Fincen Form 101 - Suspicious Activity Report By The Securities And Futures Industries Page 2
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1
2
3
4Part VI
Part III
2
Law Enforcement or Regulatory Contact Information
Part IV
31 If a law enforcement or regulatory authority has been contacted (excluding submission of a SAR) check the appropriate box.
a
DEA
f
Secret Service
k
NYSE
p
State securities regulator
b
U.S. Attorney (**32)
g
CFTC
l
Other RFA
q
Foreign
c
IRS
h
SEC
m
Other RE-futures (CME, CBOT, NYMEX, NYBOT)
r
Other (Explain in Part VI)
d
FBI
i
NASD
n
Other state/local
e
ICE
j
NFA
o
Other SRO-securites (PHLX, PCX, CBOE, AMEX, etc.)
33 Name of individual contacted (for all of Item 31)
32 Other authority contacted (for Item 31 l through r) ** List U.S. Attorney office here.
34 Telephone number of individual contacted (Item 33)
35 Date contacted
(
)
_____/_____/_________
MM
DD
YYYY
Part IV
Reporting Financial Institution Information
*37 EIN / SSN / ITIN
*36 Name of financial institution or sole proprietorship
*38 Address
*41 ZIP code
*40 State
*39 City
42 Additional branch address locations handling account, activity or customer.
43
Multiple locations (See instructions)
44 City
45 State
46 ZIP code
49 NFA ID number
48 SEC ID number
47 Central Registration Depository number
50 Has this reporting individual/entity coordinated this report with another reporting individual/entity? Yes
(Provide details in Part VI) No
51 Type of institution or individual- Check box(es) for functions that apply to this report
s
Securities dealer
j
I A
a
Agricultural trade option merchant
t
Securities floor broker
k
Investment company - mutual fund
b
Affiliate of bank holding company
l
Market maker
u
Securities options broker-dealer
c
CPO
v
SRO-securities
m
Municipal securities dealer
d
CTA
w
Specialist
n
NFA
e
Direct participation program
o
RE-futures
x
Subsidiary of bank
f
FCM
y
U.S. Government broker-dealer
p
Other RFA
g
Futures floor broker
z
U.S. Government interdealer broker
q
Securities broker - clearing
h
Futures floor trader
r
Securities broker - introducing
i
IB-C
aa
Other (Describe in Part VI)
Part V
Contact For Assistance
*52 Last name of individual to be contacted regarding this report
*53 First name
*54 Middle initial
*57 Date report prepared
*55 Title/Position
*56 Work phone number
(
)
_____/_____/_________
MM
DD
YYYY
Send completed reports to:
Detroit Computing Center
Attn: SAR-SF
P.O. Box 33980
Detroit, MI 48232
05/24/10
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