COVERED TRANSACTION REPORT (CTR) | AMLC Form No. (Complete al parts thet enply—see instructions) Date ofRopot ano) 1 —Ghosk al bores) atop aC) Amends reportdated—__@aawoorrryr) > C2 neiviuat person © D_ligte persons 9 L) Corporation PART | Reporting Covered Institution Information 2 Name of covered istoton 3 Rinne of business (a branch, spacty location) ToS Fas Saad, ae 3 Sipaniang aay tt BOT) Osec ie [a Rasiese ‘initio, bulking no. & street Barangay oy ‘province Zp e0%e 7 Haine of contact person B Telephone nos, Ga Fst a, | 8 Fa 08 iisposiion Part ll Person(s) Involved in Transaction(s) Section A_ individual Person 0. Name Fist Wit TT Home adees ‘tio. balding no. & stool” Barangay ay province Zp coi 12 Home el ro. 49 LISSSLIGSIS CTT io. “P44 Dae of Binh [8 Place of inh I= (town, city, province) 18 Vom fax, ao) 17 Business name 78 Business fo. no 18 Business fax io. 20 Rares nitne, building no & scot barangay province Tp code ‘Thansacton rivals Ue Opening ofan BeCOU, PASE CMB ih SECTOR 21 Transaction was enor into by the ctontn person Dyes Ono 22 Document to vary identity a] Divers oense —b Z_Alion registration eC Passpeat 40) Company iD 0L) Others 23 Issuing autholy 24 Number 25 Oataissued JT 26 Date ol exoiy I 7. TaiTOaFYYY) TITDONYYY)[ 27 Relate ship 6 covered instion (Ghee aif appicabye Boxes) a Daccountant bOAtiomey © [Customer Dotter e [Agent { Cltorower 9 [Director ny CiSharenolder i appraiser § Di8roker k Dlempioyee 1D] Depositor mE] Other (please specify) 2s the relationship an employment lationship? Dale oF suspension, termination, resignation aClves = bLINo Yes spectty (AN ODNCYPY) ¢ [1Siillemployed —_¢ (Terminated ¢ Cl Suspended 1 E] Resigned Section B Multiple Persons Please accomplish te for contained ih Aiex "A" Tor each naval 30 Number of indtviuats 31 Number of attached forms oF Annex“A"_ Section © Corporation or Partnership TE Rogiated name BF Regiatallon ne. 34 Date of regralon L _iveyooyewwy) | 35 Aras 6 Telephone nos init. billing no. and sree Parangay Seen eee EEE 7 Fane: ay Ponce Wp eoda [38 Nata ofbusiness 39 Bocuiant to venly Tegal existence 21) Cerificate of registration iMncal permits bO_Artcos of incorporaton/By.4 aus 61 Others PART Ill Description of Transaction 4 Type oF account __[] Bank _b( Secwiies_e (Insurance _d D1 other -TDesérilio of Wansaction (check al @pfeablo boxes) aC] single transaction bE series or combination of transactions (2) conducted within tia (5) consecutive banking daye 6 amount invalved isn excess of Pho Mion rie equiv ©) clients not propery identiied £ E) amount of transaction Is not commensurate with cients siness or fnanelal capaciy ‘9. no underlying legal or rade cbtgation, purpose, origin or oconomie jutitealion 1B) unusually latge and complex 11 cash depositor investment naving no credible purpose or erigin, underlying trade obligation fr contact In oretgn curoncySingle Wansaction 42 Amount involved 48 Type of wansaciion” a) Philippine currency Php 00 Laas 5G Foogneureny) 0 cL Cashiers check’s) — 2] Deposit dO) Money order(s} oe 00 bE) withdrawal eC Bank drafts) amis 00 Fund tanster Ey Travolrs checks ra 4 Remittance OCF Secures a 0 {1 Bis payment 5 Omer 1 Lean payment #8 Branch “45 Account Number SEC af] Secures purchase 5 ae NG Secuntes tne me | mao SceaeeCHaeECeae Series or combination of transactions transaction. 47 Number of transactions. 43. Number of attached fons of Annex "8" ic 1G] Policy purchase 1D Pokcy sae kD Poicy sotemont ' 1 Paiicy cancelation OQ others ‘lease specty) Ir fhe transection involves a seras or combination of transactions, .ccmmpish the form contained in Annex “Bfor each PARTIV Persons Preparing Report Tart Tieposiion “50 Companies ofice oF his equivalent Test Tulorposiion Tat Tilepestion “Spraiae "SY Senior oicer with rank nol Tower Han sensor view present) Fist Fiat ‘Sigiatare rt Spats “25 Beran Whe Gaal relly wah The Gisioner i the WaASBSION cx wG GUE Tia nlamal vapor TH. 2D Attached —b) NotAttached. Reasons. 82 Copy of aulhorizaion fom cavered ination of porsons making, jreparing and approving His reportGoneral inctructions, Who Must File—Each covered institution must fle AMLC Foxe fs (CTR) for each transaction by, thug, ‘or fo tho covered ineiution wich involves a transaction in Philijine Gen or its equivalent in foregn curtency of more ‘han Php4,000,000.00, Muiliple transactions must be treated 3 @ since tansaction ithe covered instiaion has knowledge that (1) they are by or on Behalf of the sara prs, atkd (2) they result in currency recelved (Cash In) oF Ccutroncy disbursed (Cash Out) by the covered institution totaling nica then Php 00,000.00 in a series of transactions. A business day is calendar day. \dentiication Requirements.— This Is important! Al incvds contacting a reportable transacton(s for themselves ‘oF for anothor person must be Wentiled by moans of an offal documents} from the covered Inston as the person's authorized to make such a repo. {completing the CTR, the covered insuton must indicate on ti form the method. ype, and numberof the identification ‘of the account holder or customer usod in the tansacion, Slate noite euch as “Known customer” or “signature card on filo" are not sulicent for form eamnpition, ‘When and Where To File.—Fis this CTR within five (5) days trv which the transaction occured to: THE EXECUTIVE DIRECTOR ANTLMONEY LAUNDERING COUNCIL BANGKO SENTRAL 1G PILIPINAS. COR. A MABINI AND P. OCAMPO STS. MALATE, MANILA Penalties —Civil and criminal penalties are provided by the law ic alle to le @ CTR orto supply information or for fling a false or raudulent CTR. Specific Instructions 4. Because of the limited space of the CTR, it may be necassz1y to submit adultonal information on atlached sheets Subinit this additional informaton on plain paper attached fo the i. Be suxe fo put the covered Insltuton's, individuals ‘or organization's name ari identifying number (elem 2, 3, 4, and 6 of the CTR) on any adltanal sheets 50 tal iit becomes separated, may be associated withthe CTR. 2, Amounts may be aggregated. The tueshold limit or mandatory fig ofa covered \ansaction report is an amount ia ‘excess of Phip4,000,000.00. This covers he folowing tansactions 3. a single, sores or combination of transactions a total anicrnt in excess of Php4,000,000.00 or an enuivaent in foreign curency based on the prevailing exchange ral within five (6) consecutive benking days where the tenis not properly Kleniied andlor the amount i not c=wiensurate with his business or financial eapacty, or Is witout any underying legal or trade ebigation, pup. cxgha or aconomie jusbtcaton, b. A singe, series or combination or patlern of urussily large and complex transactions in excess of hp4000,000.00 or an equivalent in foreign curry Isiced on the prevaling exchenge rate, especialy cash ‘deposits and investments having ne credible purpose ar «righ, underying trade obligation or contract 3. Enter the ful adress of the covered institution where tha tansaetion occutred. bere are multiple Wansactions, Provide Information on the office or branch where any one ofthe tsactions has occurred. 4. The CTR sholl be signed by the employee(s) wio deat decty with customer Inthe Wansaction and who made the ina intemal report within the covered insttuton, the Compliance cer ofthe covered institution, wio made the necessary evaluation ofthe transaction and 3 senior offical of te covered instiution witha rank not lower tian Senior vice-president, who approved the fling of the CTR.AMLCFORMNO. ANNEX “A’ Form for Information on Individuals Section B Multiple Persons Incividual Information 1 Raine Tat ia ie 2 Bisinass naive F CSSSTTSSIST ito Faia al bith Beier (uO) B Tens. TO Fans. 7 Place of bith (own, oly province) O Rates STTelephone w05. Unite, Buling no. and street Darangay 10 Fax ay proves Bp axie TTiransaclon ivoWes tie opening ofa acount lease CamMBEN his Soca 41 Transaction was entered into by the cent in person Ors Ono 12 Document to verity idontiy aL] Diiversiicense 6) Allonrocistration [Passport ‘4 Company 0 eC) Others 43 Issuing authority 14 Numton 15 Date issued 77 16 Batol expiry —T—T TDD YY) MADDY) 17 Relationship fo covered ination = a Dcoountant » Diatomey «© [eustomer «Dotteer © CiAgont f DBorrower 8 Director h DiSharehotser 1 Claooraiser iDBroker 1 FIEmptoyee 1D Deposiior m1 Other TBs he lationship anemone velatonship? TB Vito oF Sisfienslon, tamination, resignalion a > TINe Yes speci ¢ L1stilempiyes © Dternated 6 Ci Suspendoa 1 GRossnedAMILC FORM NO. ANNEX “5 Form for Individual Transaction in a Series. Transaction No. 1 Amount involved af] Phitppine currency Php 29 Foreign curency 200 © Cashier's checks) dG) Money order(s) eC Bank aranys) 10) Travelers checks ‘9() Securities AO Otners © Branch 3 Recount Number T Ty oFersacton 4] Deposit 9) Securities purchase 16 Withdrawat AOI Secures sale C1 Fund anstor (Posey purchase Lsss%————| «E] Remittance 11 Policy Sole ©] Bis payment KE] Poy setlement 1 TT Loan payment 1] Policy canettation Tah nib, RY mj Ones (pease speciy) Transai fi.n No. iz 1 Arnouns vee a] Phitipine curency Php 09 DE! Fowsneurency —_ 9 fF Cases checkisy = 09 GL Honey ovate) in ‘00 eL | Bank aanis) a 09 TE) Travele's ches 0 91 Securities ie 0 BID Others [7 wane —~ Resant Wambo 7 ype of waseTOR 21 Deposit 40) Seourtis purchase 5 witranat 1G) Seourtis sate 61 Fund tanster i] Policy purchase a —— HE] Remitiance iG) Fol sale ©) Bis payment KC) Paley setlement ae 11 Loan payment 1] Policy cancelation TDA Others (please specity)