Bank Secrecy Act

FinCEN Report 111

Suspicious Activity Report
December 2011 Please type or print. Always complete entire report.
See instructions for items marked with an asterisk ( * ).
BSA E-File Only This report may be jointly filed (See instructions). OMB Control Number 1506-0065
*1 Check all that apply. (See instructions for restrictions on checking multiple boxes and for joint filing).
Type of
a. Initial report b. Correct/Amend prior report c. Continuing activity report d. Joint report
Filing e. Prior report document control/file number if items 1b or 1c are checked (see instructions) _________________________________

Part I Subject Information 2 Check: a if entity, b if all critical* subject information is unavail (does not include item 24).
*3 Individual’s last name or entity’s legal name a. Unk *4 First name a. Unk 5 Middle initial

5a Gender b. Male 6 Alternate name, e.g., AKA - individual or DBA - entity 7 Occupation or type of business 7a NAICS Code
c. Fem.
d. Unk
*8 Address a. Unk *9 City a. Unk *10 State a. Unk

*11 ZIP/Postal Code a. Unk *12 Country code *13 TIN a. Unk 14 TIN type a EIN
*(If 13 is b SSN-ITIN
a. Unk
known) c Foreign
*15 Form of identification for subject: a. Unk
b Driver’s license/state ID c Passport d Alien registration z Other _______________________________

e Number f Issuing State ____ g Country____

*16 Date of birth a. Unk 17 Phone number - Type 18 Phone number 18a Ext. (If any)
____/____/______ a Home b Work
MM DD YYYY c Mobile d Fax
19 E-mail address (If available) 19a Website (URL) address (If available) 20 Corroborative statement to filer?
a Yes b No

21 Relationship of the subject to an institution listed in Part III or IV (check all that apply) 21a Institution TIN
b Accountant c Agent d Appraiser e Attorney f Borrower g Customer h Director i Employee
j No relationship to institution k Officer l Owner or Controlling Shareholder z Other ___________________________
22 If item 21h, i, k, or l is checked, indicate status of relationship 23 Action date if 22 b, c, or d is checked
a Relationship continues b Terminated c Suspended /barred d Resigned ____/____/_____
Note: A joint SAR cannot be filed if any boxes in 22 are checked. MM DD YYYY

*24 Financial inst. TIN and acct. number(s) affected that are related to subject, if any. Check “Yes” if closed. a. No known acct. involved
b. Non-US Fin. Inst.
c. TIN d. acct # e. Yes f. acct # g. Yes

h. TIN i. acct # j. Yes k. acct # l. Yes

25 Subject’s role in suspicious activity (If applicable) a Purchaser/Sender b Payee/Receiver c Both a & b
*26 Amount involved in this report a Amt. unk. b No amt. involved
Part II Suspicious Activity Information
See Instructions $ , , , .00
*27 Date or date range of suspicious activity for this report 28 Cumulative amount only if box 1c is checked (See instructions)
a. From: ____ /____ / ______ b. To: ____ / ___ / ______
MM DD YYYY MM DD YYYY
$ , , , .00
When completing items 29 through 38, check all that apply.
29. Structuring 30. Terrorist Financing
a. Alters transaction to avoid BSA recordkeeping requirement a. Known or suspected terrorist/terrorist organization
b. Alters transaction to avoid CTR requirement z. Other:_________________________________________
c. Customer cancels transaction to avoid BSA reporting 31. Fraud (Type)
and recordkeeping requirements a. ACH g. Mail
d. Multiple transactions below BSA recordkeeping threshold b. Business loan h. Mass-marketing
e. Multiple transactions below CTR threshold c. Check i. Pyramid scheme
f. Suspicious inquiry by customer regarding BSA reporting d. Consumer loan j. Wire
or recordkeeping requirements e. Credit/Debit card z. Other
z. Other:________________________________________ f. Healthcare _____________________________

Catalog No. 49342F V37.4 (Rev. 11/29/11)

 Part II Suspicious Activity Information* (continued) (Check all that apply). 2
32. Casinos 33. Money laundering
a. Inquiry about end of business day a. Exchanges small bills for large bills or vice versa
b. Minimal gaming with large transactions b. Suspicion concerning the physical condition of funds
c. Suspicious intra-casino funds transfers c. Suspicion concerning the source of funds
d. Suspicious use of counter checks or markers d. Suspicious designation of beneficiaries, assignees or
z. Other:_____________________________________________ joint owners
34. Identification / Documentation e. Suspicious EFT/wire transfers
f. Suspicious exchange of currencies
a. Changes spelling or arrangement of name
g. Suspicious receipt of government payments/benefits
b. Multiple individuals with same or similar identities
h. Suspicious use of multiple accounts
c. Provided questionable or false documentation
i. Suspicious use of noncash monetary instruments
d. Refused or avoided request for documentation
j. Suspicious use of third-party transactors (straw-man)
e. Single individual with multiple identities
k. Trade Based Money Laundering/Black Market Peso Exchange
z. Other:_____________________________________________
l. Transaction out of pattern for customer(s)
z. Other _____________________________
35. Other suspicious activities
a. Account takeover 36. Insurance
b. Bribery or gratuity a. Excessive insurance
c. Counterfeit instruments b. Excessive or unusal cash borrowing against policy/annuity
d. Elder financial exploitation c. Proceeds sent to or received from unrelated third party
e. Embezzlement/theft/disappearance of funds d. Suspicious life settlement sales insurance
f. Forgeries (e.g.,STOLI’s, Viaticals)
g. Identity theft e. Suspicious termination of policy or contract
h. Little or no concern for product performance penalties, f. Unclear or no insurable interest
fees, or tax consequences z. Other:_____________________________________________
i. Misuse of “free look”/cooling-off/right of rescission
j. Misuse of position or self-dealing 37. Securities/Futures/Options
k. Suspected public/private corruption (domestic) a. Insider trading
l. Suspected public/private corruption (foreign) b. Market manipulation/wash trading
m. Suspicious use of informal value transfer system c. Misappropriation
n. Suspicious use of multiple transaction locations d. Unauthorized pooling
o. Transaction with no apparent economic, business, or lawful z. Other:_________________________________________
purpose
p. Two or more individuals working together 38. Mortgage Fraud
q. Unauthorized electronic intrusion a. Appraisal fraud c. Loan Modification fraud
r. Unlicensed or unregistered MSB b. Foreclosure fraud d. Reverse mortgage fraud
z. Other _________________________________ z. Other ___________________________

39 Were any of the following product type(s) involved in the suspicious activity? (Check all that apply)

a Bonds/Notes g Futures/Options on futures m Options on securities s Swap, hybrid, or

b Commercial mortgage h Hedge fund n Penny stocks/Microcap securities other derivative
c Commercial paper i Home equity loan o Prepaid access z Other (List below)
d Credit card j Home equity line of credit p Residential mortgage
e Debit card k Insurance/Annuity products q Security futures products
f Forex transactions l Mutual fund r Stocks

40 Were any of the following instrument type(s)/payment mechanism(s) involved in the suspicious activity? (Check all that apply)
a Bank/Cashier’s check d Gaming instruments g Personal/Business check z Other (List below)
b Foreign currency e Government payment h Travelers checks
c Funds transfer f Money orders i U.S. Currency

41 Commodity type (If applicable) 42 Product/Instrument description (If needed) 43 Market where traded
(Three to five letter code)

44 IP address (If available) 45 CUSIP® number 46 CUSIP® number

 Part III Information about Financial Institution Where Activity Occurred (See instructions) 3
*47 Type of financial a Casino/Card Club b Depository institution c Insurance company *48 Primary
Institution Federal
(check only one) d MSB e Securities/Futures z Other _______________________ regulator
49 If item 47a is checked indicate type (Check only one)
a State licensed casino b Tribal authorized casino c Card club z Other(specify)______________________
50 If item 47e is checked, indicate type of Securities and Futures institution or ind. where activity occurred - Check box(es) that apply to this report.
a Clearing broker-securities d Introducing broker-commodities g Investment company
b Futures Commission Merchant e Introducing broker-securities h Retail foreign exchange dealer
c Holding company i Subsidiary of financial/bank holding company
f Investment Adviser
z Other __________________________
51 Financial institution identification number (Check one box to indicate type) f
a CRD number b IARD number c NFA number d RSSD number e SEC number

52 Financial institution’s role in transaction (if applicable) a Selling location b Paying location c Both a & b
*53 Legal name of financial institution a. Unk 54 Alternate name, e.g., AKA - individual or trade name, DBA - entity

*55 TIN a. Unk 56 TIN type a EIN

(If 55 is b SSN-ITIN
known) c Foreign
*57 Address a. Unk *58 City a. Unk 59 State *60 ZIP/Postal Code a. Unk

*61 Country a. Unk 62 Internal control/file number 63 Loss to financial institution (If applicable)
(2-letter code) $ , , , .00
64 Branch’s role in transaction (if applicable) a Selling location b Paying location c Both a & b
*65 Address of branch or office where activity occurred If no branch activity involved, check this box a 66 RSSD number

67 City 68 State 69 ZIP/Postal Code 70 Country

(2-letter code)

71 Branch’s role in transaction (if applicable) a Selling location b Paying location c Both a & b
72 Address of branch or office where activity occurred (If applicable) a Check if additional branch 73 RSSD number
addresses are listed in Part V

74 City 75 State 76 ZIP/Postal Code 77 Country

(2-letter code)
*78 Primary Federal
Part IV Filing Institution Contact Information regulator
*79 Filer name (Holding Co., lead fin. inst., or agency, if applicable). *80 TIN *81 TIN a EIN
type b SSN/ITIN
c Foreign
*82 Type of financial a Casino/Card Club b Depository institution c Insurance company
Institution
(check only one) d MSB e Securities/Futures z Other _______________________

83 Type of Securities and Futures institution or individual filing this report - Check box(es) for functions that apply to this report
a Clearing broker-securities f Introducing broker-securities j SRO Futures
b CPO/CTA g Investment Adviser k SRO Securities
c Futures Commission Merchant h Investment company l Subsidiary of financial/bank holding company
d Holding company i Retail foreign exchange dealer z Other __________________________
e Introducing broker-commodities
84 Financial institution identification number (Check one box to indicate type) f
a CRD number b IARD number c NFA number d RSSD number e SEC number
*85 Address *86 City 87 State *88 ZIP/Postal Code

*89 Country 90 Alternate name, e.g., AKA - individual or trade name, DBA - entity 91 Internal control/file number
(2-letter code)

92 LE contact agency 93 LE contact name 94 LE contact phone number (Include Area Code) 94a Ext. ( if any)

95 LE contact date ____ / ___ /_____ * 96 Filing institution contact office

MM DD YYYY
*97 Filing institution contact office phone number (Include Area Code) 97a Ext. ( if any) *98 Date filed
(See inst.) ____ / ___ /_____
MM DD YYYY
 Part V *Suspicious Activity Information - Narrative 4
Explanation/description of suspicious activity(ies). This section of the report is critical. The care with which it is completed may determine
whether or not the described activity and its possible criminal nature are clearly understood by investigators. Provide a clear, complete, and
chronological narrative description of the activity. The narrative should address as much of the information listed below as possible which covers the
who/what/when/where of the activity.
 Describe the conduct that raised suspicion, why it was suspicious and  Indicate whether the suspicious activity is an isolated incident or
the date discovered. Did the activity have a material impact on or affect relates to another transaction. Note if this is an updated report
the financial institution’s soundness? and if so, provide the date of the original SAR regarding this activity.
 Explain whether the transaction(s) was completed or only attempted.  Indicate whether there is any related litigation. If so, specify the
 Describe supporting documentation (e.g., transaction records, new names of the parties involved and the court where the action is
account information, tape recordings, e-mail messages, correspon- pending.
dence, etc.). The filer (and joint filer if appropriate) must retain  Indicate whether U.S. or foreign currency and/or U.S. or foreign
a copy of the SAR and its supporting documentation for five negotiable instrument(s) were involved. If foreign, provide the
years from the date the SAR was filed. amount, name of currency, and country of origin.
 Explain who benefited, financially or otherwise, from the transaction(s),  Describe any funds transfers, including in or out identifier numbers,
how much and how (if known). parties involved, dates, amounts, and financial institutions involved.
 Describe and retain any admission, or explanation of the  Indicate for a foreign national any available information on subject’s
transaction(s) provided by the subject(s), or other persons. Indicate to passport(s), visa(s), and/or identification card(s). Include date,
whom and when it was given. country, city of issue, issuing authority, and nationality.
 Describe and retain any evidence of cover-up or evidence of an  Indicate the type of institution filing this report, if this is not clear.
attempt to deceive federal or state examiners, or others.  Indicate if a law enforcement agency has been contacted, list the
 Indicate where the possible violation of law(s) took place (e.g., main name of the agency and the name of any person contacted, their title,
office, branch, other). If the institution or branch has been closed, their telephone number, and when they were contacted.
indicate date.  If correcting or amending a prior report, complete the form in its
 Recommend any further investigation that might assist law entirety and note the changes here in Part V. See instructions.
enforcement authorities.  SAR’s are confidential. Please refer to following references: OCC:
 Indicate whether any information has been excluded from this 12 CFR 21.11, FRB: 12 CFR 208.62, OTS: 12 CFR 563.180, FDIC: 12
report; if so, state reasons. CFR 353, NCUA: 12 CFR 748, FinCEN: 31 CFR 1000.
 Describe subject(s) position(s) if employed by the financial
institution.
Information already provided in earlier parts of this form need not be repeated if the meaning is clear.

Supporting documentation should not be filed with this report. Maintain the information for your files.
Enter the explanation/description narrative in the space below. If necessary, continue the narrative on a duplicate of this page or a blank page.
Tips on SAR form preparation and filing are available in the SAR Activity Reviews at www.fincen.gov/pub_reports.html or the “SAR
Narrative Guidance Package” at www.fincen.gov/narrativeguidance_webintro.pdf.
Do not include legal disclaimers in this narrative.
Paperwork Reduction Act Notice: The purpose of this form is to provide an effective and consistent means for financial institutions to notify appropriate law enforcement agencies of known or suspected criminal conduct
or suspicious activities that take place at or were perpetrated against financial institutions. This report is required by law, pursuant to authority contained in the following statutes. Board of Governors of the Federal Reserve
System: 12 U.S.C. 324, 334, 611a, 1844(b) and (c), 3105(c) (2) and 3106(a). Federal Deposit Insurance Corporation: 12 U.S.C. 93a, 1818, 1881-84, 3401-22. Office of the Comptroller of the Currency: 12 U.S.C. 93a,
1818, 1881-84, 3401-22. National Credit Union Administration: 12 U.S.C. 1766(a), 1786(q). Financial Crimes Enforcement Network: 31 U.S.C. 5318(g). Information collected on this report is confidential (5 U.S.C.
552(b)(7) and 552a(k)(2), and 31 U.S.C. 5318(g)). The Federal financial institutions’ regulatory agencies and the U.S. Departments of Justice and Treasury may use and share the information. Public reporting and
recordkeeping burden for this information collection is estimated to average of two (2) hours per response, and includes time to gather and maintain data in the required report, review the instructions, and complete the
information collection. Send comments regarding this burden estimate, including suggestions for reducing the burden, to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20503
and, depending on your primary Federal regulatory agency, to Secretary, Board of Governors of the Federal Reserve System, Washington, DC 20551; or Assistant Executive Secretary, Federal Deposit Insurance
Corporation, Washington, DC 20429; or Legislative and Regulatory Analysis Division, Office of the Comptroller of the Currency, Washington, DC 20219; or Office of Thrift Supervision, Enforcement Office, Washington,
DC 20552; or National Credit Union Administration, 1775 Duke Street, Alexandria, VA 22314; or Office of the Director, Financial Crimes Enforcement Network, Department of the Treasury, P.O. Box 39, Vienna, VA 22183.
The agencies may not conduct or sponsor, and an organization (or a person) is not required to respond to, a collection of information unless it displays a currently valid OMB control number.