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FIC/STR……………..
FINANCIAL INTELLIGENCE CENTRE
GHANA
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SUSPICIOUS TRANSACTION REPORT
Regulation 34 (4) |
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A person who makes a suspicious transaction report shall not disclose the contents to another person, or reveal the personal details of the officer of the Centre who receives the report to another person. |
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Send completed form to: Financial Intelligence Centre ( ................................. ) Address Accra Or by fax:(030) 2 ................ |
Report No.: ...............................
Date of report ......... ./ ......... ./ ...... Day Month Year |
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Use this form to report suspicious transaction related to money laundering, proceeds of any crime or financing of activities related to terrorism.
Items marked with asterisk (*) must be completed. Those that are marked 'if applicable' must be completed where applicable to the transaction being reported. For all other items, one has to make reasonable efforts to get the information.
PLEASE REFER TO THE ANTI-MONEY LAUNDERING REGULATIONS, 2011 L.I................... FOR MORE DETAILS ABOUT SUSPICIOUS TRANSACTION REPORTS BEFORE COMPLETING THIS FORM |
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PART 1- Information On Reporting Institution/Person |
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1. Which of the following types of reporting persons or entities best describe you?* 1.1........ Bank 1.2......... Non-Bank 1.3 ........ Auctioneer 1.4............ Lawyer 1.5 ........ Accountant .6 .........Foreign Exchange Dealer 1.7 ..... NGO 1.8 ......Insurance 1.9 ........ Casino .10 ....... Inward Funds Remittance 1.11....Real Estate 1.12 .......... Trust 1.13 ...... Car Dealer 1.14 .......Precious Metals & Stones Dealer 1.15 ..... Religious Body 1.16 ...... Oil/Gas 1.17 ......Mining 1.18 ......... Freight Forwarder 1.19 ......... Timber 1.20 .......... Others (please specify) ................................................................................. |
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1. Full address ……………………………………………………. 2. Telephone No* …………… 3. Fax No*…… 4. Nature of Business* 5. Supervised by (if applicable) BoG…………NIC………………..SEC……… Others (please specify)……………………………………… 6. Full Name of Contact Person* and Telephone No.*……………………… 7. Name and Title of reporting officer* Signature of reporting officer*…
Date of Signature* …………./……………../………………… Day Month Year |
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PART 2 - Identification Of Party To The Transaction |
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2. First name(s)*……………… 1. Surname or Name of Entry*………… 3. Previous Names*……………………… 4. Individual's Identity*(enclose copy) Passport… National Identity Card…………
Driver's Licence ………. National Health Insurance Card ………… Voter's ID ….. Others (description) …………………….. 5. Full address*……………………………………………… 6. Country*………………… 7. Office phone number* (with area code)……… 8. Individual’s date of birth*……/…../… 9. Date of incorporation (if applicable)…… …………./……………../………. Day Month Year
10. Date of Commencement of Business*………./……………………./……… Day Month Year 11. Individual's occupation*or Type of Business……………………………………… 12. Relationship to reporting institution* 13. Is the relationship an insider relationship?* Yes/ No……………………………………………………..14. If yes please specify"……………………………………… ………………………..Stillemployed………/Suspended/………………..Terminated………………….Resigned Date of Suspension/Termination/Resignation* ……………./…………./…………. Day Month Year |
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PART 3 - Transaction Details & Suspicion |
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1. Date of Transaction* 2. Date of posting if different from date of transaction* ………../………./…… ………………/………………./… Day Month Year Day Month Year
3. Funds involved in the transaction* A……..Cash D….Electronic funds transfer G….Insurance Policy J....Others (specify) B………Cheque E……………. Bank Draft H……….Money………….Order……….. C..... . . Foreign Currency F.... Securities I………Real Estate 4. Amount of Transaction*........................... 5. Type of Account*………………… 6. Bankaccountdetai1s*…………………………………………………………………… 7. Status of the account at the time the transaction was initiated (if applicable)………… 8. Reason for suspicion*(complete Part V as well)…………………………………… 9. Has the suspicious activity had a material impact on, or otherwise affected, the financial soundness of the institution or person?*………. Yes / No |
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PART 4 - Name of all officers, employees or agents dealing with the transaction |
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1. Full Name of person dealing with this transaction* Name………… Institution………………….. Capacity in which dealing………… ………………………… ……………………………… ………………………………. ………………………….. ……………………………. …………………………………….
2. Other Contacts* Full Name*……………………. Title/ Occupation*…………… Telephone No. *……………………………….. |
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PART 5 - Description Of Suspicious Activity |
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this section of this report is critical.
Describe clearly and completely the facts or unusual circumstances that led to the suspicion of money laundering or terrorist financing*.
The completeness of this section may determine whether or not the described conduct and its possible criminal nature are clearly understood. *
If necessary continue the narration on a duplicate of this page. |
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PART 6 - Description Of Action Taken |
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Please describe what action was taken by you as a result of the suspicious transaction(s)* Eg. Account frozen, refusal to complete transaction.
State also whether the suspect made any voluntary statement as to the origin or source of the proceeds. Kindly enclose copy of the statement, if any.
If necessary continue the narration on a duplicate of this page. |