Form No: - FIS-STR-CBTR-06

Federal Democratic Republic of Ethiopia SUSPICIOUS OR UNUSUAL

Financial Intelligence Service (FDRE FIS) CROSS BORDER TRANSACTION REPORT

Entities should report Suspicious/Unusual transactions to Financial Intelligence Service based on the proclamation No.
780/2013.

B: Particulars of person/passenger or entity that is being reported or conducting a transaction

PLEASE NOTE !
1. If a passenger is different from Entity or organization he/she must be greater than 18 years old.
2. Please complete as many fields as possible in part B
3. Complete part B1 if you are reporting a Person.
4. Complete part B2 if you are reporting an Entity.
5. Fields marked with asterisks (*) are mandatory’s.
6. If multiple persons or entities are being reported, please supply details for each on a separate page

B1: Particulars of person/passenger being reported

1. Means of transportation (mark with an X): Land Air Sea

2. Direction of Travel (mark with an X):* Entering to Eth. Leaving Eth.

3. Person’s Involvement (mark with an X):* Individual On behalf of another person
4. Full name(s) of person:-------------------------------------------------------------------------------------------------------------------------------------------------------------
5. other name(s) of a person----------------------------------------------------------------------------------------------------------------------------------------------------------
6. Identification type (mark with an X): Known Unavailable Others __________________________________

6.1) If it is Known; Please! Register the followings

Identification information
Residence identification number *
Other Identification number *
Birth date *
Sex *
Passport number *
Issuing Country of Passport *
Nationality

7. Country of Residence :--------------------------------------------------------------------------------------------------------------------------------

8. Country of origin : ---------------------------------------------------------------------------------------------------------------------------------------
9. Occupation of a person:--------------------------------------------------------------------------------------------------------------------------------
10. Permanent Address(mark with an X):* Known Unavailable Others _________________________

10.1) If the address is known, please provide the following:

Address information

Country
State/region*
Sub-city/Zone*
Woreda*
Town
House No. *
Postal Address

Form Number FIS-STR-CBTR-06 Page 1

 Form No: - FIS-STR-CBTR-06

Federal Democratic Republic of Ethiopia SUSPICIOUS OR UNUSUAL

Financial Intelligence Service (FDRE FIS) CROSS BORDER TRANSACTION REPORT

Final Destination

10.2) Address in Ethiopia if different from the above:

Entities should report Suspicious/Unusual transactions to Financial Intelligence Service based on the proclamation No.
780/2013. Address information while in Ethiopia

State/region*

City/Town*

Sub-city/Zone*

Hotel Name *

Room No(if known)

11. Telephone number(s) and E-mail address of a person/passenger (e.g. +251 -----------------------)

Telephone number(s) and E-mail address

Business mobile Tel No *
Business Tel No: *
Business Fax No:
Residential Tel No
E-mail address

B2: Particulars of Entity or Organization being reported

1. Means of transportation (mark with an X): Land Air Sea

2. Direction of Travel (mark with an X):* Entering to Eth. Leaving Eth.
3. Full Name(s) of Entity *---------------------------------------------------------------------------------------------------------------------------------------------
4. Type of Business * --------------------------------------------------------------------------------------------------------------------------------------------------
5. Registration No-): --------------------------------------------------------------------------------------------------------------------------------------------------
6. Tax Identification Number of Entity -------------------------------------------Issuing Country -----------------------------------------------------------
7. Country of Origin (if other than Ethiopia): ---------------------------------------------------------------------------------------------------------------------
8. Address of Entity (mark with an X): Known Unavailable Others _______________________
8.1) If the address is known, please provide the following:

Form Number FIS-STR-CBTR-06 Page 2

 Form No: - FIS-STR-CBTR-06

Federal Democratic Republic of Ethiopia SUSPICIOUS OR UNUSUAL

Financial Intelligence Service (FDRE FIS) CROSS BORDER TRANSACTION REPORT

Entities should report Suspicious/Unusual transactions to Financial Intelligence Service based on the proclamation No.
780/2013.
Address information
Country
State/region*
Sub-city/Zone*
Woreda*
Town
House No. *
Business Tel no
Business Fax no
E-mail address
Postal Address

9. Person/Individual information who conducting the transaction on behalf of company/orgs.

a. Full Name(s) of a Person *--------------------------------------------------------------------------------------------------------------------------

b. Other Name(s) of a Person---------------------------------------------------------------------------------------------------------------------------
c. Identification type (mark with an X): Known Unavailable Others _____________________
If it is known; please! Register the followings

Identification information
Residence identification number *
Other Identification number *
Birth date *
Sex *
Passport number *
Issuing Country of Passport *
Nationality

10. Country of Residence :--------------------------------------------------------------------------------------------------------------------------------

11. Country of origin : ---------------------------------------------------------------------------------------------------------------------------------------
12. Occupation of a person:--------------------------------------------------------------------------------------------------------------------------------
13. Permanent Address(mark with an X):* Known Unavailable Others ______________________
13.1) If the address is known, please provide the following:

Address information
Country
State/region*
Sub-city/Zone*
Woreda*
Town
House No. *
Postal Address
Final Destination

Form Number FIS-STR-CBTR-06 Page 3

 Form No: - FIS-STR-CBTR-06

Federal Democratic Republic of Ethiopia SUSPICIOUS OR UNUSUAL

Financial Intelligence Service (FDRE FIS) CROSS BORDER TRANSACTION REPORT

Entities should report Suspicious/Unusual transactions to Financial Intelligence Service based on the proclamation No.
780/2013.

Address information while in Ethiopia

State/region*
City/Town*
Sub-city/Zone*
Hotel Name *
Room No(if known)
13.2) Address in Ethiopia if different from the above:

14. Telephone number(s) and E-mail address of a person/passenger (e.g. +251 -----------------------)
Telephone number(s) and E-mail address
Business mobile Tel No *
Business Tel No: *
Business Fax No:
Residential Tel No
E-mail address

C: Transaction movement direction, Type and Associates information

PLEASE NOTE 1. Please complete as many fields as possible in part c

2. If multiple transactions are involved, please supply details for each transaction on a
separate page
1. Transaction Date *-----------------------------------------------------------------------------------------------------------------------------

2. Country from which CBNI was moved( If possible) ---------------------------------------------------------------------------------------

3. Country to which CBNI is to be moved( If possible) ---------------------------------------------------------------------------------------

4. Manner or the type of CNBI and/or precious metals/stones in which the transaction was conducted (Mark with X) *
Currency Travelers’ Cheque Cheque Money Order Bill of exchange Promissory Note
Precious metals/stones Others
4.1) If Precious metals/stones or others is selected; Please! Name the item and weight of material ________________________________

___________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

5. Currency code in which the transaction was conducted (eg ETB, USD)* ----------------------------------------------------------------------------------

6. Amount *--------------------------------------

7. Purpose or reason why carry CBNI -------------------------------------------------------------------------------------------------------------------------------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Form Number FIS-STR-CBTR-06 Page 4

 Form No: - FIS-STR-CBTR-06

Federal Democratic Republic of Ethiopia SUSPICIOUS OR UNUSUAL

Financial Intelligence Service (FDRE FIS) CROSS BORDER TRANSACTION REPORT

Entities should report Suspicious/Unusual transactions to Financial Intelligence Service based on the proclamation No.
780/2013.
8. Owner of CBNI information (If different from passenger)*
Name and address of owner of CNBI from whom the passenger is received (if possible)
Person/Entity name
Country
City/town
Tel No
e-mail address
Final destination

9. Intended recipient of CBNI information (If different from passenger)*

Name and address of Intended recipient of CNBI (if possible)
Person/Entity name
Country
City/town
Tel No
e-mail address
Final destination

10. Associates
a. Individual Association
If the subject of the disclosure has an associate and the associate is an individual, fill in the following about the associate. If
there are 2 or more associates that are individuals, attach the number of pages required to give the following information for
the other associate(s).
Individual Information
Full Name *
Other name(s)
Id Card No. *
Occupation
Reason For Association to main subject
Gender
Nationality
Passport No.
Place of work

b. Companies Association
If the subject of the disclosure has an associate and the associate is a company, fill in the following about the associate. If
there are 2 or more associates that are companies, attach the number of pages required to give the following information for
the other associate(s).
Name *

Registered address *

Form Number FIS-STR-CBTR-06 Page 5

 Form No: - FIS-STR-CBTR-06

Federal Democratic Republic of Ethiopia SUSPICIOUS OR UNUSUAL

Financial Intelligence Service (FDRE FIS) CROSS BORDER TRANSACTION REPORT

Entities should report Suspicious/Unusual transactions to Financial Intelligence Service based on the proclamation No.
780/2013.
Type of business

Other particulars

Reason for association to main subject

D. List of available documents

Provide a list of all available documents related to this report:

___________________________________________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

E. Particulars of Suspicious or Unusual Activity and Signature

1) Provide clearly and completely the events that led to the formation of the conclusion that the
relevant activity is suspicious or unusual and state the reasons for the conclusion being formed
and, what crime do you suspect has been committed.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Form Number FIS-STR-CBTR-06 Page 6

 Form No: - FIS-STR-CBTR-06

Federal Democratic Republic of Ethiopia SUSPICIOUS OR UNUSUAL

Financial Intelligence Service (FDRE FIS) CROSS BORDER TRANSACTION REPORT

Entities should report Suspicious/Unusual transactions to Financial Intelligence Service based on the proclamation No.
780/2013.
___________________________________________________________________________________
___________________________________________________________________________________

2) Signature

Prepared By Confirmed By

Full name _______________________________ Full name ____________________________

Signature _______________________________ Signature _____________________________

Date __________________________________ Date _________________________________

Form Number FIS-STR-CBTR-06 Page 7