®
27 CUSIP
number
28 CUSIP
number
29 CUSIP
number
®
®
®
Part III
Part III
*30 Type of suspicious activity:
o
Significant wire or other transactions
h
Identity theft
a
Bribery/gratuity
without economic purpose
i
Insider trading
b
Check fraud
p
Suspicious documents or ID presented
j
Mail fraud
c
Computer intrusion
q
Terrorist financing
k
Market manipulation
d
Credit/debit card fraud
r
Wash or other fictitious trading
l
Money laundering/Structuring
e
Embezzlement/theft
s
Wire fraud
m
Prearranged or other non-competitive trading
f
Commodity futures/options fraud
t
Other (Describe in Part VI)
n
Securities fraud
g
Forgery
Catalog No. 35349U
Rev. 03/11
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