Fincen Form 109 - Suspicious Activity Report By Money Services Business - 2011 Page 2
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1
2
3Part II
Suspicious Activity Information, Continued
2
*20 Purchases and redemptions (check box “P” for purchase or box “R” for redemption)
Instrument
P
R
Issuers
Total Instruments
Total Amount (US Dollars)
Money Orders:
______________________________________________
______
$__________________.00
______________________________________________
______
$__________________.00
______________________________________________
______
$__________________.00
Traveler’s Checks:
______________________________________________
______
$__________________.00
______________________________________________
______
$__________________.00
______________________________________________
______
$__________________.00
Money Transfers
______________________________________________
______
$__________________.00
______________________________________________
______
$__________________.00
______________________________________________
______
$__________________.00
*21 Currency Exchanges:
Tendered Currency/Instrument
Country
Received currency
Country
Amount (US Dollars)
If bulk small currency
__________________________
______
__________________
______
$__________________.00
If bulk small currency
__________________________
______
__________________
______
$__________________.00
Part III
Transaction Location
22
Multiple transaction locations
23 Type of business location (check only one)
a
Selling location
b
Paying location
c
Both
*24 Legal name of business
25 Doing business as
*27 City
*28 State
*26 Permanent address (number, street, and suite no.)
*29 Zip Code
33 Internal control/file number
*31 Business telephone number
32 Country
*30 EIN (entity) or SSN/ITIN (individual)
(If available)
Code
(
)
(If not US)
Reporting Business
Part IV
34
The Reporting Business is the same as the Transaction Location (go to Part V)
36 Doing business as
*35 Legal name of business
*38 City
*39 State
*37 Permanent address (number, street, and suite no.)
*40 Zip Code
43 Country
44 Internal control/file number
*41 EIN (entity) or SSN/ITIN (individual)
*42 Business phone number (include area code)
(If available)
Code
(
)
(If not US)
Part V
Contact for Assistance
*45 Designated contact office
*46 Designated phone number (Include area code)
47 Date filed (See instructions)
(
)
______/______/________
MM
DD
YYYY
48 Agency (If not filed by a Money Services Business)
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