Suspicious Activity
Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
Previous versions of SARs Form will not be accepted after 31 December 2016
DISCLOSURE MADE UNDER: PROCEEDS OF CRIME ACT 2015, DRUG TRAFFICKING OFFENCES
ACT, TERRORISM ACT 2005 & GAMBLING ACT 2005
☐ Check box if amending a previous report.
GFIU REF No:Click here to enter text.
PART A Reporting Financial Institution Information
1.
Name of financial institution
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2.
Address of financial institution
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3.
City
4.
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5.
Postcode
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Country
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6.
Point of contact for this disclosure
a. Name: Click here to enter text.
b. Telephone: Click here to enter text.
c. Email: Click here to enter text.
d. Fax: Click here to enter text.
7.
Which of the following types of reporting entities best describes you?
☐ Accountant
☐ Bank
☐ Lawyer
☐ Casino
☐ Gaming Company
☐ Life Insurance Co.
☐ e-Money
☐HVD
☐ MSB
☐ Estate Agent
☐ Trust Company
☐ Regulator
☐ Jewellers
☐ Charity
☐ Fund Manager
☐ Co. Management
☐ Independent Asset Manager ☐ Government Department
☐ Other (please specify) Click here to enter text.
8.
Have you made a previous disclosure on this person/ entity?
☐ NO
☐ YES
If YES please include reference number: Click here to enter text.
9.
Is this a request for appropriate consent as required by legislation?
☐ NO
☐ YES
Page 1 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
PART B Suspect Information - Personal
If your report concerns more than one individual, additional copies of Form Part B - 1 can be
downloaded from http://www.fsc.gi/amlgn/downloads.htm
1. Report concerning more than one individual?
☐ YES
☐ NO
2. Last name
3. First name
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4. Middle name (if any)
5. Alias(es)
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6. Date of birth (DD/MM/YYYY)
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7. Gender
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8. Address
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9. City
10. Country
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Choose an item.
11. Post code
12. Occupation & Employer (if known)
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13. Contact Number (if known, include
country code)
14. Email
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15. Subject’s identification document
16. Document number
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Choose an item.
17. Expiry date (DD/MM/YYYY)
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18. Nationality
Choose an item.
19. Have you attached subject’s identification documents?
☐ YES
☐ NO
20. Relationship to financial institution: Please select the most appropriate box(es)
☐ Beneficial Owner
☐ Director
☐ Secretary
☐ Shareholder
☐ Introducer
☐ Agent.
☐ Account Holder
☐ Trustee
☐ Policy holder
☐ Trust settlor ☐ Trust Beneficiary
☐ Company Management
☐ Solicitor/Lawyer
☐ Appointed Power of Attorney
☐ Other (please specify) Click here to enter text.
Page 2 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
PART C - 1 Suspect Information - Entity
If your report concerns more than one Entity, additional copies of Form Part C-1 can be
downloaded from http://www.fsc.gi/amlgn/downloads.htm
1.
Report concerning more than one
2.
Entity?
☐ YES
3.
Choose an item.
☐ NO
Name
4.
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5.
Incorporation number
Type of business
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6.
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7.
Entity:
Date of Incorporation (DD/MM/YYYY)
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Registered Address
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8.
City
9.
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10. Post code
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11. Country of incorporation (if available)
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12. Contact number (if any, include
country code)
Country
Choose an item.
13.
Email
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Page 3 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
Suspect Information – Entity - Shareholder
PART C - 2
Please note for each Shareholder:
If employees of local Management Company fill out Section 1.
If a Company fill out Section 2.
If another individual, please use Form B-1
Please use additional Form C-2 if required
All forms can be downloaded from http://www.fsc.gi/amlgn/downloads.htm
Section 1 – if employee of a local Management Company only
Shareholder Number 1
Employee:
Company
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Shareholder Number 2
Employee:
Company
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Section 2 – if a Company only
Shareholder Number 1
Company Name:
Registered number:
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Country of incorporation:
Registered office:
Choose an item.
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Shareholder Number 2
Company Name:
Registered number:
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Country of incorporation:
Registered office:
Choose an item.
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Page 4 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
Suspect Information – Entity - Director(s)
PART C - 3
Please note for each Director:
If employees of local Management Company fill out Section 1.
If a Company fill out Section 2.
If another individual, please use Form B-1
Please use additional Form C-3 if required
All forms can be downloaded from http://www.fsc.gi/amlgn/downloads.htm
Section 1 – if employee of a local Management Company only
Director Number 1
Employee:
Company
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Director Number 2
Employee:
Company
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Section 2 – if a Company only
Director Number 1
Company Name:
Registered number:
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Country of incorporation:
Registered office:
Choose an item.
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Director Number 2
Company Name:
Registered number:
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Country of incorporation:
Registered office:
Choose an item.
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Page 5 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
Suspect Information – Entity - Secretary
PART C - 4
Please note for each Secretary:
If employees of local Management Company fill out Section 1.
If a Company fill out Section 2.
If another individual, please use Form B-1
Please use additional Form C-4 if required
All forms can be downloaded from http://www.fsc.gi/amlgn/downloads.htm
Section 1 – if employee of a local Management Company only
Secretary Number 1
Employee:
Company
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Secretary Number 2
Employee:
Company
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Section 2 – if a Company only
Secretary Number 1
Company Name:
Registered number:
Click here to enter text.
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Country of incorporation:
Registered office:
Choose an item.
Click here to enter text.
Secretary Number 2
Company Name:
Registered number:
Click here to enter text.
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Country of incorporation:
Registered office:
Choose an item.
Click here to enter text.
Page 6 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
Suspect Information – Entity - Trustee(s)
PART C - 5
Please note for each Trustee:
If employees of local Management Company fill out Section 1.
If a Company fill out Section 2.
If another individual, please use Form B-1
Please use additional Form C-5 if required
All forms can be downloaded from http://www.fsc.gi/amlgn/downloads.htm
Section 1 – if employee of a local Management Company only
Trustee Number 1
Employee:
Company
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Click here to enter text.
Trustee Number 2
Employee:
Company
Click here to enter text.
Click here to enter text.
Section 2 – if a Company only
Trustee Number 1
Company Name:
Registered number:
Click here to enter text.
Click here to enter text.
Country of incorporation:
Registered office:
Choose an item.
Click here to enter text.
Trustee Number 2
Company Name:
Registered number:
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Country of incorporation:
Registered office:
Choose an item.
Click here to enter text.
Page 7 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
PART D Reasons for suspicions
1.
Suspicion Classification, please select: Choose an item.
2.
Please state the general grounds for your suspicion:
3.
This is a free text field. Please describe clearly and completely the factors or unusual
circumstances that lead to the suspicion. If this report is about one or more
transactions that were attempted, also describe why each one was not completed.
Click here to enter text.
Page 8 of 11
Choose an item.
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
PART E
1.
Description of action taken (if applicable)
This is a free text field. Please describe what action, if any, was or will be taken by
you as a result of the suspicious transactions.
Click here to enter text.
Page 9 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
PART F
Suspicious Transactions
If your report concerns more than one transaction, additional copies of Form Part F-1 can be
downloaded from http://www.fsc.gi/amlgn/downloads.htm alternatively
if you have provided your own attachment of transactions please tick this box ☐
1. Date [Click to select a date.]
2. Amount (include currency)
Click here to enter text.
3. Source
Account No:
Sort Code:
Click here to enter text.
Click here to enter text.
Institution:
Account name:
Click here to enter text.
Click here to enter text.
4. Destination
Account No:
Sort Code:
Click here to enter text.
Click here to enter text.
Institution:
Account name:
Click here to enter text.
Click here to enter text.
5. Type:
☐ Cheque
☐ Cash
☐ SWIFT
☐ Other
If other, please specify: Click here to enter text.
Page 10 of 11
Suspicious Activity Report
(SAR DF-1)
PLEASE COMPLETE FORM AND SUBMIT TO GFIU
Confirmation
I confirm that I have completed this Suspicious Activity Report and the contents of the document
are to the best of my knowledge, true and correct.
Name of MLRO:
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Today’s date: [Click to select a date.]
If documents are attached to this SAR – provide list:
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Page 11 of 11