Laundering Transaction Reporting Form by (Reporting Agency)
Serial number: ___ (3 digits)Date:
I. Basic customer information: (Information about one or more customers may be provided; please expand the form if necessary.)(1) Name: ______
(2) Date of birth/registration:______
(3) Classification:_____(1:male; 2: female; 3: domestic company; 4: foreign company; 5: non-corporation or firm; 6: others)
(4) Customer type: ____(1:general savings account; 2: credit card account; 3: wealth management account; 4: credit account; 5: securities account; 6: trust account; 7: foreign exchange account; 8: insurance account; 9: investment trust; A: ATM transactions and no customer information available; B: electronic payment user; 0: others)
(5) Politically exposed persons (PEPs):____(0:no;1: yes)
(6) ID/registration number:______
(7) Passport number:______
(8) Alien Resident Certificate (ARC) or AlienPermanentResident Certificate (APRC)number:______
(9) Nationality:______
(10) Citizenship:____(0: native; 1: foreigner with an ARC or an APRC; 2: foreigner without an ARC or an APRC; 3: Mainland Chinese with an ARC; 4: Mainland Chinese without an ARC; 5: legal entity)
(11) Occupation:______
(12) Telephone:______
(13) Address:
______
______
(14) Insurance policy number:______
(15) Effective date of the contract:______(Fields 14 and 15 are for the insurance services only.)
(16) Electronic payment account:______
(17) Identity verification method 1:______(cell phone number)
(18) Identity verification method 2:______(e-mail address or social media account)(Fields 16-18 areforelectronicpayment services only. )
II. Basic information on the transaction agent: (Information about one or more transaction agents may be provided; please expand the form if necessary.)
(1) Name:______
(2) Date of birth/registration:______
(3) Classification: ____ (1:male; 2: female; 3: domestic company; 4: foreign company; 5: non-corporation or firm; 6: others)
(4) ID/registration number:______
(5) Passport number:______
(6) Citizenship:_____(0: native; 1: foreigner with an ARC or an APRC; 2: foreigner without an ARC or an APRC; 3: Mainland Chinese with an ARC; 4: Mainland Chinese without an ARC)
(7) Nationality:______
(8) Occupation:______
(9) Telephone:______
(10) Place of transaction:______
(11) Address:______
(12) Relationship with the customer:______(1:spouse; 2: lineal or collateral relative; 3: relative other than those specified in No. 1 & 2; 4: employer/employee; 5: friend; 6: person in charge of the non-personal accounts; 7: insurance applicant; 8: beneficiary; 9: cannot be confirmed; 0:others)
III. Transaction details:
(1) Whether the transaction has been completed:(0:notcompleted;1:completed)
____
(2) Transaction type:
Banking services(01: cash withdrawals; 02: cash deposits; 03: transfer payments; 04: transfer receipts; 05: outward remittance; 06: inward remittance; 07: check payments; 08: check receipts; 09: electronic transaction payments; 10: electronic transaction receipts; 11: foreign currency payments; 12: foreign currency receipts; 13: settlement payments; 14: settlementreceipts; 99:others)_____
Insurance services(21: premium payment; 22: premium refund; 23: dissolution of contract; 24: insurance benefits; 25: loan; 26: loan repayment; 99: others)_____
Centralized securities depository(31: depositing securities to be sold in others’ accounts; 32: transferring dividends to thepledgersfor pledging of securities through the book-entry system; 99: others)_____
Electronic payment institutions (41: making payments for real transactions for others; 42: collecting payments for real transactions for others; 43: accepting deposits for storing value; 44: transferring funds between electronic payment accounts; 99: others)_____
Jewelry retail businesses(61:purchase; 62: sale; 99: others)_____
Land administration agents and real estate brokers(50:buying and selling real estate; 99: others)_____
Lawyers, notaries, and accountants(50:buying and selling real estate; 51: managing money, securities, or other assets; 52: managing bank, savings, or securities accounts; 53: offering services regarding company establishment, operation, or management; 54: establishing, operating, or managing legal entities or arrangements as well as buying and selling business entities; 55: acting as nominal representative of a legal entity; 56: acting as or arranging another person to act as director, secretary, or partner of a company or assuming a similar position in another legal entity; 57: providing the registered office, place of business, residence, mailing address, or administrative address for companies, partnerships, or businesses of other types; 58: acting as or arranging another person to act as trustee for a trust or other similar contracts or assuming other similar roles; 59: acting as or arranging another person to act as substantial shareholder; 99: others)_____
Other financial institutions or designated reporting agencies (UseChinese script)
(3) The bank where the account is held:______
(4) The bank where the transaction was?processed:
______
(5) Start date of the suspicious transaction:______
(6) End date of the suspicious transaction:______
(7) Transaction currency: ______
(8) Transaction amount: ______
(9) Equivalent to NT$ ______
(10) Type of securities: ______
(11) Number of shares: ______
IV.Transaction account: (One or more transaction accounts may be provided; please expand the form if necessary.)
1.______2. ______
V.Statement of reasons for suspicion:
VI.Identify signs of a suspicious transaction by using Article 10 numbered items._____ of signs of a suspicious transaction
VII. _____ pages of related transaction data enclosed
VIII.Name of the agency (head office) reporting the suspicious transaction
Dedicated person (responsible person):______
Contact person:______
Phone number of contact person:
______
Fax number of contact person:
______/ Responsible person of the branch office/company:
______
Phone number of responsible person of the branch office/company:
______
Fax number of responsible person of the branch office/company:
______
Address of Anti-Money Laundering Division, Investigation Bureau:No.74,Jhonghua Rd., Sindian Dist., New Taipei City 231, Taiwan (R.O.C.).
For questions about related practices, please contact the Anti-Money Laundering Division: 02-29112241 ext. 6210~6219.
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