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BSA QUESTIONAIRE

In order to satisfy regulatory compliance regarding the Bank Secrecy Act and the impact it has on Commercial
Business Accounts; please complete the following questionnaire
By signing the attached Membership Application and Signature Card, you are stating that you have provided
__________Federal Credit Union with the most current information about your business and that, in the event of a
change of ownership or Authorized Signers, you will notify ___________ Federal Credit Union immediately and
complete the necessary documents to reflect those changes.
Business Name: _______________________________ Business Account Number: ________________________
Business Address:
1.

Please list your primary business type. (Example: Hotel, Restaurant, Car Dealer, Bar, etc.)

2.

In what state(s) is your business physically located7 ______________________________________________

3.

How much will your opening deposit be with us today? _______________________________________ How
are you making that deposit (circle one) Cash Check Money Order
Transfer within Apple
Wire Transfer

4.

Does your business cash checks or money orders for your customers? Yes No
If so, do you have a maximum dollar amount you will cash? S_________________________

5.

Are you intending to use ___________ Federal Credit Union to process Wire Transfers? Yes No If so, what will
be the average dollar amount wired?
Does your business sell Money Orders?
Yes
No
$__________________________

6.
7.

What type of deposits will you be typically making with ______________ Federal Credit Union? (Circle all that
apply)
Cash
Checks
ACH Deposits
Wire Transfers
Other
____________________

Cash
Est. ft of Cash Deposits/month: 0-5 5-10 More than 10
Flow much ($)/month: $l-$1,000 $1,000-$5,000 $5,000-$10,000 More than $10,000
Est. # of Cash Withdrawals/month: 0-5 5-10 More than 10
How much (5)/month: $1-$l,000 $1,000-$5,000 $5,000-$10,000 More than $10,000

Checks
Est. # of Checks Deposited/month:
0-5 5-10 More than 10
How much (5)/month: $l-$l,000 $1,000-$5,000 $5,000-$10,000 More than $10,000
Est. ft of Check Written/month: 0-5 5-10 More than 10
How much ($)/month: $1 -$1,000 $1 ,000-$5,000 $5,000-$ 10,000_ More than $10,000

ACH
Est. # of ACH Direct Deposits/month: 0-5 5-10 More than 10
How much (5)/month: $l-$l,000 $1,000-$5,000 $5,000-$10,000 More than $10,000
Est. ft of ACH Direct Payments/month: 0-5 5-10 More than 10
How much ($)/month: $1 -$1,000 $1 ,000-$5,000 $5,000-$ 10,000_ More than $10,000

WIRE TRANSFERS
Est. ft of Incoming Wire/Funds Transfers/month:
0-5 5-10 More than 10 How much ($)/month: $1$i,000 $1,000-$s,000 $5,000-$lO,000 More than $10,000
Est. # of Outgoing Wire/Funds Transfers/month:
0-5 5-10 More than 10 How much (5)/month: $1$1,000 $l,000-$5,000 $5,000-$10,000 More than $10,000~
Place of origin of wire/funds transfers:
Place of destination of wire/funds transfers:

ATM TRANSACTIONS
Est. # of ATM Deposits/month: 0-5 5-10 More than 10
How much (5)/month:
$l-$l,000 $1,000-$5,000 $5,000-$10,000 More than $10,000
Est. ft of ACH Withdrawals/month: 0-5 5-10 More than 10
How much ($)/month:
$1 -$1,000 $1 ,000-$5,000 $5,000-$ 10,000_ More than $10,000

8.

What amount do you estimate to be the highest dollar amount that will be deposited to your account
at ______________ Federal Credit Union at one time?
$_________________________________________________________

9.

How often will you be making deposits to your account? _____________________________________________

10. What do you estimate will be your average deposit amount per transaction?
$______________________________________________________________

11. What credit union services do you anticipate you will use? (Circle all that apply)
Teller Line
Netbranch
ATM (DBA only)
Money Orders
Night Depository
Official Checks ACH Debit
ACH Credit
Wire Transfers

Signature and Title:

_____________________________________________________

Date Signed:

______________________

FinCEN has defined money services businesses (MSBs) to include five distinct types of financial services providers
and the U.S. Postal Service: (1) currency dealers or exchangers; (2) check cashers; (3) issuers of travelers checks,
money orders, or stored value; (4) sellers or redeemers of travelers checks, money orders, or stored value; and (5)
money transmitters (whose accounts reflect debiting and crediting from professional transmitters). Among other
requirements, certain money services business principals are required to register with FinCEN (see 31 CFR 103.41).
Additionally, many states require MSBs to obtain a license.

Below is the:
Certification and Acknowledgement
I certify that this business is not a Money Services Business as defined by FinCEN at 31 CFR 103.41 and it
performs none of the services described in the citation.
Date_______________________Signature_____________________________________