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Suspicious Activity Report by Depository Institutions June 30, 2007 Previous editions will not be accepted after Dec. 31, 2007 Please type or print. Always complete entire report. See instructions for items marked with an asterisk ( * ). This report may be jointly filed (See instructions). (Formerly Form TD F 90-22.47) Regulator FDIC: FinCEN: FRB: NCUA: OCC: OCC: OTS: Form No. 6710/06 111 FR 2230 2362 8010-1 8010-9 1601 OMB No. 3064-0077 1506-0001 7100-0212 3133-0094 1557-0180 1557-0180 1550-0003 1 Check this box only if amending or correcting a prior report. 1b Check this box if this report is being filed jointly with another financial institution (See instructions for restrictions on joint filing. Also note instructions for listing joint filer information). Part I Subject Information 2 1a Check box a Check this box if this is a recurring report (See instructions). if multiple subjects b if subject information is unavailable 5 Middle initial *4 First name *3 Individual’s last name or entity’s legal name 6 Also known as (AKA - individual) or doing business as (DBA - entity) *8 Address 7 Occupation or type of business *10 State *9 City *11 ZIP Code *12 Country (If not US) (enter 2-digit code) *13 SSN/ITIN or EIN *14 Date of birth _____/_____/_________ MM *15 Forms of identification for subject: a Driver’s license/state ID b Passport c Alien registration z f Issuing Authority _______________________ 16 Phone number - personal (include area code) ( *19 Is the relationship an insider relationship? a If Yes specify: c Still employed at institution d 18 E-mail address (If available) 17 Phone number - work (include area code) ) Suspended ) Yes e b No Terminated f Resigned 21 Admission or confession? 20 If “yes” to item 19, date of action for d, e, or f. a _____/_____/_________ MM Note: A joint SAR cannot be filed if item 19 is checked “yes.” Part II YYYY Other ____________________________________ e Number ( DD DD Yes b No YYYY Suspicious Activity Information *23 Total amount involved in suspicious activity *22 Date or date range of suspicious activity From ____ / _____ / _______ MM DD $ To ____ / _____ / _______ YYYY MM DD YYYY , , a Amount unknown , .00 *24 Summary characterization of suspicious activity (check all that apply): a b c d e f Bank Secrecy Act/structuring/ money laundering Bribery/gratuity Check fraud Check kiting Commercial loan fraud Computer intrusion z Other g h i j k l m Consumer loan fraud Counterfeit check Counterfeit credit/debit card Counterfeit instrument (other) Credit card fraud Debit card fraud Defalcation/embezzlement n o p q r t u False statement Misuse of position or self dealing Mortgage loan fraud Mysterious disappearance Wire transfer fraud Terrorist financing Identity theft ___________________________________________ (type of activity) 25 Loss amount prior to recovery (If applicable) $ , , 26 Amount of recovery (if applicable) , .00 $ , , , .00 Paperwork Reduction Act Notice: The purpose of this form is to provide an effective and consistent means for financial institutions to notify appropriate law enforcement agencies of known or suspected criminal conduct or suspicious activities that take place at or were perpetrated against financial institutions. This report is required by law, pursuant to authority contained in the following statutes. Board of Governors of the Federal Reserve System: 12 U.S.C. 324, 334, 611a, 1844(b) and (c), 3105(c) (2) and 3106(a). Federal Deposit Insurance Corporation: 12 U.S.C. 93a, 1818, 1881-84, 3401-22. Office of the Comptroller of the Currency: 12 U.S.C. 93a, 1818, 1881-84, 3401-22. Office of Thrift Supervision: 12 U.S.C. 1463 and 1464. National Credit Union Administration: 12 U.S.C. 1766(a), 1786(q). Financial Crimes Enforcement Network: 31 U.S.C. 5318(g). Information collected on this report is confidential (5 U.S.C. 552(b)(7) and 552a(k)(2), and 31 U.S.C. 5318(g)). The Federal financial institutions’ regulatory agencies and the U.S. Departments of Justice and Treasury may use and share the information. Public reporting and recordkeeping burden for this information collection is estimated to average 60 minutes per response, and includes time to gather and maintain data in 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, depending on your primary Federal regulatory agency, to Secretary, Board of Governors of the Federal Reserve System, Washington, DC 20551; or Assistant Executive Secretary, Federal Deposit Insurance Corporation, Washington, DC 20429; or Legislative and Regulatory Analysis Division, Office of the Comptroller of the Currency, Washington, DC 20219; or Office of Thrift Supervision, Enforcement Office, Washington, DC 20552; or National Credit Union Administration, 1775 Duke Street, Alexandria, VA 22314; or Office of the Director, Financial Crimes Enforcement Network, Department of the Treasury, P.O. Box 39, Vienna, VA 22183. The agencies 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. Catalog No. 49342F (Rev. 6/07) Part III Reporting Financial Institution Information 28 EIN for company listed in item 27 27 Name of holding company or lead financial institution (If filing institution) 29 Address of company listed in item 27 *33 Name of financial institution 30 City This is: a 2 (See instructions) 31 State Filing institution or b Joint filer *35 Address of financial institution 32 ZIP Code *34 EIN for institution listed in item 33 36 Internal control/file number(If available) *37 City *39 ZIP Code *38 State *40 Primary Federal Regulator a FRB b FDIC c NCUA d OCC e OTS f IRS g SEC h CFTC z Other *41 Account number(s) affected that are related to subject listed in Part I, if any. Check “Yes” if closed. Enter name (items 3 - 5) or entity (item3) from Part I. Last name/Entity: First name: Mi: a Yes b Yes c Yes d Yes *42 Relationship of the subject (Part I) to the above listed financial institution (check all that apply): a Accountant b Agent h Director i Employee c j Appraiser d Attorney e Officer k Shareholder z Borrower f Broker g Customer Other *43 Address of branch or office where activity occurred 44 City 45 State 46 ZIP Code 47 Country (If not US, enter 2 digit code) 48 Address of branch or office where activity occurred (if required) 49 City 50 State 51 ZIP Code 52 Country (If not US, enter 2 digit code) 53 Address of branch or office where activity occurred (if required) 54 City 55 State 56 ZIP Code 58 Address of branch or office where activity occurred (if required) 59 City 60 State 57 Country (If not US, enter 2 digit code) Check if additional branch addresses are listed in Part V 61 ZIP Code 62 Country (If not US, enter 2 digit code) Part IV Contact for Assistance * 63 Designated contact office *64 Designated phone number (include area code) *65 Date filed (See instructions) ( ) _____ / ____ /_______ MM DD YYYY 66 Agency (if not filed by financial institution) Special note: If this report is being filed jointly, box 1b must be checked and Item 33 completed. A Part III and Part IV must be completed for each institution. Reminder: A joint SAR cannot be filed if box 19 is checked “yes”. If mailing, send each completed SAR report to: Enterprise Computing Center - Detroit Attn: SAR-DI P.O. Box 33980 Detroit, MI 48232-0980 A free secure e-filing system is available to file this report. Go to http://bsaefiling.fincen.treas.gov for more information and to register. Part V *Suspicious Activity Information - Narrative 3 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 narrative description of the activity. The narrative should address as much of the information listed below as possible which covers the who/what/when/where of the activity. a. Describe the conduct that raised suspicion, why it was suspicious and the date discovered. Did the activity have a material impact on or affect the financial institution’s soundness? 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.). The filer (and joint filer if appropriate) must retain a copy of the SAR and its supporting documentation and retain such documentation on 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, or others. g. Indicate where the possible violation of law(s) took place (e.g., main office, branch, other). If the institution or branch has been closed, indicate date. h. Recommend any further investigation that might assist law enforcement authorities. i. Indicate whether any information has been excluded from this report; if so, state reasons. j. Indicate whether the suspicious activity is an isolated incident or relates to another transaction. Note if this is an updated report and if so, provide the date of the original SAR regarding this activity. k. Indicate whether there is any related litigation. If so, specify the names of the parties involved and the court where the action is pending. 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. Describe any funds transfers, including in or out identifier numbers, parties involved, dates, amounts, and financial institutions involved. n. 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. o. Describe subject(s) position(s) if employed by the financial institution. p. Indicate the type of institution filing this report, if this is not clear. q. Indicate if a law enforcement agency has been contacted, list the name of the agency and the name of any person contacted, their title, their telephone number, and when they were contacted. r. If correcting or amending a prior report, complete the form in its entirety and note the changes here in Part V. See instructions. s. SAR’s are confidential. Please refer to following references: OCC: 12 CFR 21.11, FRB: 12 CFR 208.62, OTS: 12 CFR 563.180, FDIC: 12 CFR 353, NCUA: 12 CFR 748, FinCEN: 31 CFR 103.18. Information already provided in earlier parts of this form need not be repeated if the meaning is clear. Supporting documentation should not be filed with this report. Maintain the information for your files. Enter the explanation/description narrative in the space below. If necessary, continue the narrative on a duplicate of this page or a blank page. Tips on SAR form preparation and filing are available in the SAR Activity Reviews at www.fincen.gov/pub_reports.html or the “SAR Narrative Guidance Package” at www.fincen.gov/narrativeguidance_webintro.pdf The reporting financial institution should not include legal disclaimers in the narrative. (FinCEN Form 111A) Suspicious Activity Report Instructions (SAR-DI) Safe Harbor Federal law (31 U.S.C. 5318(g)(3)) provides complete protection from civil liability for a ll 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 States, 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”. This applies to the filer and joint filer(s). Notification Prohibited: Federal law (31 U.S.C. 5318(g)(2)) requires that a financial institution and its directors, officers, employees and agents, who, voluntarily or by means of a suspicious activity report, report suspected or known criminal violations or suspicious activities, may not notify any person (subject) involved in the transaction that the transaction has been reported. See narrative checklist item “s.” In situations involving violations requiring immediate attention, such as when a reportable violation is ongoing, the financial institution shall immediately notify, by telephone, appropriate law enforcement and financial institution supervisory authorities in addition to filing a timely suspicious activity report. List any such contact in Part V. General Instructions Definition: Depository Institution. For the purposes of suspicious activity reporting in accordance with 31 CFR 103.18, and the use of this suspicious activity report form, the term Depository Institution includes those entities listed in 31 CFR 103.11(c) as well as bank holding companies and nonbank subsidiaries of bank holding companies. A. When to file General. Every Depository Institution shall file with the Treasury Department, to the extent and in the manner required by 31 CFR Part 103.18, a report of any suspicious transaction relevant to a possible violation of law or regulation. A Depository Institution may also file with the Treasury Department by using the Suspicious Activity Report specified in 31 CFR Part 103.18, 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 this section. associations, savings association service corporations, credit unions, bank holding companies, nonbank subsidiaries of bank holding companies, Edge and Agreement corporations, and U.S. branches and agencies of foreign banks, are required to make this report following the discovery of: a. Insider abuse involving any amount. Whenever the Depository Institution detects any known or suspected Federal criminal violation, or pattern of criminal violations, committed or attempted against the Depository Institution or involving a transaction or transactions conducted through the Depository Institution, where the Depository Institution believes that it was either an actual or potential victim of a criminal violation, or series of criminal violations, or that the Depository Institution was used to facilitate a criminal transaction, and the Depository Institution has a substantial basis for identifying one of its directors, officers, employees, agents or other institution-affiliated parties as having committed or aided in the commission of a criminal act regardless of the amount involved in the violation. b. Violations aggregating $5,000 or more where a subject can be identified. Whenever the Depository Institution detects any known or suspected Federal criminal violation, or pattern of criminal violations, committed or attempted against the financial institution or involving a transaction or transactions conducted through the Depository Institution and involving or aggregating $5,000 or more in funds or other assets, where the Depository Institution believes that it was either an actual or potential victim of a criminal violation, or series of criminal violations, or that the Depository Institution was used to facilitate a criminal transaction, and the Depository Institution has a substantial basis for identifying a possible subject or group of subjects. If it is determined prior to filing this report that the identified subject or group of subjects has used an “alias,” then information regarding the true identity of the subject or group of subjects, as well as alias identifiers, such as drivers’ licenses or social security numbers, addresses and telephone numbers, must be reported. c. Violations aggregating $25,000 or more regardless of a potential subject. Whenever the Depository Institution detects any known or suspected Federal criminal violation, or pattern of criminal violations, committed or attempted against the Depository Institution or involving a transaction or transactions conducted through the financial institution and involving or aggregating $25,000 or more in funds or other assets, where the Depository Institution believes that it was either an actual or potential victim of a criminal violation, or series of criminal violations, or that the Depository Institution was used to facilitate a criminal transaction, even though there is no substantial basis for identifying a possible subject or group of subjects. 1. All Depository Institutions operating in the United States, including insured banks, savings Catalog No. 49343Q 1 d. Transactions aggregating $5,000 or more that involve potential money laundering or violations of the Bank Secrecy Act. Any transaction (which for purposes of this subsection means a deposit, withdrawal, transfer between accounts, exchange of currency, loan, extension of credit, purchase or sale of any stock, bond, certificate of deposit, or other monetary instrument or investment security, or any other payment, transfer, or delivery by, through, or to a Depository Institution, by whatever means effected) conducted or attempted by, at or through the Depository Institution and involving or aggregating $5,000 or more in funds or other assets, if the Depository Institution knows, suspects, or has reason to suspect that: i. The transaction involves funds derived from illegal activities or is intended or conducted in order to hide or disguise funds or assets derived from illegal activities (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 law or regulation or to avoid any transaction reporting requirement under Federal law; ii. The transaction is designed to evade any regulations promulgated under the Bank Secrecy Act; or iii. The transaction 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 Depository Institution knows of no reasonable explanation for the transaction after examining the available facts, including the background and possible purpose of the transaction. 2. The Bank Secrecy Act requires all 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 Depository Institution to file a CTR whenever a currency transaction exceeds $10,000. 3. 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 or criminal aspects of the transaction). If a currency transaction equals or is below $10,000 and is suspicious, the institution should only file a suspicious activity report. 4. A Depository Institution is required to file a suspicious activity report no later than 30 calendar days after the date of initial detection of facts that may constitute a basis for filing a suspicious activity report. If no subject was identified on the date of detection of the incident requiring the filing, a Depository Institution may delay filing a suspicious activity report for an additional 30 calendar days to identify a subject. In no case shall reporting be delayed more than 60 calendar days after the date of initial detection of a reportable transaction. (Rev. 6/07) 2 5. This suspicious activity report does not need to be filed for those robberies and burglaries that are reported to local authorities, or (except for savings associations and service corporations) for lost, missing, counterfeit, or stolen securities that are reported pursuant to the requirements of 17 CFR 240.17f-1. B. How to make a report: NOTE: If this report is jointly filed, both of the filing institutions must retain a copy of the SAR. Each institution must retain their supporting documentation for a period of five years from the date the report was filed. 1. This form should be e-filed through the Bank Secrecy Act E-filing System. Go to http://bsaefiling.fincen.treas.gov to register. 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. This form is also available through your primary federal regulator. 2. If not filed electronically or through magnetic media, send each completed suspicious activity report to: Enterprise Computing Center - Detroit Attn: SAR-DI P.O. Box 33980 Detroit, MI 48232-0980 3. While all items should be completed fully and accurately, items marked with an asterisk (*) must be completed according to the provisions of paragraph 4 below. 4. If the information for a item marked with a asterisk (*) is not known or not applicable, enter special response “XX” to complete the item. To indicate “Total amount” as unknown, check the box provided. Non-asterisk fields should be left blank if the information is unknown or not applicable. 5. Complete each suspicious activity report by providing as much information as possible on initial and corrected or amended reports. 6. Do not include supporting documents with the filed suspicious activity report. Retain a copy of the report and all supporting documentation (e.g. transaction records, new account information, tape recordings, correspondence, e-mail messages, etc.) or business record equivalent in 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. 7. Type or complete the report using block written letters. 8. If more than one subject 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 V by “item number,” and add the additional information. C. Specific Suspicious Activity Report preparation instructions Item 1--Check the box if this report amends (adds missing data) or corrects errors in the prior report. (See Part V, item “r”). 9. Enter all dates in MM / DD / YYYY format where MM = month, DD = day, and YYYY = year. Precede single numbers with zero, i.e., 01,02, etc. If the month or day is unknown, enter “00” in place of the month or day. Item 1a-- Check this box if this is a recurring report filed on continuing activity. 10. Record telephone numbers using the format (XXX) XXX-XXXX. List fax numbers and international telephone numbers in Part V. Part I Subject Information 11. Always enter an individual’s name by entering the last name, first name, and middle initial in the appropriate items. If the last or first name is not known, enter “XX” in the item. If the middle initial is unknown leave the item blank. 12. Enter all identifying numbers (alien registration, driver’s license/state ID, Employer Identification Number (EIN), Individual Taxpayer Identification Number (ITIN), Foreign National ID, passport, and Social Security Number (SSN), etc.) starting from left to right. Do not include spaces, dashes, or other punctuation. 13. Enter all Post Office ZIP Codes from left to right with at least the first five numbers or all nine numbers (ZIP + 4) if known. 14. Enter all monetary amounts in U.S. Dollars. Use whole dollar amounts rounded up. Enter the amount as a number string without punctuation. If foreign currency is involved, state the name of currency and country of origin in Part V. 15. Addresses. 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. Do not use a post office box for an individual, unless no other address is available. For an individual, enter any apartment or suite number and road or route number. If a post office box is used for an entity, enter the street name, suite number, and road or route number. If the individual is from Mexico or Canada, enter the appropriate state or territory code in the state item and MX or CA as appropriate in the country item. If the address is from another foreign country, enter “XX” in the state item and the appropriate two-digit country code in the country item. Complete any part of the address that is known, even if the entire address is not known. If the address is in the U.S., leave the country field blank. Lists of two-digit country and state codes are available on the FinCEN web site at www.fincen.gov/reg_bsaforms.html, or by calling 1-800-949-2732 and selecting option 5 to request a list by mail. 16. If you have questions or require further assistance, go to www.fincen.gov, contact your primary regulator, or call the FinCEN Helpline at 800-949-2732. Item 1b -- Check this box if this is a jointly filed report with another financial institution. 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--If there are multiple subjects involved, check box “2a” and complete a separate Part I for each subject and attach behine page one. Check box “2b” only if NO 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--Individual/entity names. See General Instruction B11 for information on completing name fields. If the subject is an entity, enter the entity’s full legal name in Item 3, and “XX” in Item 4. Individual/entity names must be repeated in Item 41 to associate the account numbers with each Part I. Item 6 Also known as--If an individual has another name under which he or she is commonly known, enter that name in Item 6. If the subject is an entity, record the trade name of the entity in Item 6 if the trade name is different from the legal name in Item 3. Item 7--Occupation or type of business. If known, identify the occupation, profession or business that best describes the individual or entity 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), or self employed. If unemployed, or retired are used enter the regular or former occupation if known. If the individual’s business activities can be described more fully, provide the additional information in Part V. Items *8, *9, *10, *11, and *12-- Address. See General Instructions B13 and B15. If any part of the address is not known, enter or “XX” in that item. Item *13--SSN/ITIN (individual) or EIN (entity). See General Instruction B12. 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 13. If that individual is an alien who has an ITIN, enter that number. If the subject is an entity, enter the EIN. If the identification number is not known, enter “XX” in Item 13. 3 Item *14--Date of birth. See General Instruction B9. If the subject is an individual, enter the date of birth. Enter “XX” if the date of birth is not known. Enter “XX” if the subject is an entity. Item *15--Forms of identification for subject. See General Instruction B12. Check the box showing the type of document used to verify the subject’s identity. If you check box “z” Other, specify the type of document used. You must list the ID number of the identifying document and the issuing authority in 15e and 15f. If no identification was available, check box 15d and enter “XX” in “Other.” Items 16, 17 & 18--Telephone numbers, Email address. See General Instruction B10. List any additional number(s) that may be available in Part V. List e-mail address if available. Item *19--Insider relationship? You must check box “a” or “b” showing whether or not there is an insider relationship. If box “a” is checked, you must also check box “c”, “d”, “e”, or “f” to identify the current relationship, and complete Item 20. Note: A joint SAR cannot be filed if item 19 is checked “yes.” Item 20--Date of Suspension, etc. Enter the date of any suspension, termination or resignation reflected in Item 18. Item 21--Admission or Confession. Check the appropriate box to indicate whether the subject has admitted or confessed to the suspicious activity. If “Yes,” describe the admission or confession more fully in Part V. Part II Suspicious Activity Information Item *22--Date or date range of suspicious activity. See General Instruction B9. Enter the date of the reported activity in the “From” field. If more than one day is involved, 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. Item *23--Total dollar amount. See General Instruction B14. Check item 23a if the amount is unknown. 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 V. For abuse by a person associated with the institution, the value of this Item can be zero (0). Do not use any words, such as “thousand”, “million”, etc. For foreign currency, convert all values to U.S. Dollars. If box “1” is checked, leave this item blank unless the amount is different than originally reported. If box “1a” is checked, enter the cumulative amount. Item *24--Type of suspicious activity. Check all that apply to identify the suspicious activity. Provide a brief explanation in Part V of why each box is checked. If none of the items apply, mark box “z” “Other,” enter a brief description on the following line, and provide in Part V an explanation of the type of suspicious activity. Items 25 and 26--Amount of loss and recovery (if applicable). Indicate in Item 25 the amount of the initial loss. This amount cannot be larger than the amount in Item 23. In Item 26 indicate the amount of any recovery. This amount cannot be larger than the amount in Item 25. Both amounts must be in U.S. Dollars. Part III Reporting Financial Institution Information If this report is being completed by a holding company or lead financial institution, complete items 27 through 32. Items 33 through 62 must reflect the location of the financial institution where the reported activity occurred. Note: Item 27 should be left blank if the reported activity occurred at the holding company or lead financial institution. In such cases the institution should complete items 33 to 62 as the filing institution and check box 33a. Note: If filed jointly, a Part III and Part IV must be completed for each institution. If reporting multiple subjects (box 2a checked) complete Part III, items 33 through 42 for each subject reported by the institution. If this report is being filed jointly (box in item 1b checked), make a copy of page two and complete items 33 through 42 for the joint filer following the same instructions as the filer. Complete branch information, items 43 through 62 if appropriate. If there are additional joint filers, make as many copies of page two as required to record the additional joint filer information. Attach any additional pages behind page two, and indicate the total number of joint filers in Part V. NOTE: Reports involving insider abuse may not be filed jointly. Item *33--Name of financial institution. Enter the full legal name of the institution, i.e. the name shown on the charter or other document creating the entity where the reported activity occurred. Check box “a”, “Filing institution” when the listed institution is the institution preparing and filing the report. Check box ”b”, “Joint filer” for all other reporting institutions. See holding company note above. Item 40--Primary Federal Regulator (This item must be completed for all reports). Depository Institutions filing this report must check box “a” through “e” (only one). For all other institutions, check box “f”, “g”, or “h” as appropriate. For institutions not listed, check box “z” other Item *41--Account number(s). Enter up to four account numbers for financial institution accounts involved in the activity. Check the box “Yes” if an account is closed. Enter additional account numbers in Part V. Enter “XX” in Item 41(a) if no accounts are involved. Enter name (Items 3-5) or entity (Item 3) from Part I, in the space provided. Auto-filled if completing a fill-in form. Item 42--Relationship to financial institution. Check the appropriate box(es) to indicate whether or not the subject identified in Part I, items 3-5 is or was associated with the reporting institution. Check all that apply. Items *43- 62--Branch or office addresses. See General Instructions B13 & B15. Provide the addresses of up to four branch locations where the most significant portion of the suspicious activity occurred. If there are more than four branches, check the box labeled “Check if additional branch ...” in the last branch address (item 58) and list the additional locations in Part V. If there are no branch addresses involved, enter “XX” in Item 43. Part IV Contact for Assistance Item *63-- Designated contact office. Enter the name of the office that the holding company or financial institution has designated to receive request for assistance with this report. This office must have an individual knowledgeable of this report available during regular business hours. Item *64--Phone number. See General Instruction B10. Enter the work telephone number of the contact office. Item *65--Date filed. See General Instruction B9. Enter the date this report was initially filed. If this is an amended or corrected report, enter the date of the amendment or correction. For electronic filing, it is the date that the report was e-filed using BSA Direct. For magnetic media filing, it is the date the magnetic media SAR was created . For all other filers, it is the date the financial institution completed and mailed/submitted the report to ECC - Detroit Item *34--EIN. See General Instruction B12. Enter the EIN of the financial institution listed in item 33. Item 66--Agency. If this report is filed by an agency other than a financial institution such as a regulator or OFAC, enter the name of the reporting agency in Item 66. Items *35, *37, *38, and *39--Address. See General Instructions B13 & B15. This address should be the address of the principal office or headquarters in the United States. Part V--*Suspicious Activity Information -Narrative. Item 36--Internal control/file number (If available). Enter any internal file or report number assigned by the reporting institution to track this report. This information will act as an identification aid if contact is required. This is the most important section, and should be completed in as much detail as possible. See page 3 of the form for specific instructions for completing the narrative. The filing/reporting financial institution should not include legal disclaimers in the narrative.
