Fincen Form 109 - Suspicious Activity Report By Money Services Business - 2011
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1
2
3Suspicious Activity Report by
109
FinCEN form
Money Services Business
March, 2011
Previous editions will not be
Please type or print. Always complete entire report. Items
accepted after September
2011
marked with an asterisk * are considered critical. (See instructions
.)
OMB No. 1506-0015
1
Check this box only if amending or correcting a prior report (see item 1 instructions)
1a
Check this box if this is a recurring report
Part I
Subject Information
2
Multiple subjects (see item instructions)
3 Subject type (check only one box)
a
Purchaser/sender
b
Payee/receiver
c
Both a & b
d
Other
*4 Individual’s last name or entity’s full name
6 Middle initial
*5 First name
*7 Address
*10 Zip Code
*11 Country Code
*8 City
*9 State
(If not US)
_
*12 Government issued identification (if available)
a
Driver’s license/state I.D.
b
Passport
c
Alien registration
z
Other ____________________________________
e Number
f Issuing state/country ____________
*13 SSN/ITIN (individual) or EIN (entity)
*14 Date of birth
15 Telephone number
(
)
______/______/________
MM
DD
YYYY
Suspicious Activity Information
Part II
*17 Total amount involved in suspicious activity
a
Amount unknown
*16 Date or date range of suspicious activity
From _____/_____/_________
To _____/_____/_________
$
,
,
,
.00
MM
DD
YYYY
MM
DD
YYYY
*18 Category of suspicious activity (check all that apply)
a
Money laundering
b
Structuring
c
Terrorist financing
z
Other (specify) ___________________________________
*19 Financial services involved in the suspicious activity and character of the suspicious activity, including unusual use (check all that apply).
a
Money order
b
Traveler’s check
c
Money transfer
z
Other _______________________________________________________
e
Currency exchange
Check all of the following that apply
(5)
Individual(s) using multiple or false identification documents
(1)
Alters transaction to avoid completing funds transfer record
(6)
Two or more individuals using the similar/same identification
or money order or traveler’s check record ($3,000 or more)
(7)
Two or more individuals working together
(2)
Alters transaction to avoid filing CTR form (more than $10,000)
(8)
Same individual(s) using multiple locations over a short time period
(3)
Comes in frequently and purchases less than $3,000
(9)
Offers a bribe in the form of a tip/gratuity
(4)
Changes spelling or arrangement of name
(10)
Exchanges small bills for large bills or vice versa
A free secure e-filing system is available to file this report.
If mailing, send each completed SAR report to:
Go to for more
Electronic Computing Center - Detroit
information and to register .
Attn: SAR-MSB
P.O. Box 331 17
Detroit, MI 48232-5980
Catalog No. 34944N
Rev. 3/01/11
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