Free Other Gov FinCEN FORM 101 (Rev. 5-2004) - Federal


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FinCEN Form 101
Effective May 2004

Suspicious Activity Report by the Securities and Futures Industries
Please type or print. Always complete entire report. Items marked with an asterisk * are considered critical. (See instructions.) OMB No. 1506 - 0019

1 Check the box if this report corrects a prior report (See instructions)

Part I

Subject Information

2 Check box a

if multiple subjects *4 First name

box b

subject information unavailable 5 Middle initial

*3 Individual's last name or entity's full name 6 Also known as (AKA - individual), doing business as (DBA - entity) *8 Address *10 State *11 ZIP code

7 Occupation or type of business *9 City

*12 Country code (If not U.S.) (See instructions)

13 E-mail address (If available) 16 Date of birth
MM

*14 SSN/ITIN (individual), or EIN (entity) *15 Account number(s) af fected, if any . Indicate if closed. Acc't #______________________ yes Acc't #______________________ yes Acc't #______________________ yes *17 Government issued identification (If available) a e f Driver's license/state ID ID number b Passport c Alien registration d Acc't #______________________ yes

__/___/_____
DD YYYY

Corporate/Partnership Resolution

Other ___________________________________________ g Issuing state or country (2 digit code) 19 Phone number - home

(

18 Phone number - work

)

(

)

20 Is individual/business associated/affiliated with the reporting institution? (See instructions) a Yes b No

Part II

Suspicious Activity Information
*22 Total dollar amount involved in suspicious activity To _____/_____/_________
MM DD YYYY MM DD YYYY

*21 Date or date range of suspicious activity From _____/_____/_________ 23 Instrument type (Check all that apply) a b c d e f g h Bonds/Notes Cash or equiv. Commercial paper Commodity futures contract Money Market Mutual Fund Mutual Fund OTC Derivatives Other derivatives i j k l m n o p Commodity options Security futures products Stocks Warrants Other securities Other non-securities Foreign currency futures/options Foreign currencies 25 CUSIP® number 28 CUSIP® number

$
q r s t

,

,

,

.00

Commodity type ________________________ (Please identify) Instrument description ___________________ Market where traded ____________________ (Enter approprite three or four-letter code.) Other (Explain in Part VI)

24 CUSIP® number 27 CUSIP® number

26 CUSIP® number 29 CUSIP® number

Part III Part III
a b c d e f g

*30 Type of suspicious activity: Bribery/gratuity Check fraud Computer intrusion Credit/debit card fraud Embezzlement/theft Commodity futures/options fraud Forgery h i j k l m n Identity theft Insider trading Mail fraud Market manipulation Money laundering/Structuring Prearranged or other non-competitive trading Securities fraud o p q r s t Significant wire or other transactions without economic purpose Suspicious documents or ID presented Terrorist financing Wash or other fictitious trading Wire fraud Other (Describe in Part VI) Rev. 05/22/04

Catalog No. 35349U

Part III Part IV
a b c d e

Law Enforcement or Regulatory Contact Information
f g h i j Secret Service CFTC SEC NASD NFA k l m n o NYSE Other RFA Other RE-futures (CME, CBOT, NYMEX, NYBOT) p q r

Part VI 2
State securities regulator Foreign Other (Explain in Part VI)

31 If a law enforcement or regulatory authority has been contacted (excluding submission of a SAR) check the appropriate box. DEA U.S. Attorney (**32) IRS FBI ICE

Other state/local Other SRO-securites (PHLX, PCX, CBOE, AMEX, etc.) 33 Name of individual contacted (for all of Item 31)

32 Other authority cont acted (for Item 31 l through r) ** List U.S. Attorney office here. 34 Telephone number of individual contacted (Item 33)

(

)

35 Date contacted _____/_____/_________
MM DD YYYY

Part IV

Reporting Financial Institution Information
*37 EIN / SSN / ITIN

*36 Name of financial institution or sole proprietorship *38 Address *39 City 42 Additional branch address locations handling account, activity or customer. *40 State 43

*41 ZIP code

Multiple locations (See instructions)

44 City

45 State

46 ZIP code

47 Central Registration Depository number

48 SEC ID number

49 NFA ID number

50 Has this reporting individual/entity coordinated this report with another reporting individual/entity? 51 Type of institution or individual- Check box(es) for functions that apply to this report jA I a Agricultural trade option merchant k Investment company - mutual fund b Affiliate of bank holding company l Market maker c CPO m Municipal securities dealer d CTA n NFA e Direct participation program o RE-futures f FCM p Other RFA g Futures floor broker q Securities broker - clearing h Futures floor trader r Securities broker - introducing i IB-C s t u v w x y z aa

Yes

(Provide details in Part VI) No

Securities dealer Securities floor broker Securities options broker-dealer SRO-securities Specialist Subsidiary of bank U.S. Government broker-dealer U.S. Government interdealer broker Other (Describe in Part VI)

Part V

Contact For Assistance
*53 First name *54 Middle initial *57 Date report prepared _____/_____/_________
MM DD YYYY

*52 Last name of individual to be contacted regarding this report *55 Title/Position

*56 Work phone number

(

)

Send completed reports to: Detroit Computing Center Attn: SAR-SF P.O. Box 33980 Detroit, MI 48232

Part VI

Suspicious Activity Information - Narrative *

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Explanation/description of suspicious activity(ies). This section of the report is critical. The care with which it is completed may determine whether or not the described activity and its possible criminal nature are clearly understood by investigators. Provide a clear , complete and chronological description ( not exceeding this page and the next page ) of the activity , including what is unusual, irregular or suspicious about the transaction(s), using the checklist below as a guide, as you prepare your account. a. Describe conduct that raised suspicion. b. Explain whether the transaction(s) was completed or only attempted. c. Describe supporting documentation ( e.g. transaction records, new account information, tape recordings, E-mail messages, correspondence, etc.) and retain such documentation in your file for five years. d. Explain who benefited, financially or otherwise, from the transaction(s), how much, and how (if known). e. Describe and retain any admission or explanation of the transaction(s) provided by the subject(s) or other persons. Indicate to whom and when it was given. f . Describe and retain any evidence of cover-up or evidence of an attempt to deceive federal or state examiners, SRO, or others. g. Indicate where the possible violation of law(s) took place ( e.g., main office, branch, other). h. Indicate whether the suspicious activity is an isolated incident or relates to another transaction. i. Indicate whether there is any related litigation. If so, specify the name of the litigation and the court where the action is pending. j. Recommend any further investigation that might assist law enforcement authorities. k. Indicate whether any information has been excluded from this report; if so, state reasons. l. Indicate whether U.S. or foreign currency and/or U.S. or foreign negotiable instrument(s) were involved. If foreign, provide the amount, name of currency , and country of origin. m. Indicate "Market where traded" and " Wire transfer identifier " information when appropriate. n. Indicate whether funds or assets were recovered and, if so, enter the dollar value of the recovery in whole dollars only . o. Indicate any additional account number(s), and any foreign bank(s) account number(s) which may be involved. p. Indicate for a foreign national any available information on subject' s passport(s), visa(s), and/or identification card(s). Include date, country , city of issue, issuing authority , and nationality . q. Describe any suspicious activities that involve transfer of funds to or from a foreign country , or transactions in a foreign currency . Identify the country, sources and destinations of funds. r. Describe subject(s) position if employed by the financial institution. s. Indicate whether securities, futures, or options were involved. If so, list the type, CUSIP ® number or ISID ® number, and amount. t . Indicate the type of institution filing this report, if this is not clear from Part IV. For example, a n IA that is managing partner of a limited partnership that is acting as a hedge fund that detects suspicious activity tied in part to its hedge fund activities should note that it is operating as a hedge fund. u. Indicate, in instances when the subject or entity has a CRD or NF A number, what that number is. v. If correcting a prior report (box in Item 1 checked), complete the form in its entirety and note the corrected items here in Part VI epeated if the meaning is clear . Maintain the information for your files.

Supporting documentation should not be filed with this report.

Information alr eady pr ovided in earlier parts of this form need not necessarily be r

Tips on SAR form preparation and filing are available in the SAR Activity Review at www.fincen.gov/pub_reports.html Enter explanation/description in the space below. Continue on the next page if necessary .

Suspicious Activity Report Narrative (continued)

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FinCEN Form 101a

Suspicious Activity Report (SAR-SF) Instructions
transaction (or a pattern of transactions of which the transaction is a part): i. Involves funds derived from illegal activity or is intended or conducted in order to hide or disguise funds or assets derived from illegal activity (including, without limitation, the ownership, nature, source, location, or control of such funds or assets) as part of a plan to violate or evade any federal law or regulation or to avoid any transaction reporting requirement under federal law or regulation; ii. Is designed, whether through structuring or other means, to evade any requirements of 31 CFR 103 or of any other regulations promulgated under the Bank Secrecy Act, Pub. L. 91-508, as amended, codified at 12 U.S.C. 1829b, 12 U.S.C. 1951-1959, and 31 U.S.C. 5311 - 5314, 5316 - 5332; iii. Has no business or apparent lawful purpose or is not the sort in which the particular customer would normally be expected to engage, and the BD, FCM or IB-C knows of no reasonable explanation for the transaction after examining the available facts, including the background and possible purpose of the transaction; or iv. Involves use of the BD, FCM or IB-C to facilitate criminal activity . 3. The obligation to identify and properly and timely report a suspicious transaction rests with each BD, FCM, and IB-C involved in the transaction, provided that no more than one report is required to be filed by any of the BDs, FCMs, or IB-Cs involved in a particular transaction (so long as the report filed contains all relevant facts). 4. A SAR-SF shall be filed no later than 30 calendar days after the date of the initial detection by the reporting BD, FCM, or IB-C of facts that may constitute a basis for filing a SAR-SF . If no suspect is identified on the date of such initial detection, a BD, FCM, or IB-C may delay filing a SAR-SF for an additional 30 calendar days to identify a suspect, but in no case shall reporting be delayed more than 60 calendar days after the date of such initial detection. In situations involving violations that require immediate attention, such as terrorist financing or ongoing money laundering schemes, the BD, FCM, or IB-C shall immediately notify by telephone an appropriate law enforcement authority in addition to filing timely a SAR-SF . BDs, FCMs, or IB-Cs wishing voluntarily to report suspicious transactions that may relate to terrorist activity may call FinCEN' s Financial Institutions Hotline at 1-866-556-3974 in addition to filing timely a SAR-SF. The BD, FCM, or IB-C may also, but is not required to, contact the SEC or the CFTC to report in such situations. 5. Exceptions. A BD, FCM, or IB-C is not required to file a SAR-SF to report: i. A robbery or bur glary committed or attempted that is reported to appropriate law enforcement authorities, or for lost, missing, counterfeit, or stolen securities with respect to which the BD files a report pursuant to the reporting requirements of 17 CFR 240.17f-1; Catalog No. 35351G

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Safe Harbor Federal law (31 U.S.C. 5318(g)(3)) provides complete protection from civil liability for all reports of suspicious transactions made to appropriate authorities, including supporting documentation, regardless of whether such reports are filed pursuant to this report' s instructions or are filed on a voluntary basis. Specifically , the law provides that a financial institution, and its directors, officers, employees, and agents, that make a disclosure of any possible violation of law or regulation, including in connection with the preparation of suspicious activity reports, "shall not be liable to any person under any law or regulation of the United S tates, any constitution, law , or regulation of any State or political subdivision of any State, or under any contract or other legally enforceable agreement (including any arbitration agreement), for such disclosure or for any failure to provide notice of such disclosure to the person who is the subject of such disclosure or any other person identified in the disclosure." Notification Prohibited Federal law (31 U.S.C. 5318(g)(2)) provides that a financial institution, and its directors, officers, employees, and agents who, voluntarily or by means of a suspicious activity report, report suspicious transactions to the government, may not notify any person involved in the transaction that the transaction has been reported. In situations involving violations that require immediate attention, such as terrorist financing or ongoing money laundering schemes, the financial institution shall immediately notify by telephone an appropriate law enforcement authority in addition to filing a timely suspicious activity report.

ii. A violation otherwise required to be reported on a SAR-SF: (a) of any of the federal securities laws or rules of an SRO by the BD or any of its officers, directors, employees or other registered representatives, other than a violation of 17 CFR 240.17a-8 or 17 CFR 405.4, so long as such violation is appropriately reported to the SEC or an SRO; or (b) under the CEA (7 U.S.C. 1 et seq.) , the regulations of the CFTC (17 CFR Chpt.1), or the rules of any RF A or RE as those terms are defined in the CEA, 7 U.S.C. 21 and 7 U.S.C. 1a(29), by the FCM or IB-C or any of its officers, directors, employees or associated persons, other than a violation of 17 CFR 42.2 as long as such violation is appropriately reported to the CFTC or a RF A or RE. 6.The Bank Secrecy Act requires financial institutions to file currency transaction reports (CTRs) in accordance with the Department of the Treasury's implementing regulations (31 CFR Part 103). These regulations require a financial institution to file a CTR whenever a currency transaction exceeds $10,000. If a currency transaction exceeds $10,000 and is suspicious, the institution must file both a CTR (reporting the currency transaction) and a suspicious activity report (reporting the suspicious aspects of the transaction). If a currency transaction is $10,000 or less and is suspicious, the institution should only file a suspicious activity report. Appropriate records must be maintained in each case. See: 31 CFR Part 103; 17 CFR 240.17a-8; 17 CFR 405.4; 17 CFR 42.2

When to file a report
1. Every broker or dealer in securities (BD), futures commission merchant (FCM), and introducing broker in commodities (IB-C) within the United States shall file with FinCEN, to the extent and in the manner required by 31 CFR 103.19 and 103.17, a report of any suspicious transaction relevant to a possible violation of law or regulation. A BD, FCM or IB-C may also file with FinCEN a report of any suspicious transaction that it believes is relevant to the possible violation of any law or regulation but whose reporting is not required by 31 CFR 103.19 or 103.17. A voluntary filing does not relieve a BD, FCM or IB-C from the responsibility of complying with any other reporting requirements imposed by the Securities and Exchange Commission (SEC), the Commodity Futures Trading Commission (CFTC), a self-regulatory organization ("SRO") (as defined in section 3(a)(26) of the Securities Exchange Act of 1934, 15 U.S.C. 78c (a)(26)), or any registered futures association (RF A) or registered entity (RE) as these terms are defined in the Commodity Exchange Act (CEA) 7 U.S.C. 21 and 7 U.S.C. 1a(29). 2. A transaction requires reporting if it is conducted or attempted by , at, or through a BD, FCM or IB-C, it involves or aggregates funds or other assets of at least $5,000, and the BD, FCM, or IB-C knows, suspects, or has reason to suspect that the

General Instructions A. Abbreviations and Definitions
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. also known as (individual) American Stock Exchange Broker or Dealer in Securities Chicago Board Options Exchange Chicago Board of Trade Chicago Mercantile Exchange Commodity Pool Operator Central Registration Depository Commodity Futures Trading Commission CTA-- Commodity Trading Advisor CUSIP®-- Committee on Uniform Securities ID Procedures DEA-- Drug Enforcement Administration DBA-- doing business as (entity) EIN-Employer Identification Number EUREX--European Exchange FBI-Federal Bureau of Investigation FCM-- Futures Commission Merchant FINRA-- Financial Industry Reg. Auth. IA-Investment Adviser IB-C-- Introducing Broker-Commodities ICE-Immigration & Customs Enforc. IRS-Internal Revenue Service ITIN-- Individual taxpayer ID number ® ISID -- International S ecurities I D Direct. KCBOT- Kansas City Board of Trade LIFFE-- London International Financial Futures Exchange Rev. 03/31/09 AKA-ASE-BD-CBOE-CBOT-CME-CPO-CRD-CFTC--

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27. MATIF-- Marche a Terme International de France. 28. MGEX-- Minneapolis Grain Exchange 29. NASDAQ--Nasdaq Stock Market 30. NFA-National Futures Association 31. NYBOT-- New York Board of Trade (CSCE, CTN, FINEX, NYFE) 32. NYMEX-- New York Mercantile Exchange 33. NYSE-- New York Stock Exchange 34. NQLX-- Nasdaq Liffe Markets 35. OTC-Over-the-counter 36. PCX-Pacific Exchange 37. PHLX-- Philadelphia Stock Exchange 38. RE-Registered Entity 39. RFA-Registered Futures Association 40. SEC-Securities and Exchange Commission 41. SRO-Self-Regulatory Organization 42. SSN-social security number 43. USFE-U. S . Futures Exchange B . How to make a report: 1. This form should be e-filed through the Bank Secr ecy Act E-Filing System. Go to http://bsaefiling.fincen.treas.gov to r egister. This form is also available for download on the Financial Crimes Enforcement Network' s Web site at www.fincen.gov, or may be ordered by calling the IRS Forms Distribution Center at (800) 8293676. If not filed electronically , send each completed suspicious activity report to: Detroit Computing Center Attn: SAR-SF P.O. Box 33980 Detroit, MI 48232 2. While all items should be completed fully and accurately, items marked with an asterisk (*) are considered critical and must be completed according to the provisions of paragraph 3 below and any special item instructions. 3. If the information for a critical item marked with an asterisk (*) is not known or not applicable, enter special response "XX" as appropriate to complete the item. Non-asterisk fields should be left blank if the information is unknown or not applicable. NOTE: The XX response for unknown may not be used in item 21(suspicious activity "From" date), the check boxes in item 30, and in Parts IV , V or VI. 4. Complete each suspicious activity report by providing as much information as possible on initial and corrected reports. 5. Do not include supporting documentation with the suspicious activity report filed. Identify and retain a copy of the suspicious activity report and all supporting documentation ( e.g. transaction records, new account information, tape recordings, E-mail messages, correspondence, etc.) or business record equivalent for your files for five (5) years from the date of the suspicious activity report. All supporting documentation must be made available to appropriate authorities upon request. 6. If more than one su bject is being reported, make a copy of page 1 , complete only the subject information in Part I, and attach the additional page(s) behind page 1. If more space is needed to complete any other item(s), identify that item in Part VI by "item number," and provide the additional information. 7. Type or complete the report using block written letters. 8. Enter all dates in MM/DD/YYYY format where MM= month, DD= day , and YYYY= year. Precede any single number with a zero, i.e., 01,02, etc. 9. List all Telephone numbers with (area code) first and then the seven numbers, using the format (XXX) XXX-XXXX. List international telephone and fax numbers in Part VI. 10. Always enter an individual's name by entering the last name, first name, and middle initial (if known). If a legal entity is listed, enter its name in the last name field and XX in the first name field. 11. Enter all identifying numbers (alien registration, Corporate/Partnership Resolution, CRD, CUSIP,® driver 's license/state ID, EIN, ITIN, For eign National ID, ISID, ® NFAID, passport, SEC, and SSN, etc.) starting from left to right. Do not include spaces, dashes, or other punctuation. Use XX as appropriate to indicate unknown (see B3) 12. Enter all Post Office ZIP codes with at least the first five numbers (all nine (ZIP + 4)) if known) and listed from left to right. 13. Enter all monetary amounts in U.S.Dollars. Use whole dollar amounts rounded up when necessary. Use this format: $0,000,000.00. If foreign currency is involved, state name of currency and country of origin in Part VI. 14. Addresses, general . Enter the permanent street address, city , two letter state/territory abbreviation used by the U.S. Postal Service, and ZIP code (ZIP+4 if known) of the individual or entity . A post office box number sho uld not be used for an individual, unless no other address is available. For an individual, also enter any apartment number or suite number, road or route number . If a P .O. Box is used for an entity , enter the street name, suite number, and road or route number . If the address of the individual or entity is in a foreign country , enter the city , province or state, postal code, and the name of the country (country codes may be found at www.fincen.gov/reg_bsaforms.html). Complete any part of the address that is known, even if the entire address is not known. If from the United States, leave country Item blank. C. Specific Suspicious Activity Report Preparation Instructions Item 1-- Type of r eport. Check Box if this report is filed to correct a previously filed SAR-SF . To correct a report, a new SAR-SF must be completed in its entirety . Note corrected items in Section VI (see line "v"). Part I Subject Information
Note: Enter information about the person(s) or entity involved that caused this report to be filed, not the victim of the activity .

Item 2 -- Multiple Subjects. If there are multiple subjects involved, check box "2a" and complete a separate Part I for each subject. Check box "2b" only if NO critical* subject information is available. If ANY subject information is available, record that information in Part 1, leave box "2b" blank, and insert the appropriate special response "XX" in any critical item for which data is missing. Items *3, *4, and 5--Name of Subject . See General Instruction B10. If the subject is an entity , enter the legal name in item 3, enter XX in item 4 and leave item 5 blank. If the entity is operated under a different trade or business name than its legal name, enter the entity' s legal name in Item 3 (e.g., Smith Enterprises, Inc.) and the name of the business in Item 6 ( e.g., Smith's Tours). If more than one Part I is required, make a copy of page 1 and provide the additional information. Item 6-- Also known as, or doing business as . If a reporting institution has knowledge of a subject's separate "AKA" and/or entity' s "DBA" name, enter it in Item 6. Item 7-- Occupation/type of business . If known, identify the occupation, profession, or business that best describes the individual in Part I ( e.g., attorney, car dealer , carpenter , doctor , farmer, plumber , truck driver, etc.). Do not use nondescript terms such as businessman, merchant, store owner (unless store's name is provided). If self employed, unemployed, or retired are used, add currrent/former profession if known ( e.g. self-employed building contractor, unemployed teacher, retired attorney etc.). If the individual' s business activities can be described more fully , provide the additional infor mation in Part VI. Items 8, 9, 10, 1 1, and 12-- *Addr ess. See General Instructions B12 and B14. Item 13-- E-mail addr ess. Enter the subject' s Email address if available. Item *14-- SSN/ITIN (individual) or EIN (entity). See General Instruction B11 and definitions. If the subject named in Items 3 through 5 is a U.S. Citizen or an alien with a SSN, enter his or her SSN in Item 14. If that individual is an alien who has an ITIN, enter that number . If the subject is an entity , enter the EIN. If unknown, enter XX in the first two spaces. Item *15-- Account number(s) . See General Instruction B11. Enter up to four affected account numbers in or through which the suspicious activity occurred. If no account number is affected or the account number is unknown, enter XX in the first account number field. Check the "yes" box to indicate if the account is closed. If more than four accounts are affected, provide the additional information in Part VI.

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Item 16-- Date of birth. See General Instruction B8. If an individual is named in Items 3 through 5, enter the date of birth. If the month and/or day is not available or unknown, fill in with zeros ( e.g., "01/00/1969" indicates an unknown date in January, 1969). Item 17-- *Government issued identification . See General Instruction B11. Check the appropriate box showing the type of document used to verify the subject's identity. Box "d" denotes that a cor porate or partnership resolution was used to identify an entity . If you check box "e", "Other" be sure to specify the type of document used. In box "f", list the ID number of the identifying document. In box "g", list the issuing authority . If all information for item 17 is unknown, check box "e" and enter XX in the space provided for "other ." Items 18 & 19-- Telephone numbers. See General Instruction B9. List any additional number(s) (e.g., hotel, cell, fax, international etc.) in Part VI. Item 20-- Institution association . Indicate whether the subject identified in Part I is, or was, associated with the reporting institution as an "associated person," as defined in section 3(a)(18) of the Securities Exchange Act of 1934 or CFTC rule 1.3(aa), or is, or was, "affiliated with" the reporting institution, as defined in the CFTC rule 4.7(a)(1)(i). If so, explain in Part VI. Part II Suspicious Activity Information Item 21-- *Date or date range of suspicious activity. See General Instruction B8. Enter the date of the reported activity in the " From" field. If more than one day , indicate the duration of the activity by entering the first date in the " From" field and the last date in the " To" field. If the same individual or organization conducts multiple or related activities within the 30 calendar day period after the date of initial detection, the reporting institution may consider reporting the suspicious transactions on one form, but only if doing so will fully describe what has occurred. A new report must be filed for other related suspicious transactions committed after the initial detection period. "XX" may not be used in the "From" date entry . Item 22-- *T otal dollar amount . See General Instruction B13. Enter the total dollar value of the funds or assets involved in the suspicious activity that is conducted by the same individual or organization within the 30 calendar day period after the date of initial detection. For multiple or related suspicious transactions, show the breakdown of this aggregated total in Part VI. For abuse by a person associated with the institution, the value of this item can be zero (0). Do not such any words as "thousand", "million", etc. For foreign currency , convert to U.S. Dollars. If unknown, enter XX. Item 23-- Instrument type . Mark the type of instrument identified in Item 23. (Check all that apply.) In Item 23b, indicate U.S. Dollars only . For Item 23r, indicate currency if other than U.S. Dollars. For Item 23s, enter appropriate three or four letter code. Items 24, 25, 26, 27, 28, and 29-- CUSIP ® Numbers. Enter up to six (6) securities numbers. If more, enter additional in Part V I. Item 30-- *T ype of suspicious activity . Check the box(es) that identifies the suspicious activity . More than one box may be checked. Provide a brief explanation in Part VI of why each box is checked. If none of these items applies, mark "other" and provide in Part VI an explanation of the type of suspicious activity . Use of XX does not apply to this item. Part III Law Enforcement or Regulatory Contact Information Items 31, 32, and 33-- Contacting enforcement authorities. If no contact, go to Part IV. See General Instructions "A. Abbreviations and Definitions" for law enforcement and regulatory identities. If you have advised any law enforcement authority SRO, RF A, or RE-futures entity of the suspicious transactions by telephone or written communication, complete this section. If box "b" or boxes "l" through "r" are checked, provide the name of the authority contacted in Item 32. If no contact, leave Items 31-35 blank. Item 34-- Telephone number of individual contacted. See General Instruction B9 for format. Item 35-- Date contacted. See General Instruction B8 for format Part IV Reporting Financial Institution Information Item 36-- *Name of financial institution or sole proprietorship . Enter the full legal name of the institution, i.e., the name shown on the charter or other document creating the entity and registered with the SEC or CFTC. If a sole proprietor, enter the business name of the proprietorship registered with the SEC or CFTC. Item 37--*Employer identification number . See General Instruction B11. Enter the reporting financial institution's EIN. If sole proprietor enter SSN or ITIN. Items *38, *39, *40, and *41-- Address. See General Instruction B 14. This address should be of the principal office or headquarters in the United States. Items 42, 43, 44, 45 and 46-- Additional address locations . See General Instruction B14. If more than one location is involved, e.g., branch office etc., provide the address of the location where the most significant portion of the suspicious transactions occurred. If more than two locations are involved check box 43 and list locations in Part VI. Item 47-- Central Registration Depository number. See General Instruction B1 1. If none, leave blank. Item 48-- SEC number . See General Instruction B11. This is a ten digit number including the prefix of either "8" or "008" depending on the system used. If none, leave blank. Item 49-- NF A identification number . See General Instruction B11. If none, leave blank. Item 50-- Joint/coordinated reporting. If this is a joint/coordinated report involving more than one individual/entity (see "When to file a report Item 3") check the appropriate box and provide the details in Part VI. Item 51-- Type of r eporting institution . Check all boxes that apply to this particular report. If none of these categories apply to you, explain in Part VI. The Federal Bureau of Public Debt, its agents, and any other federal agency issuers of Federal Securities should mark "U.S. Government broker/dealer." S tate or municipal issuers of municipal securities should mark "Municipal broker/dealer." A securities SRO, RF A, or RE-futures entity filing this form should identify the institution type as that of the member institution for which this report is being filed, and in Part V, (Items 52, 53, 54, 55, 56, and 57) identify the securities SRO, RF A or RE-futures entity individual to contact. Part V Contact for assistance

Items 52, 53, and 54-- *Contact individual. See General Instruction B10. Item 55-- *Title/Position . Enter the job title/ position of the contact individual. Item 56 -- *Work t elephone n umber. See General Instruction B 9. Item 57-- *Date report prepared. See General Instruction B8. Part VI * Suspicious Activity Information Narrative See page 3 of the form for instructions. Paperwork Reduction Act Notice: The purpose of this form is to provide an effective means for financial institutions to notify appropriate law enforcement agencies of suspicious transactions that occur by , through, or at the financial institutions. This report is required by law , pursuant to authority contained in 31 U.S.C. 5318(g). Information collected on this report is confidential (31 U.S.C. 5318(g)). Federal securities and futures regulatory agencies and the U.S. Departments of Justice and Treasury, and other authorized authorities may use and share this information. Public reporting and recordkeeping burden for this form is estimated to average 2 hours per response, and includes time to gather and maintain information for the required report, review the instructions, and complete the information collection. Send comments regarding this burden estimate, including suggestions for reducing the burden, to the Office of Management and Budget, Paperwork Reduction Project, Washington, DC 20503 and to the Financial Crimes Enforcement Network, Attn.: Paper work Reduction Act, P.O. Box 39, Vienna VA 221830039. The agency may not conduct or sponsor, and an organization (or a person) is not required to respond to, a collection of information unless it displays a currently valid OMB control number .