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Suspicious Activity Report

Suspicious Activity Report

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Published by penlandwatch
Suspicious Activity Report form (blank sample form)- to be completed by bank and submitted to regulators
Suspicious Activity Report form (blank sample form)- to be completed by bank and submitted to regulators

More info:

Published by: penlandwatch on Jun 13, 2008
Copyright:Attribution Non-commercial

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08/31/2010

pdf

text

original

 
EX
HIBI
T
B
 
Suspicious
ort
FRB:
FR 2230
OMB No. 7100-0212
Activit
Re
p
FDIC:
6710/06
OMB No. 3064-0077
July 2003
OCC:
8010-9,8010-1
OMB No. 1557-0180
Previous editions will not be accepted after December 31, 2003
OTS:
1601
OMB No. 1550-0003
NCUA:
2362
OMB No. 3133-0094
ALWAYS •
REPORT
TREASURY:
TD F 90-22.47
OMB No. 1506-0001
(see instructions)
I
s
1
Check box below only if correcting a prior report.
u
Corrects Prior Report (see instruction #3 under "How to Make a Report")
Reporting Financial Institution Information
2 Name of Financial Institution
3 EIN
4 Address of Financial Institution
5
Primary Federal Regulator
a
u
ederal Reserve d
u
OCC
6 City
7 State
8 Zip Code
b El FDIC
e
u
OTS
-
c
u
NCUA
9
Address of Branch Office(s) where activity occurred
u
Multiple Branches (include information in narrative, Part V)
10 City
11
State
12 Zip Code13 If institution closed, date closed
MMDD
YYYY
14 Account number(s) affected, if anyClosed?Closed?
a
u
Yes
u
Noc
u
Yes
u
No
b
u
Yes E] No
d
u
Yes
u
No
Suspect Information
u
Suspect Information Unavailable
15 Last Name or Name of Entity16 First Name
E! Middle
18
Address
19 SSN, EIN or TIN
20 City21 State
22 Zip Code23 Country
24 Phone Number - Residence (include area code)
25 Phone Number - Work (include area code)
26 Occupation/Type of Business27 Date of Birth28 Admission/Confession?
//
a
u
Yes
b [] No
MMDD
YYYY
29 Forms of Identification for Suspect:
a
u
Driver's License/State ID
b
u
Passport
c
u
Alien Registration
d
u
OtherNumberIssuing Authority30 Relationship to Financial Institution:
a
u
Accountant
d
u
Attorney
g
u
Customer
j
u
Officer
b
u
Agent
e
u
Borrower
h
u
Director
k
u
Shareholder
c
u
Appraiserf
u
Broker
i
u
Employee
I
u
Other
31 Is the relationship an insider relationship?
a
u
es
b
M No
32 Date of Suspension, Termination, Resignation
IfYes specify:
c
u
till employed at financial institution e
u
erminated
d
u
Suspended
f
u
esigned
MM
DDYYYY
Catalog
No. 22285L
 
Suspicious Activity Information
ate range of suspicious activity
7
4 Total dollar amount involved in known or suspicious activity
Fom
To
Loo
D
YYYY
6^M
DD
YWY
35 Summary characterization of suspicious activity:
I
u
Debit Card Fraud
a
u
Bank Secrecy Act/Structuring/
f
u
Computer Intrusion
m
u
Defalcation/Embezzlement
Money Laundering
g
u
Consumer Loan Fraud
n
u
False Statement
b
u
Bribery/Gratuity
h
u
Counterfeit Check
o
u
Misuse of Position or Self Dealing
c
u
Check Fraud
i
F-1 Counterfeit Credit/Debit Card
p
u
Mortgage Loan Fraud
d
u
Check Kiting
j
u
Counterfeit Instrument (other)
q
u
Mysterious Disappearance
e
u
Commercial Loan Fraud
k
u
redit Card Fraud
r
u
Wre Transfer Fraud
s
u
ther
t
u
Terrorist Financing(type of activity)
u
u
Identity Theft
36 Amount of loss prior to recovery
(if applicable)
37 Dollar amount of recovery (if applicable)38 Has the suspicious activity had a
material impact on, or otherwise
$ ;
i
.00
$
.00
affected, the financial soundness
f
h
i
39 Has the institution's bonding company been notified?
o
t
e
nstitution?
a
u
Yes
b
u
No
a
u
es
b
u
No
40 Has any law enforcement agency already been advised by telephone, written communication, or otherwise?
a
u
DEA
d
u
Postal Inspection
g
u
Other Federal
b
u
FBIe
u
Secret Service
h
u
Statec
u
IRS
f
u
U.S. Customs
i
u
Local
j
u
Agency Name (for g, h or i)
41
Name of person(s) contacted at Law Enforcement Agency42 Phone Number (include area code)43 Name of person(s) contacted at Law Enforcement Agency44 Phone Number (include area code)
Contact for Assistance
R
I
7
5La
N
ame
46 First Name47 Middle
48 Title/Occupation49 Phone Number (include area code)50 Date Prepared
51
Agency (if not filed by financial institution)

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