Blank Fincen 109 Template

FinCEN Form 109a Suspicious Activity Report by Money Services Business -- Instructions

1

Safe Harbor

i. The transaction involves funds derived

4. SSN -- Social Security Number

from illegal activity or is intended or conducted

5. Instruments -- includes Money order(s)

Federal law (31 U.S.C. 5318(g)(3)) provides

in order to hide or disguise funds or assets derived

and/or Traveler’s Check(s)

complete protection from civil liability for all

from illegal activity (including, without limitation,

6. Redeemer --A business that accepts

reports of suspicious transactions made to

the nature, source, location, ownership or control

appropriate authorities, including supporting

of such funds or assets) as part of a plan to violate

instruments in exchange for currency or other

documentation, regardless of whether such

or evade any Federal law or regulation or to avoid

instruments for which it is not the issuer is a

reports are filed pursuant to this report’s

any transaction reporting requirement under

redeemer. The MSB definition in 31 CFR

instructions or are filed on a voluntary basis.

Federal law or regulation;

1010.100(ff)(4) extends to “redeemers” of

Specifically, the law provides that a financial

money orders and traveler’s checks only insofar

institution, and its directors, officers, employees

ii. The transaction is designed, whether

as the

and agents, that make a disclosure of any possible

through structuring or other means, to evade any

instruments involved are redeemed for monetary

violation of law or regulation, including in

regulations promulgated under the Bank Secrecy

value — that is, for currency or monetary or other

connection with the preparation of suspicious

Act; or

negotiable or other instruments. The taking of the

activity reports, “shall not be liable to any person

instruments in exchange for goods or general ser-

under any law or regulation of the United States,

iii. The transaction has no business or

vices is not redemption under BSA regulations.

any constitution, law, or regulation of any State or

apparent lawful purpose and the money services

C. General Instructions

political subdivision of any State, or under any

business knows of no reasonable explanation for

contract or other legally enforceable agreement

the transaction after examining the available facts,

(including any arbitration agreement), for such

including the background and possible purpose

1. This form should be e-filed through the

disclosure or for any failure to provide notice of

of the transaction.

Bank Secrecy Act E-filing System. Go to

such disclosure to the person who is the subject

iv. The transaction involves the use of the

http://bsaefiling.fincen.treas.gov/index.jsp

of such disclosure or any other person identified

to register. This form is also available for down-

in the disclosure”.

money services business to facilitate criminal

load on the Financial Crimes Enforcement

activity.

Network’s Web site at www.fincen.gov, or may

Notification Prohibited

b. To the extent that the identification of

be ordered by calling the IRS Forms Distribution

Center at (800) 829-3676.

transactions required to be reported is derived

Federal law (31 U.S.C. 5318(g)(2)) provides that

from a review of clearance records or other similar

2. If not filed electronically or through magnetic

a financial institution, and its directors, officers,

records of money orders or traveler’s checks that

media, send each completed suspicious activity

employees, and agents, who report suspicious

have been sold or processed, an issuer of money

report to:

transactions to the government voluntarily or as

orders or traveler’s checks shall only be required

required by 31 CFR 1022.320, may not notify

to report a transaction or a pattern of transactions

Electronic Computing Center-Detroit

any person involved in the transaction that the

that involves or aggregates funds or other assets of

ATTN: SAR-MSB

transaction has been reported.

at least $5,000.

P.O. Box 33117

2. File a SAR-MSB no later than 30 calendar

Detroit, MI 48232-5980

Notification Required

days after the date of initial detection of facts that

3. While all items should be completed fully

constitute a basis for filing the report.

and accurately, items marked with an asterisk (*)

In situations involving suspicious transactions

3. The Bank Secrecy Act requires that each

must be completed according to the provisions of

requiring immediate attention, such as ongoing

paragraph 4 below.

money laundering schemes, a money transmitter;

financial institution (including a money services

a currency dealer or exchanger; or an issuer, seller,

business) file currency transaction reports (CTRs)

4. If the information for a item marked with a

or redeemer of money orders and/or traveler’s

in accordance with the Department of the Treasury

asterisk (*) is not known or not applicable, enter

checks shall immediately notify, by telephone,

implementing regulations (31 CFR Chapter X).

special response “XX” to complete the item. To

an appropriate law enforcement authority. In

These regulations require a financial institution

indicate “Total amount” as unknown, check the

addition, a timely SAR-MSB form shall be filed,

to file a CTR (FinCEN Form 104) whenever a

box provided. Non-asterisk fields should be left

including recording any such notification in Part

currency transaction exceeds $10,000. If a

blank if the information is unknown or not

VI on the form.

currency transaction exceeds $10,000 and is

applicable.

suspicious, a money transmitter, or issuer, seller

5. Complete each suspicious activity report by

or redeemer of money orders and/or traveler’s

A. When To FileA Report:

checks or currency dealer or exchanger must

providing as much information as possible on initial

and amended or corrected reports.

file two forms, a CTR to report the currency

1. Money transmitters; currency dealers and

transaction and a SAR-MSB to report the

6. Do not include supporting documents when

suspicious aspects of the transaction. If the

exchangers; and issuers, sellers and redeemers

suspicious activity involves a currency

filing the suspicious activity report . Retain a copy

of money orders and/or traveler’s checks that are

transaction that is $10,000 or less, the institution

of the suspicious activity report and all supporting

subject to the requirements of the Bank Secrecy

is only required to file a SAR-MSB. Appropriate

documentation or business record equivalent in

Act and its implementing regulations (31 CFR

records must be maintained in each case. See

your files for five (5) years from the date of the

Chapter X are required to file a suspicious

31 CFR Chapter X.

report. All supporting documentation (such as

activity report (SAR-MSB) with respect to:

copies of instruments; receipts; sale, transaction

a. Any transaction conducted or attempted

B. Abbreviations and Definitions

or clearing records; photographs, surveillance

by, at, or through a money services business

audio and/or video recording medium) must be

1. EIN -- Employer Identification Number

made available to appropriate authorities upon

involving or aggregating funds or other assets of

request.

at least $2,000 (except as described in section

2. IRS -- Internal Revenue Service

“b” below) when the money services business

3. ITIN -- Individual Taxpayer Identification

knows, suspects, or has reason to suspect that:

Number

Catalog No. 35084Y

Rev. 3/1/11

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7. Type or complete the report using block

even if the entire address is not known. If the

document used. In box “e” list the number of the

written letters.

street address, city, or ZIP Code is unknown,

identifying document. In box “f” list the issuing

enter “NA” in the item. If a state or country is

state or country. If more space is required, enter

8. If more than one subject is being reported,

unknown, enter “XX” in the item.

the additional information in Part VI. If the subject

use as many copies of the Part I Subject

is an entity or an individual’s identification was

Information page as necessary to record the

D. Item Preparation Instructions

not available, check box “z” and enter “XX” in

additional subjects. Attach the additional page(s)

“Other.”

behind page 1. If more than one transaction

Item 1. Check the box if this report amends

Item 13

*SSN/ITIN (individual) or EIN

location is being reported, use as many copies of

(adds missing data) or corrects errors in the prior

the Part III Transaction Location Information page

report. (See Part V, item “s”).

(entity).

See General Instruction 12 and

as necessary to record the additional locations.

definitions. If the subject named in Items 4

Attach the additional page(s) behind page 2. If

Item 1a-- Check this box if this is a recurring

through 6 is a U.S. Citizen or an alien with a SSN,

more space is needed for the Part VI Narrative,

report filed on continuing activity.

enter his or her SSN in Item 13. If that person is

add as many blank continuation pages as

an alien who has an ITIN, enter that number. For

necessary to complete the narrative. Attach the

Part I Subject Information

an entity, enter the EIN. If the SSN, ITIN, or EIN

additional pages behind page 3.

was unknown or not applicable, enter “XX” in this

If more space is needed to complete any other

Item 2 Multiple subjects. Check this box if

item.

multiple subjects are involved. Attach Part I

Item 14

*Date of birth. See General

item, identify that item in Part VI by “item

Subject continuation pages behind page 1 to

number” and provide the additional information.

account for all additional subjects involved in the

Instruction 9. If the subject is an individual, enter

suspicious activity.

the date of birth. If the month and/or day is not

9. Enter all dates in MM/DD/YYYY format

available or unknown, fill in with zeros (e.g., “01/

where MM = month, DD = day, and YYYY =

Item 3 Subject type. Check box “a” if the

00/1969” indicates an unknown date in January,

year. Precede any single number with a zero,

subject purchased a money order(s) or traveler’s

1969).

i.e., 01, 02, etc.

check(s) or sent a money transfer(s). Check box

Item 15 Telephone number. See General

“b” if the subject cashed a money order(s) or

10. Enter all telephone numberswith (area

traveler’s check(s) or received payment of a money

Instruction 10. Enter the U.S. home or business

code) first and then the seven numbers, using

transfer(s). Check box “c” if both “a” and “b”

number for individual or entity. List foreign

the format (XXX) XXX-XXXX. List fax and

apply. If the transaction is a currency exchange

telephone numbers and any additional U.S.

international telephone numbers in Part VI.

check box “c.” Check box “d” Other and describe

numbers (e.g., hotel, etc.) in Part VI.

in Part VI if the subject is an individual other than

Part II Suspicious Activity Information

11. Always enter an individual’s name by

a customer. Examples are MSB employees and

entering the last name, first name, and middle

agents.

Item 16 *Date or date rangeof suspicious

initial (if known). If a legal entity is listed, enter

its legal name in the last name item and trade

Items 4, 5, and 6 *Name of subject. See

activity. See General Instruction 9. Enter the

name in the first name item.

General Instruction 11. Enter the name of the

date of the reported suspicious activity in the

subject individual in Items 4 through 6. If the

“From” field. If more than one day is involved,

12. Enter all identifying numbers (alien

MSB knows that the individual has an “also known

indicate the duration of the activity by entering

registration, driver’s license/state ID, EIN, ITIN,

as” (AKA) or “doing business as” (DBA) name, enter

the first date in the “From” field and the last date

Foreign National ID, passport, SSN, vehicle

that name in Part VI. If the subject is an entity,

in the “To” field.

license number, etc.) starting from left to right.

enter the legal name in Item 4 and the trade or

Do not include spaces or other punctuation.

DBA name in item 5. If the legal name is not

Item 17 *Total dollar amount. See General

known, enter the DBA name in Item 4. If there is

Instruction 14. If unknown, check box 17a.If the

13. Enter all ZIP Codeswith at least the first

more than one subject, use as many Part I Subject

suspicious activity only involved purchases, or

five numbers (ZIP+4, if known).

Information continuation pages as necessary to

redemptions, or currency exchanges, enter the

provide the information about each subject.

total U.S. Dollar value involved in the reported

14. Enter all monetary amounts in U.S.

Attach the additional copies behind page 1. When

activity. For instance, if multiple money orders

Dollars. Use whole dollar amounts rounded up

there is more than one purchaser and/or payee

from more than one issuer were redeemed, enter

when necessary. Use this format: $000,000,000.

(e.g., two or more transactions), indicate in Part VI

the total of all money orders redeemed. If

If foreign currency is involved, record the

whether each subject is a purchaser or payee and

multiple activities are involved, such as a

currency amount in U.S. Dollars, name, and

identify the instrument or money transfer

redemption of money orders combined with

country of origin in the Part VI narrative.

information associated with each subject. If part

purchase of a money transfer, enter the largest

of an individual’s name is unknown, enter “XX” in

activity amount in Item 17. For instance, if the

15. Addresses, general. Enter the permanent

the appropriate name item. If the subject is an

transaction involved redeeming $5,000 in money

street address, city, two letter state/territory

entity, enter “XX” in Item 5 (if the trade or legal

orders and purchase of a $3,500 money transfer ,

abbreviation used by the U.S. Postal Service, and

name is not known) and in Item 6.

the Item 17 amount would be $5,000.

ZIP code (ZIP+4, if known) of the individual or

Items 7 - 11 *Permanent address. See

Item 18

*Category of suspicious activity.

entity. A post office box number should not be

used for an individual, unless no other address is

General Instructions 13 and 15. Enter “XX” if the

Check the box(es) which best identifies the

available. For an individual also enter any

street address, city, and ZIP Code items are

suspicious activity. Check box “b Structuring”

apartment number or suite number and road or

unknown or not applicable. Enter “XX” if the

when it appears that a person (acting alone, in

route number. If a P.O. Box is used for an entity,

state or country is not known.

conjunction with, or on behalf of other persons)

enter the street name, suite number, and road or

Item 12 *Government issued identification (if

conducts or attempts to conduct activity designed

route number. If the address is in a foreign

to evade any record keeping or reporting

country, enter the city, province or state if Canada

available). See General Instruction 12. Check

requirement of the Bank Secrecy Act. If box “d”

or Mexico, and the name of the country.

the box showing the type of document used to

is checked, specify the type of suspicious activity

Complete any part of the address that is known,

verify subject identity. If you check box

which occurred. Describe the character of such

“z Other”, be sure to specify the type of

activity in Part VI. Box “z” should only be used if

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no other type of suspicious activity box

Item 24 *Legal name of business. Enter

aid if contact is required.

adequately categorizes the transaction.

the legal name of the business where the

Part V Contact for Assistance

Item 19 *Financial services involved.

transactions took place.

Item *45-- Designated contact office. Enter

Check any of boxes “a” through “e” that apply to

Item 25 Doing business as.Enter the trade

identify the services involved in the suspicious

name by which the business is commonly known.

the name of the office that the financial institution

activity. If box “z” is checked, briefly explain the

has designated to receive request for assistance

service on the following line. If “unusual use” is

Items 26-29, 32 *T ransaction location

with this report. This office must have an individual

involved, check the appropriate service box(s)

address. Enter the transaction location address

knowledgeable of this report available during

and box “z” and note “unusual use” and explain

by following General Instructions 13 and 15.

regular business hours.

in Part VI. Check all of boxes “1” through “10”

Item * 46--Phone number. See General

that apply to describe the character of the

Item 30 *EIN (entity) or SSN/ITIN

Instruction B10. Enter the work telephone number

suspicious activity.

(individual). See General Instruction 12 and

of the contact office.

Item 20 *Purchases and redemptions

definitions. If the business identified in Item 24

has an EIN, enter that number in Item 30. If not,

Item *47--Date filed. See General Instruction

(See definition 6 on page 1 of the instructions).

enter individual owner’s SSN or ITIN.

B9. Enter the date this report was filed. For

Enter information about purchases or

electronic filing, it is the date that the report was

redemptions of money orders, traveler’s checks,

Item 31 *Business telephone number. See

e-filed using BSA Direct. For magnetic media

or money transfers. Check the appropriate box

General Instruction 10. Enter the telephone

filing, it is the date the magnetic media was

in column “P” or “R” to identify the entry as a

number of the business listed in Item 24.

forwarded to DCC. For all other filers, it is the

purchase or redemption. Enter the name of the

date the financial institution completed the final

issuers, the total number of instruments

Item 32 Country code. Enter the 2-digit

review and mailed/submitted the report to DCC.

purchased or redeemed, and the total amount of

country code if not US.

Item 48--Agency. If this report is filed by an

the instruments. You can enter up to three

agency other than an MSB, such as a federal or state

issuers in each instrument category. If more than

Item 33 Internal control/file number (If

examiner, enter the name of the reporting agency in

three issuers are involved, enter the information

available). Enter any internal file or report number

Item 48.

on the additional issuers in Part VI.

assigned by the reporting institution to track this

Item 21 *Currency Exchanges. Record up

report. This information will act as an identification

Part VI Suspicious Activity Information --

aid if contact is required.

to two currency exchanges made by the subject(s).

Part IV Reporting Business Information

Narrative*

Check the box “If bulk small currency” if a large

number of small bills was used to pay for the

Enter a narrative describing all aspects of the

currency exchange. Enter the name of the

Item 34 Check this box and go to Part V if the

suspicious activity not covered by form data items.

currency or type of monetary instrument used to

reporting business is the same as the Part III

See page 3 of the form for instructions on

pay for the exchange, and the two-digit code for

Transaction Location. If the reporting business is

completing the narrative. If the initial Part VI

the country that issued the currency. An example

different, complete Part IV.

narrative page is not sufficient, use as many Part

of this would be “Pesos” for the name of the

VI Narrative continuation pages as necessary to

currency and “MX” representing Mexico as issuer

Item 35 *Legal name of business.Enter the

complete the narrative. Attach the continuation

of the currency. Enter the name of the currency

legal name of the reporting business.

pages behind the initial narrative page. Legal

received in exchange and the two-digit code for

disclaimers will not be included in this narrative.

the country that issued the currency. Enter the

Item 36 Doing business as.Enter the trade

Paperwork Reduction Act Notice

value of the exchange in U.S. Dollars. If there

name by which the reporting business is commonly

were more than two currency exchanges, enter

known (if other than the legal name).

the information about the additional exchanges

The purpose of this form is to provide an effective

in Part VI.

Items 37-40, 43 *Reporting business

means for a money services business (MSB) to notify

address. Enter the reporting business address by

appropriate law enforcement agencies of suspicious

Part III Transaction Location Information

following General Instructions 13 and 15.

transactions and activities that occur by, through, or at an

MSB. This report is authorized by law, pursuant to

Item 22 Multiple selling and/or paying

Item 40 *EIN (entity) or SSN/ITIN

authority contained in 31 U.S.C. 5318(g). Information

collected on this report is confidential (31 U.S.C. 5318(g)).

business locations. Check the box if the reported

(individual). See General Instruction 12 and

Federal regulatory agencies, State law enforcement

activity occurred at multiple selling and/or paying

definitions. If the business identified in Item 35

agencies, the U.S. Departments of Justice and Treasury,

business locations. Fill out as many Part III

has an EIN, enter that number in Item 41. If not,

and other authorized authorities may use and share this

Transaction Location Information sections as

enter individual owner’s SSN or ITIN.

information. Public reporting and record keeping burden

necessary to record all locations. Attach the

Item 42 *Business phone number. Enter the

for this form is estimated to average 60 minutes per

additional sections behind page 2 of the SAR-

response, and includes time to gather and maintain

MSB.

telephone number of the reporting business. If

information for the required report, review the instructions,

the reporting business telephone number is a

and complete the information collection. Send comments

Item 23 Type of business location(s).Check

foreign telephone number, leave Item 44 blank

regarding this burden estimate, including suggestions for

box “a” if this is the selling location where the

and enter the number in the Part VI Narrative.

reducing the burden, to the Office of Management and the

customer purchases a money order(s) or traveler’s

See General Instruction 10.

Budget, Paperwork Reduction Project, Washington, DC

20503 and to the Financial Crimes Enforcement Network,

check(s), or initiated a money transfer(s), or

Attn.: Paperwork Reduction Act. P.O. Box 39, Vienna

exchanged currency. Check box “b” if this is the

Item 43 Country code.Enter the 2-digit country

VA 22183-0039. The agency may not conduct or sponsor,

paying location where the customer cashed a

code if not US.

and an organization (or a person) is not required to respond

money order(s) or traveler’s check(s) or received

Item 44 Internal control/file number (If

to, a collection of information unless it displays a currently

payment of a money transfer(s). Check box “c” if

valid OMB control number.

multiple transactions are reported and the business

available). Enter any internal file or report number

was both a selling and paying location for one or

assigned by the reporting institution to track this

more transactions.

report. This information will act as an identification