Suspicious Activity Report Form (SAR)

Appendix D

Money Laundering & Financing of Terrorism Guidelines Supervisory Authority, Antigua and Barbuda September 2011

Purpose of the SAR Form The Suspicious Activity Report form is used to report any suspicious transactions or activities that may be related to money laundering or financing of terrorism. The information provided on this form will help detect and prevent such activities.

Section 1: Identity of Subject(s) Conducting the Suspicious Activity or Transaction

• 4. Name of individual or entity

  • (a) Surname or name of entity: _____________________________________________________
  • (b) First name: _______________________________________________________
  • (c) Middle name: ______________________________________________________
  • (d) Alias (if any): ______________________________________________________
  • (e) Trading as: ______________________________________________________

• 5. Address

  • (a) Street: ______________________________________________________________
  • (b) City: _______________________________________________________________
  • (c) State/Province: ______________________________________________________
  • (d) Postcode: __________________________________________________________
  • (e) Country: ______________________________________________________________

Privacy Statement The provisions of Section 13 of the Money Laundering Prevention Act (MLPA) and Regulations 6 of the Money Laundering Prevention Regulations (MLPR) are designed to help detect money laundering and uncover transactions involving the proceeds of crime. Information reported to the Supervisory Authority at the ONDCP is kept confidential. However, the Supervisory Authority is legally authorized to share the information with another law enforcement authority where the disclosure is required by law or necessary for a legal investigation.

Tipping Off Financial institutions (including employees, staff, directors, owners, or other authorized representatives) shall not notify any person that this SAR has been filed and information relating thereto furnished to the Supervisory Authority. Criminal offense is committed contrary to Section 13(5) of the MLPA for failure to comply with this obligation.

Section 2: Subject Information

• 6. Date of birth (dd/mm/yyyy): ______________________________________________________
• 7. Country of registration: _______________________________________________________
• 8. Occupation/Type of business: _______________________________________________________

Section 3: Details of the Transaction or Activity

• 9. Telephone number (home): _____________________________________________________
• 10. Telephone number (business): _____________________________________________________
• 11. Subject’s relationship to the reporting financial institution
  • (a) Customer
  • (b) Accountant
  • (c) Agent
  • (d) Appraiser
  • (e) Attorney
  • (f) Borrower
  • (g) Broker
  • (h) Director
  • (i) Employee
  • (j) Officer
  • (k) Shareholder
  • (l) Other: _______________________________________________________
• 12. Is the subject working with or for the institution?
  • (a) Yes
  • (b) No

Section 4: Details of the Transaction or Activity

• 20. Accounts affected
  • (1) Account number: _______________________________________________________
  • (2) Account number: _______________________________________________________
  • (3) Account number: _______________________________________________________