SCHEDULE 1(Subsection 9(1) and section 11)Suspicious Transaction or Attempted Transaction Report
PART A
Information with Respect to Reporting Person or Entity and Place of Business Where Transaction Is Conducted or Attempted
1*
Person’s or entity’s name
2*
Type of person or entity, as described in any of paragraphs 5(a) to (h.1), (k) and (m) of the Act, or, if person or entity is referred to in paragraph 5(i), (j) or (l) of the Act, type of prescribed business, profession or activity referred to in that paragraph
3*
Identification number assigned to person or entity by Centre
4*
Number that identifies place of business
5*
Address of place of business
6*
Contact person’s name
7
Contact person’s email address
8*
Contact person’s telephone number
PART B
Information with Respect to Transaction or Attempted Transaction
1*
Date of transaction or attempted transaction or night deposit indicator
2
Time of transaction or attempted transaction
3
Posting date, if different from date of transaction or attempted transaction
4*
Type and amount of funds or other assets involved, other than virtual currency
5*
Type and amount of each fiat currency or virtual currency involved
6*
Method by which transaction or attempted transaction conducted
7*
Exchange rates used
8*
In the case of transaction or attempted transaction involving virtual currency, transaction identifiers, including sending and receiving addresses
9*
Indication of whether transaction completed
10*
If transaction not completed, reason why not completed
11
Purpose of transaction or attempted transaction
12
Source of funds or virtual currency involved
13
Name of every person or entity that is source of funds or virtual currency involved and their account number or policy number or, if no account number or policy number, identifying number
14*
Following details of remittance of, or in exchange for, funds or virtual currency received:
(a)
method of remittance
(b)
if remittance is in funds, type and amount of each type of funds involved
(c)
if remittance is in virtual currency, type and amount of each virtual currency involved
(d)
if remittance is not in funds or virtual currency, type of remittance and its value, if different from amount of funds or virtual currency received
(e)
name of every person or entity involved and their account number or policy number or, if no account number or policy number, identifying number
PART C
Account and Reference Number Information
1*
Every account number and other equivalent reference number connected to transaction or attempted transaction
2*
Type of account
3*
Branch number, institution number and similar numbers connected to account or reference number
4*
Name of each account holder
5*
Type of fiat currency or virtual currency of account
6
Date account opened
7
Date account closed
8*
Status of account
PART D
Information with Respect to Person or Entity That Conducts or Attempts To Conduct Transaction
1
Person’s or entity’s name
2
Person’s or entity’s address
3
Person’s or entity’s email address
4
Person’s or entity’s telephone number
5
Person’s or entity’s URL
6
Nature of person’s or entity’s principal business or their occupation
7*
Identification number assigned to person or entity by reporting person or entity
Jurisdiction and country of issue of document or other information
10
Relationship of person or entity to person or entity conducting or attempting to conduct transaction
11
In the case of a person,
(a)
their alias
(b)
their date of birth
(c)
their country of residence
(d)
their citizenship
(e)
their employer’s name
(f)
their employer’s business address
(g)
their employer’s business telephone number
12
In the case of an entity,
(a)
name of each person — up to three — who is authorized to bind entity or to act with respect to account
(b)
its registration or incorporation number and jurisdiction and country of issue of that number
(c)
information respecting ownership, control and structure of entity
(d)
name of each person who directly or indirectly owns or controls 25% or more of entity
(e)
if entity is a corporation,
(i)
name of each director
(ii)
address of each director
(iii)
telephone number of each director
(iv)
name of each person who directly or indirectly owns or controls 25% or more of shares of corporation
(f)
if entity is a trust
(i)
name of each trustee
(ii)
address of each trustee
(iii)
telephone number of each trustee
(iv)
name of each settlor of trust
(v)
address of each settlor of trust
(vi)
telephone number of each settlor of trust
(vii)
name of each beneficiary of trust, other than widely held or publicly traded trust
(viii)
address of each beneficiary of trust, other than widely held or publicly traded trust
(ix)
telephone number of each beneficiary of trust, other than widely held or publicly traded trust
(x)
name of each person who directly or indirectly owns or controls 25% or more of units of widely held or publicly traded trust
(xi)
address of each person who directly or indirectly owns or controls 25% or more of units of widely held or publicly traded trust
(xii)
telephone number of each person who directly or indirectly owns or controls 25% or more of units of widely held or publicly traded trust
PART F
Information with Respect to Beneficiary
1*
Beneficiary’s name
2
Beneficiary’s address
3
Beneficiary’s email address
4
Beneficiary’s telephone number
5
Nature of beneficiary’s principal business or their occupation
6
Identification number assigned to beneficiary by reporting person or entity
7
Type of document or other information used to identify beneficiary, or to verify their identity, and number of document or number associated with information
8
Jurisdiction and country of issue of document or other information
9
User name of beneficiary that receives payment online
10
If beneficiary is a person,
(a)
their alias
(b)
their date of birth
(c)
their country of residence
(d)
their employer’s name
11
If beneficiary is an entity,
(a)
name of each person — up to three — who is authorized to bind entity or to act with respect to account
(b)
its registration or incorporation number and jurisdiction and country of issue of that number
PART G
Description of Suspicious Activity
1*
Detailed description of grounds to suspect that transaction or attempted transaction is related to commission or attempted commission of money laundering offence or terrorist activity financing offence
