SUSPICIOUS TRANSACTIONS / SUSPICIOUS ACTIVITY REPORT
Made in accordance with the Provisions of Section 55(3) of the Proceeds of Crime Act, Ch. 11:27 (as amended)
For official use only
Instructions:
Notice to staff
1.
ALWAYS COMPLETE ENTIRE REPORT
Your reference No.
Reports on suspicious Financial Transaction/Activity shall be made to the Financial Intelligence Unit as soon as possible, but in any event, within
fourteen (14) days of the date on which the financial institution or listed business knew or had reasonable grounds to suspect that the funds used
for a transaction were the proceeds of a specified offence.[S.55(3B)]
It is an offence to fail to report a suspicious transaction or activity for which the penalty is (a) on summary conviction, five hundred thousand
dollars and imprisonment for a term of two years (b) on conviction on indictment, a fine of three million dollars and imprisonment for a term of
seven years. [S.57(l)]
Check appropriate box:
a.
Initial Report
b.
Corrected Report
c.
Supplemental Report
PART I
REPORTING FINANCIAL INSTITUTION OR RELEVANT BUSINESS
ACTIVITY INFORMATION
2.
Name of Financial Institution or Person or Company engaged in a relevant business activity ………………………....……………………………
3.
Address of Financial Institution or Person or Company engaged in a relevant business activity ………………………………….…………………
4.
Address of Branch Office(s) where activity occurred...........................................................................................………………………….……………………
5.
Asset Size of Financial Institution or Person or Company engaged in a relevant business activity: $………………………………………………..
6.
If Institution or relevant business activity closed, date closed .............. /............. /……....…..
DD
MM YY
7.
Account Number(s) affected (if any)
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
…………………………..…………………………………………………………………………………………………………………………
8.
Have any of the Institution's or relevant business accounts related to this matter been closed?
(a)
( )Yes
if yes identify
……………………………………. / ……………………………………
……………………………………. / ……………………………………
……………………………………. / ……………………………………
(b) ( ) No
PART II
SUSPECT INFORMATION
9.
Last Name or Name of Entity: ………………………… 10. First Name:……………………………… 11. Middle Initial:……….. . .
12.
Address: …………………………………………………………………………………………………………………………………
. . .…………………………………………………………………………………………………………………………………………
13.
Date of Birth ………/…………/……. . . . . . . .
DD
MM
YY
(a)
Co. Reg. No..………………………………
(b)
VAT Reg. No. ………………………………
(c)
B.I.R. No. …………………………………
16.
Occupation: ……………………………. .
17.
Forms of Identification for Suspect:
(a) ( ) Driver’s License
14. Home No..…………………………………
(b) ( ) Passport
14 a.
Cell No. . .…………………………………
15.
Work No …………………………. ……… .
(c) ( ) Trinidad & Tobago I.D. Card
(d) ( ) Other
………Number……………………………………..
………Issuing Authority…………………………………………………………..
………Number……………………………………..
………Issuing Authority………………………………………………………… .
………Number……………………………………..
………Issuing Authority…………………………………………………………
………Number……………………………………..
………Issuing Authority…………………………………………………………
SUSPICIOUS TRANSACTIONS / SUSPICIOUS ACTIVITY REPORT
18.
Relationship to Financial Institution:
( ) (a) Accountant
( ) (e) Borrower
( ) (i) Employee
( ) (b) Agent
( ) (f ) Broker
( ) (j) Officer
( ) (c) Appraiser
( ) (g) Customer
( ) (k) Shareholder
( ) (d) Attorney
( ) (h) Director
( ) (l) Other
PART III
SUSPICIOUS TRANSACTIONS OR ACTIVITY INFORMATION
19.
Date of Suspicious Transactions or Activity: ...……./ ………/ ………..
DD
MM
20. Dollar amount involved in known or suspicious transactions or activity
YY
$ .……………………………………………..
PART IV
(Deleted by Act No. 10 of 2009).
PART V
PREPARER INFORMATION
21.
Last Name: ……………………… 22. First Name: ………………………………
24.
Title: ……………………………
23. Middle Initial: ………………
25. Phone Number: …………………………… 26. Date Prepared: ……/………/………
DD
MM
YY
PART VI
CONTACT FOR ASSISTANCE
(IF DIFFERENT THAN PREPARER INFORMATION IN PART IV)
27.
Last Name: …………………………… . .
28. First Name: …………………………………
29. Middle Initial:…………
30.
Title: ……………………………………
31. Phone Number:
32.
Institution: …………………………………………………………………………………………………………………………
PART VII
SUSPICIOUS ACTIVITY INFORMATION/EXPLANATION/DESCRIPTION
Explanation/Description of known or suspected violation of law or suspicious activity. This section of the report is critical. The care with which it is written may make the difference in whether
or not the described conduct and its possible criminal nature are clearly understood. Provide below a chronological and complete account of the possible violation of law, including what is
unusual, irregular or suspicious about the transaction, using the following checklist as you prepare your account. If necessary, continue the narrative on a duplicate of this page.
a)
Describe supporting documentation and retain for 6 years.
b)
Explain who benefitted financially or otherwise, from the transaction, how much, and how.
c)
Retain any confession, admission, or explanation of the transaction provided by the suspect and indicate to whom and when it was given.
d)
Retain any confession, admission, or explanation of the transaction provided by any other person and indicate to whom and when it was given.
e)
Retain any evidence of cover-up or evidence of an attempt to deceive institution.
f)
Indicate where the possible violation took place (e.g., main office, branch, other).
g)
Indicate whether the possible violation is an Isolated Incident or relates to other transactions.
h)
Indicate whether there is any related litigation; if so, specify.
i)
Recommend any further investigation that might assist law enforcement authorities.
j)
Indicate whether any information has been excluded from this report; if so, why?
k)
Indicate whether currency and/or monetary Instruments were involved. If so, provide the amount and/or description.
(NARRATIVE REPORT)
Indicate any account number that may be involved or affected.
l)
(Narrative Report)
CONTINUED ON SEPARATE SHEETS ( ) YES
DATE…………………………………….
( ) NO
DOCUMENTS ATTACHED ( ) YES
( ) NO
SIGNATURE……………………………………………………