decision of the head of the indonesian financial ... · for public cognizance, hereby ordering the...
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ELIPS II. 2/9/2006 Page 1 of 3
DECISION OF THE HEAD OF THE INDONESIAN FINANCIAL TRANSACTION
REPORTS AND ANALYSIS CENTER
NUMBER: 2/6/KEP.PPATK/2003
CONCERNING
GUIDELINES ON THE PROCEDURE OF SUSPICIOUS FINANCIAL
TRANSACTION REPORTING FOR FINANCIAL DEALERS
THE HEAD OF THE INDONESIAN FINANCIAL TRANSACTION REPORTS
AND ANALYSIS CENTER
Considering: a. whereas the role of financial dealers is significant in
the prevention and eradication of money laundering
criminal acts among other things through the
submission of suspicious financial transactions;
b. whereas in order to create a uniform understanding
among financial dealers in reporting suspicious
financial transactions as well as producing precise,
correct, and accountable reports of suspicious
financial transactions;
c. whereas in connection therewith it is necessary to
issue guidelines on the procedure for suspicious
financial transactions reporting for financial dealers in
a Decision of the Head of Indonesian Financial
Transaction Reports and Analysis Center;
In view of: 1. Law Number 15 Year 2002 regarding Criminal Acts of
Money Laundering (State Gazette of the Republic of
Indonesia Year 2002 Number 30, Supplement to the
State Gazette of the Republic of Indonesia Number
4191) as amended by Law Number 25 Year 2003
(State Gazette of the Republic of Indonesia Year
2003 Number 108, Supplement to the State Gazette
of the Republic of Indonesia Number 4324);
ELIPS II. 2/9/2006 Page 2 of 3
2. Decree of the President of the Republic of Indonesia
Number 201/M Year 2002;
HAS DECIDED:
To stipulate: DECISION OF THE HEAD OF THE INDONESIAN
FINANCIAL TRANSACTION REPORTS AND ANALYSIS
CENTER REGARDING GUIDELINES ON THE
PROCEDURE FOR SUSPICIOUS FINANCIAL
TRANSACTION REPORTING FOR FINANCIAL DEALERS.
Article 1
(1) These Guidelines shall be applicable to Financial Dealers in the form of
commercial banks, rural credit banks, securities companies, mutual fund
managers, custodians, insurance companies, pension funds, and
financing institutions.
(2) Financial dealers in reporting Suspicious Financial Transactions as
intended in paragraph (1) shall be obligated to refer to the Guidelines on
the Procedure for Suspicious Financial Transaction Reporting for
Financial Dealers as intended in the attachment to this Decision.
(3) Guidelines on the Procedure for Suspicious Financial Transaction
Reporting for Financial Dealers shall be an inseparable part of this
Decision.
Article 2
Guidelines on the Procedure for Suspicious Financial Transaction Reporting for
Financial Dealers shall be the guidelines that contain, among other things,
information to be reported, procedures for filling out Suspicious Financial
Transaction report form, time limit for submitting the report and the
consequences for not submitting the report, address of report submission,
reporting procedures, and confidentiality.
ELIPS II. 2/9/2006 Page 3 of 3
Article 3
(1) The obligation of reporting Suspicious Financial Transactions for Financial
Dealers as intended in the article 1 paragraph (1) to the Indonesian
Financial Transaction Report and Analysis Center shall be effective as
from October 18, 2003.
(2) Suspicious Financial Transaction Reporting particularly for Financial
Dealers of commercial banks can be conducted manually as well as
electronically starting from October 18, 2003.
(3) Suspicious Financial Transaction Reporting particularly for Financial
Dealers of rural credit banks, securities companies, mutual fund
managers, custodians, insurance companies, pension funds, and
financing institutions must be conducted manually since October 18,
2003.
(4) Suspicious Financial Transaction Reporting for Financial Dealers as
intended in paragraph (3) may also be conducted electronically starting
from January 1, 2004.
Article 4
This decision shall come into effect as from the date of its stipulation.
For public cognizance, hereby ordering the announcement of this Decision of the
Head of the Indonesian Financial Transaction Reports and Analysis Center by
publishing it in the Official Gazette of the Republic of Indonesia.
Stipulated in: Jakarta
On: October 15, 2003
THE HEAD OF THE INDONESIAN FINANCIAL
TRANSACTION REPORTS AND ANALYSIS
CENTER
Sgd.
Dr. Yunus Husein
FIRST EDITION INDONESIAN FINANCIAL TRANSACTION REPORTS AND ANALYSIS CENTER (PPATK)
Guidelines on the Procedure for Suspicious Financial Transaction
Reporting for Financial Dealers
Guideline
IIIAttachment to the Decision of the Head of the Indonesian Financial Transaction Reports and Analysis Center Number 2/6/KEP.PPATK/2003
I N D O N E S I A N F I N A N C I A L T R A N S A C T I O N R E P O R T S A N D A N A L Y S I S C E N T E R ( P P A T K )
GUIDELINE III
Guidelines on the Procedure for Suspicious Financial Transaction Reporting for Financial Dealers
First Edition
Indonesian Financial Transaction Reports and Analysis Center (PPATK) E-mail: [email protected]
Tel: 62.21.3862579 • Fax: 62.21.3866337 Jakarta, 2003
Table of ContentsCHAPTER 1: INTRODUCTION................................................................. 1 CHAPTER 2: INFORMATION TO BE REPORTED ................................. 3 CHAPTER 3: PROCEDURES FOR FILLING OUT SUSPICIOUS FINANCIAL TRANSACTION REPORT FORM ........................................ 4
A. MANUAL REPORTING.............................................................. 4 B. ELECTRONIC REPORTING.................................................... 26
CHAPTER 4: REPORT SUBMISSION TIME LIMIT ............................... 27 CHAPTER 5: SUBMISSION ADDRESS ................................................. 29
A. MANUAL REPORTING............................................................ 29 B. ELECTRONIC REPORTING.................................................... 29
CHAPTER 6: REPORTING PROCEDURES........................................... 30
A. MANUAL REPORTING............................................................ 30 B. ELECTRONIC REPORTING.................................................... 30
CHAPTER 7: CONFIDENTIALITY .......................................................... 32 CHAPTER 8: MISCELLANEOUS ........................................................... 34 ATTACHMENT: SAMPLE OF SUSPICIOUS FINANCIAL TRANSACTION REPORT FORM USER GUIDE
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CHAPTER 1: Introduction
With regard to the implementation of the duties of the Indonesian Financial Transaction Reports and Analysis Center (“PPATK”) as set forth in Law Number 15 Year 2002 concerning Criminal Acts of Money Laundering as amended by Law Number 25 Year 2003 (“TPPU Law”) particularly Article 26 sub-paragraph (c), it is stated that the duty of PPATK is to draw up guidelines regarding Suspicious Financial Transaction reporting procedures. The guidelines are further provided for in a decision of the Head of the PPATK (Article 13 paragraph 7 of TPPU Law). These guidelines are needed so that Suspicious Financial Transaction Report by Financial Dealers (PJK) can be conducted precisely, correctly and accountably, considering that the report is one of the main sources of information required in implementing PPATK’s duties. It is expected that the guidelines can also create a common understanding among PJK in reporting Suspicious Financial Transactions to the PPATK. PJK can submit Suspicious Financial Transaction Reports by applying the following methods: a. Manually, namely by sending a hard copy of Suspicious
Financial Transaction Reports in compliance with the sample of Suspicious Financial Transaction report form attached to these guidelines; or
b. Electronically, namely by submitting Suspicious Financial
Transaction Report on-line through the Internet by accessing PPATK’s server using user id and password determined by PPATK.
PJK intending to submit Suspicious Financial Transaction
Reports electronically, must first submit a “Request for Electronic Reporting” by e-mail to:
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[email protected] PPATK will provide user id, password, and server address for Suspicious Financial Transaction Report individually to each PJK. As long as PJK has not received any user id and password, Suspicious Financial Transaction Reports shall be submitted manually.
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CHAPTER 2: INFORMATION TO BE REPORTED
Information to be reported by PJK in the Suspicious Financial Transaction Reports is described in a sample form of Suspicious Financial Transaction Reports (see ATTACHMENT). The information to be submitted either Manually or Electronically is the same and is based on the sample form of Suspicious Financial Transaction Reports.
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CHAPTER 3: Procedures for Filling Out Suspicious Financial Transaction Reporting Form A. Manual Reporting
1. DESCRIPTION ON THE FILLING OUT OF SUSPICIOUS FINANCIAL TRANSACTION REPORTING FORM FOR BANKS
Filling
Out No. Description
I. IDENTITY OF TRANSACTION ENACTORS A. Individual Account Holder Fill out No. 1 to 11, if the enactor is an Individual Account Holder
1. Full Name: Full Name of the Individual Account Holder as transaction enactor.
2. Nickname/Alias: Self-explanatory.
3. Sex: Self-explanatory.
4. Place and Date of Birth: Self-explanatory.
5. Nationality: Self-explanatory.
6. Full address of domicile (use of P.O. BOX not allowed): The latest domicile address of the account holder.
7. Telephone Number (can be more than one): Self-explanatory.
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Filling Out No.
Description
8. Occupation: Including occupation such as student, college student and housewife.
9. Office Address: For student/college student, fill out with the school/college address. For housewife, fill out with the relevant home address.
10. Taxpayer Registration Number (NPWP): Self-explanatory.
11. Proofs of Identity (can be more than one): Self-explanatory.
B. Corporate Account Holder Fill out No. 12 to 21, if the enactor is a Corporate Account Holder.
12. Name of Company: Self-explanatory.
13. Type of Legal Entity/other Entities: Examples of type of legal entity/other entities are Limited Liability Company (PT), Limited Partnership (CV), Firm, Commercial Business, Foundation, Cooperatives, Non-Government Organization (NGO), Political Party.
14. Domicile of Legal Entity/other Entities: Fill out the state of origin of such legal entity/other entities of account holder. For legal entity/other entities originating from Indonesia, it must be filled out with “Indonesia”.
15. Taxpayer Registration Number (NPWP): Self-explanatory.
16. Company’s address (P.O. BOX not allowed): Self-explanatory.
17. Telephone Number (can be more than one): Self-explanatory.
18. Main Business Line: In accordance with the main business line of the company.
19. Business License/other licenses from the competent authority: Fill out with the Type and Number of License in accordance with the Type and Number of the License owned by the company. Can be more than one.
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Filling Out No.
Description
20. Names of the Company’s Executives: Fill out according to the latest company’s Articles of Association available at the Bank. Bank may add the number of form of the Company’s Executives according to its need.
21. Names of the Owner/Majority Shareholders: Fill out according to the latest company’s Articles of Association available at the Bank. Bank may add the number of form of the Owner/Majority Shareholders according to its need.
C. Beneficial Owner/Intermediary/Proxy/Walk-in Customer If suspicious financial transactions involve Beneficial
Owner/Intermediary/Attorney-in-Fact/Walk-in Customer. C.1. Individual Fill out No. 22 to 32 if Beneficial Owner/Intermediary/Proxy/Walk-
in Customer is an Individual. 22. Full Name:
Full name of the Beneficial Owner/Intermediary/Proxy/Walk-in Customer.
23. Nick name: Self-explanatory.
24. Sex: Self-explanatory.
25. Place and Date of Birth: Self-explanatory.
26. Nationality: Self-explanatory.
27. Full address of domicile (use of P.O. BOX not allowed): The latest domicile address and telephone number of the customer.
28. Telephone Number (can be more than one): Self-explanatory.
29. Occupation: Including occupation such as student, college student, and housewife.
30. Office Address: For student/college student, fill out with the school/college address.
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Filling Out No.
Description
For housewife, fill out the concerned home address. 31. Taxpayer Registration Number (NPWP):
Self-explanatory. 32. Proofs of identity (can be more than one):
Self-explanatory. C.2. Corporate Fill out No. 33 to 42, if the Beneficial
Owner/Intermediary/Proxy/Walk-in Customer is a Company. 33. Name of Company:
Self-explanatory. 34. Type of Legal Entity/other Entities:
Examples of type of legal entity/other entities are Limited Liability Company (PT), Limited Partnership (CV), Firm, Commercial Business, Foundation, Cooperatives, Non-Government Organization (NGO), Political Party.
35. Domicile of Legal Entity/other Entities: Fill out with the country of origin of such legal entity/other entities of account holder. For legal entity/other entities originating from Indonesia, it must be filled out with “Indonesia”.
36. Taxpayer Registration Number (NPWP): Fill out with “Not obligated to possess Taxpayer Registration Number (NPWP)” if the customer is not obligated to possess Taxpayer Registration Number
37. Company’s Address (use of P.O. BOX not allowed): Self-explanatory.
38. Telephone Number (can be more than one): Self-explanatory.
39. Main Business Line: In accordance with the main business line of the company.
40. Business License/other licenses from the competent authority: Fill out with the Type and Number of License in accordance with the Type and Number of the License owned by the company. Can be more than one.
41. Names of the Company’s Executives: Fill out according to the latest company’s Articles of
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Filling Out No.
Description
Association available at the Bank. The Bank may add the number of form of the Company’s Executives according to its need.
42. Names of the Owner/Majority Shareholders: Fill out according to the latest company’s Articles of Association available at the Bank. The Bank may add the number of form of the Owner/Majority Shareholders according to its need.
II. DETAILS OF SUSPICIOUS FINANCIAL TRANSACTIONS 43. Type of Transactions: (for example: cash deposit,
withdrawal, money transfer, purchase of TC, etc.). If the Suspicious Financial Transactions consist of a series of several transactions, please describe them in Number 54.
44. Date of Transactions: The date of transactions that trigger the occurrence of suspicions or having the indication of Suspicious Financial Transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 54.
45. Value of Transactions (in Rupiah): The value (in Rupiah) of transactions that trigger the occurrence of suspicions or having the indication of Suspicious Financial Transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 54.
46. Payment Instruments used: For example: Check, Clearing Account Letter, Traveller’s Cheque or cash/bank-notes, and others. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 54.
47. Does it use foreign currency? Select “Yes” or “No”.
48. Do such transactions use cash money? Select “Yes” or “No”.
49. Are they walk-in customers? Select “Yes” or “No”.
50. Accounts used for transactions: For example: Clearing Account, Savings Account, Time
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Filling Out No.
Description
Deposit, and others. 51. Office of Reporting Bank where transactions occur:
Shall be the offices where Suspicious Financial Transactions occur.
52. Other Banks related to such transactions (if any): Other banks as fund sender or receiver. If Suspicious Financial Transaction involves several banks, please describe them in Number 54.
53. Third Party related to such transactions (if any): Names of third party transferring fund to or receiving fund from other bank. If Suspicious Financial Transaction involves several parties, please describe them in Number 54.
54. Details and description of the Suspicious Financial Transactions: Detailed description concerning the background, data of the enactor and transactions, as well as indicators and elements of Suspicious Financial Transaction that can be identified by bank. Including in this description are other matters related to the transaction of customer among other things customer purpose in opening account, customer profile, other PJK, other parties, and information concerning the parties conducting transactions in the name of customer.
55. Codes of Bank: In accordance with the code (sign) of the respective banks given by PPATK.
56. Names of Bank: Self-explanatory.
57. Names and signatures of Bank officials: Self-explanatory.
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2. DESCRIPTION ON THE FILLING OUT OF SUSPICIOUS
FINANCIAL TRANSACTION REPORTING FORM FOR INSURANCE COMPANIES
Filling Out No.
Description
I. IDENTITY OF POLICYHOLDER A. Individual Policyholder
Fill out No. 1 to 11, if the enactor is an Individual Policyholder. 1. Full Name:
Full Name of the Individual Policyholder as transaction enactor.
2. Nickname/Alias: Self-explanatory.
3. Sex: Self-explanatory.
4. Place and Date of Birth: Self-explanatory.
5. Nationality: Self-explanatory.
6. Full address of domicile (use of P.O. BOX not allowed): The latest domicile address of the policyholder.
7. Telephone Number (can be more than one): Self-explanatory.
8. Occupation: Including occupation such as student, college student and housewife.
9. Office Address: For student/college student, fill out with the school/college address. For housewife, fill out with the concerned home address.
10. Taxpayer Registration Number (NPWP): Self-explanatory.
11. Proofs of Identity (can be more than one): Self-explanatory
B. Corporate Policyholder Fill out No. 12 to 21, if the enactor is a Corporate Policyholder.
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Filling Out No.
Description
12. Name of Company: Self-explanatory.
13. Type of Legal Entity/other Entities: Examples of type of legal entity/other entities are Limited Liability Company (PT), Limited Partnership (CV), Firm, Commercial Business, Foundation, Cooperatives, Non-Government Organization (NGO), Political Party.
14. Domicile of Legal Entity/other Entities: Fill out with country of origin of such legal entity/other entities of account holder. For legal entity/other entities originating from Indonesia, it must be filled out with “Indonesia”.
15. Taxpayer Registration Number (NPWP): Self-explanatory.
16. Company’s address (P.O. BOX not allowed): Self-explanatory
17. Telephone Number (can be more than one): Self-explanatory.
18. Main Business Line: In accordance with the main business line of the company.
19. Business License/other licenses from the competent authority: Fill out with the Type and Number of License in accordance with the Type and Number of the License owned by the company. Can be more than one.
20. Names of the Company’s Executives: Fill out according to the latest company’s Articles of Association available at the Insurance Company. The Insurance Company may add the number of form of the Company’s Executives according to its need.
21. Names of the Owners/Majority Shareholders: Fill out according to the latest company’s Articles of Association available at the Insurance Company. The Insurance Company may add the number of form of the Owners/Majority Shareholders according to its need.
C. Proxy Holder of Policy Shall be the authorized by the Policyholder to conduct a
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Filling Out No.
Description
transaction that in this case is indicated as Suspicious Financial Transactions.
C.1. Proxy Holder of Individual Policy Fill out No. 22 to 32, if Proxy Holder of Policy is an Individual.
22. Full Name: Full Name of the Proxy Holder of Policy.
23. Nickname/Alias: Self-explanatory.
24. Sex: Self-explanatory.
25. Place and Date of Birth: Self-explanatory.
26. Nationality: Self-explanatory.
27. Full address of domicile (use of P.O. BOX not allowed): The latest domicile address of the proxy holder of policy.
28. Telephone Number (can be more than one): Self-explanatory.
29. Occupation: Including occupation such as student, college student and housewife.
30. Office Address: For student/college student, fill out with the school/college address. For housewife, fill out with the home address concerned.
31. Taxpayer Registration Number (NPWP): Self-explanatory.
32. Proofs of Identity (can be more than one): Self-explanatory.
C.2. Proxy Holder of Corporate Policy Fill out No. 33 to 42, if the Proxy Holder of Policy is a Company.
33. Name of Company: Self-explanatory.
34. Type of Legal Entity/other Entities: Examples of type of legal entity/other entities are Limited Liability Company (PT), Limited Partnership (CV), Firm, Commercial Business, Foundation, Cooperatives, Non-
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Filling Out No.
Description
Government Organization (NGO), Political Party. 35. Domicile of Legal Entity/other Entities:
Fill out with country of origin of such legal entity/other entities of account holder. For legal entity/other entities originating from Indonesia, it must be filled out with “Indonesia”.
36. Taxpayer Registration Number (NPWP): Fill out with “Not obligated to possess Taxpayer Registration Number (NPWP)”, for those who are not obligated to possess Taxpayer Registration Number.
37. Company’s address (P.O. BOX not allowed): Self-explanatory.
38. Telephone Number (can be more than one): Self-explanatory.
39. Main Business Line: In accordance with the main business line of the company.
40. Business License/other licenses from the competent authority: Fill out with the Type and Number of License in accordance with the Type and Number of the License owned by the company. Can be more than one.
41. Names of the Company’s Executives: Fill out according to the latest company’s Articles of Association available at the Insurance Company. The Insurance Company may add the number of form of the Company’s Executives according to its need.
42. Names of the Owner/Majority Shareholders: Fill out according to the latest company’s Articles of Association available at the Insurance Company. The Insurance Company may add the number of form of the Owner/Majority Shareholders according to its need.
II. DETAILS OF SUSPICIOUS FINANCIAL TRANSACTIONS 43. Type of Insurance/Policy:
Self-explanatory. 44. Date of Transactions:
The date of transactions that trigger the occurrence of suspicions or having the indication of Suspicious Financial
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Filling Out No.
Description
Transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 54.
45. Value of Transactions (in Rupiah): The value (in Rupiah) of transactions that triggers the occurrence of suspicions or having the indication of Suspicious Financial Transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 54.
46. Payment Instruments used: For example: Check, Clearing Account Letter, Money Transfer, or cash/bank-notes, and other. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 54.
47. Does it use foreign currency? Select “Yes” or “No”.
48. Do such transactions use cash money? Select “Yes” or “No”.
49. Accounts used for transactions: Information about bank account used in conducting suspicious financial transactions related to Insurance.
50. Reporting Insurance Company where transactions occur: Shall be the head office or branch office of the insurance company where Suspicious Financial Transactions occur. If Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 54.
51. Name of Beneficiary: Self-explanatory.
52. Address of Beneficiary: Self-explanatory.
53. Account Number and Beneficiary Bank: Self-explanatory.
54. Details and description of the Suspicious Financial Transactions: Detail description concerning the background, data of the enactor and transactions, as well as indicators and elements of Suspicious Financial Transaction that can be identified by
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Filling Out No.
Description
insurance company. Including in this description are other matters related to the transaction of customer among other things customer purpose in policy coverage, customer profile, other PJK, other parties, and information concerning the parties conducting transactions in the name of customer.
55. Codes of Insurance: In accordance with the code (sign) of the respective insurance companies given by PPATK.
56. Names of Insurance Company: Self-explanatory.
57. Names and signatures of Insurance officials: Self-explanatory
3. DESCRIPTION ON THE FILLING OUT OF SUSPICIOUS
FINANCIAL TRANSACTION FORM FOR PENSION FUNDS AND FINANCING INSTITUTIONS
Filling Out No.
Description
I. IDENTITY OF TRANSACTION ENACTORS A. Individual Account Holder
Fill out No. 1 to 11, if the enactor is an individual account holder 1. Full Name:
Full Name of the individual account holder as transaction enactor.
2. Nickname/Alias: Self-explanatory.
3. Sex: Self-explanatory.
4. Place and Date of Birth: Self-explanatory.
5. Nationality: Self-explanatory.
6. Full address of domicile (use of P.O. BOX not allowed):
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Filling Out No.
Description
The latest domicile address of the account holder. 7. Telephone Number (can be more than one):
Self-explanatory. 8. Occupation:
Including occupation such as student, college student and housewife.
9. Office Address: For student/college student, fill out with the school/college address. For housewife, fill out with the home address concerned.
10. Taxpayer Registration Number (NPWP): Self-explanatory.
11. Proofs of Identity (can be more than one): Self-explanatory
B. Corporate Account Holder Fill out No. 12 to 21, if the enactor is a Corporate Account Holder.
12. Name of Company: Self-explanatory.
13. Type of Legal Entity/other Entities: Examples of type of legal entity/other entities are Limited Liability Company (PT), Limited Partnership (CV), Firm, Commercial Business, Foundation, Cooperatives, Non-Government Organization (NGO), Political Party.
14. Domicile of Legal Entity/other Entities: Fill out with country of origin of such legal entity/other entities of account holder. For legal entity/other entities originating from Indonesia, it must be filled out with “Indonesia”.
15. Taxpayer Registration Number (NPWP): Self-explanatory.
16. Company’s address (P.O. BOX not allowed): Self-explanatory
17. Telephone Number (can be more than one): Self-explanatory.
18. Main Business Line: In accordance with the main business line of the company.
19. Business License/other licenses from the competent
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Filling Out No.
Description
authority: Fill out with the Type and Number of License in accordance with the Type and Number of the License owned by the company. Can be more than one.
20. Names of the Company’s Executives: Fill out according to the latest company’s Articles of Association available at PJK. The PJK may add the number of form of the Company’s Executives according to its need.
21. Names of the Owners/Majority Shareholders: Fill out according to the latest company’s Articles of Association available at PJK. The PJK may add the number of form of the Owner/Majority Shareholders according to its need.
C. Beneficial Owner/Intermediary/Proxy Holder If suspicious financial transactions involve Beneficial Owner/Intermediary/Proxy Holder
C.1. Beneficial Owner/Intermediary/ Individual Proxy Holder Fill out No. 22 to 32, if the enactor is Beneficial Owner/Intermediary/ Individual Proxy Holder.
22. Full Name: Full name of the Beneficial Owner/Intermediary/Proxy Holder.
23. Nick name: Self-explanatory.
24. Sex: Self-explanatory.
25. Place and Date of Birth: Self-explanatory.
26. Nationality: Self-explanatory.
27. Full address of domicile (use of P.O. BOX not allowed): The latest domicile address and telephone number of Beneficial Owner/Intermediary/Proxy Holder.
28. Telephone Number (can be more than one): Self-explanatory.
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Filling Out No.
Description
29. Occupation: Including occupation such as student, college student, and housewife.
30. Office Address: For student/college student, fill out with the school/college address. For housewife, fill out the home address concerned.
31. Taxpayer Registration Number (NPWP): Self-explanatory.
32. Proofs of identity (can be more than one): Self-explanatory.
C.2. Beneficial Owner/Intermediary/ Corporate Proxy Holder Fill out No. 33 to 42, if the enactor is Beneficial Owner/Intermediary/ Corporate Proxy Holder.
33. Name of Company: Self-explanatory.
34. Type of Legal Entity/other Entities: Examples of type of legal entity/other entities are Limited Liability Company (PT), Limited Partnership (CV), Firm, Commercial Business, Foundation, Cooperatives, Non-Government Organization (NGO), Political Party.
35. Domicile of Legal Entity/other Entities: Fill out with the country of origin of such legal entity/other entities of account holder. For legal entity/other entities originating from Indonesia, it must be filled out with “Indonesia”.
36. Taxpayer Registration Number (NPWP): Fill out with “Not obligated to possess NPWP”, for those who are not obligated to possess Taxpayer Registration Number
37. Company Address (use of P.O. BOX not allowed): Self-explanatory.
38. Telephone Number (can be more than one): Self-explanatory.
39. Main Business Line: In accordance with the main business line of the company.
40. Business License/other licenses from the competent authority: Fill out with the Type and Number of License in accordance
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Filling Out No.
Description
with the Type and Number of the License owned by the company. Can be more than one.
41. Names of the Company’s Executives: Fill out according to the latest company’s Articles of Association available at PJK. The PJK may add the number of form of the Company’s Executives according to its need.
42. Names of the Owner/Majority Shareholders: Fill out according to the latest company’s Articles of Association available at PJK. The PJK may add the number of form of the Owner/Majority Shareholders according to its need.
II. DETAILS OF SUSPICIOUS FINANCIAL TRANSACTIONS 43. Type of Transactions:
For example: acquittal and contribution payment transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
44. Date of Transactions: The date of transactions that triggers the occurrence of suspicions or having the indication of Suspicious Financial Transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
45. Value of Transactions (in Rupiah): The value (in Rupiah) of transactions that triggers the occurrence of suspicions or having the indication of Suspicious Financial Transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
46. Payment Instruments used: For example: Check, Clearing Account Letter, Traveller’s Cheque or cash/bank-notes, and others. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
47. Does it use foreign currency? Select “Yes” or “No”.
48. Do such transactions use cash money?
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Filling Out No.
Description
Select “Yes” or “No”. 49. Accounts used for transactions:
Example for Financing Institutions: Consumer, Leasing, Factoring, and Credit. Example for Pension Funds: Participation Account.
50. Office of Reporting PJK where transactions occur: Shall be the head office or branch office where Suspicious Financial Transactions occur. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
51. Other PJKs related to such transactions (if any): Other PJKs related to such transactions.
52. Third Party related to such transactions (if any): Names of other individual related to such transactions.
53. Details and description of Suspicious Financial Transactions: Detail description concerning the background, data of the enactor and transactions, as well as indicators and elements of Suspicious Financial Transaction that can be identified by PJK. Including in this description are other matters related to the transaction of customer among other thing customer’s profile, other PJK, other parties, and information concerning individual conducting transactions in the name of customer.
54. Codes of PJK: In accordance with the code (sign) of the respective PJKs given by PPATK.
55. Names of PJK: Self-explanatory.
56. Names and signatures of PJK officials: Self-explanatory
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4. DESCRIPTION ON THE FILLING OUT OF SUSPICIOUS
FINANCIAL TRANSACTION FORM FOR SECURITIES COMPANIES, MUTUAL FUND MANAGERS, AND CUSTODIANS.
Filling Out No.
Description
I. IDENTITY OF TRANSACTION ENACTORS A. Individual Customer
Fill out No. 1 to 11, if the enactor is an Individual Account Holder. 1. Full Name:
Full Name of the individual account holders as transaction enactor.
2. Nickname/Alias: Self-explanatory.
3. Sex: Self-explanatory.
4. Place and Date of Birth: Self-explanatory.
5. Nationality: Self-explanatory.
6. Full address of domicile (use of P.O. BOX not allowed): The latest address of account holder.
7. Telephone Number (can be more than one): Self-explanatory.
8. Occupation : Including occupation such as student, college student and housewife.
9. Office Address: For student/college student, fill out with the school/college address. For housewife, fill out with the concerned home address.
10. Taxpayer Registration Number (NPWP): Self-explanatory.
11. Proofs of Identity (can be more than one): Self-explanatory
B. Corporate Account Holder
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Filling Out No.
Description
Fill out No. 12 to 21, if the enactor is a Corporate Account Holder.12. Name of Company:
Self-explanatory. 13. Type of Legal Entity/other Entities:
Examples of type of legal entity/other entities are Limited Liability Company (PT), Limited Partnership (CV), Firm, Commercial Business, Foundation, Cooperatives, Non-Government Organization (NGO), Political Party.
14. Domicile of Legal Entity/other Entities: Fill out with country of origin of such legal entity/other entities of account holder. For legal entity/other entities originating from Indonesia, it must be filled out with “Indonesia”.
15. Taxpayer Registration Number (NPWP): Self-explanatory.
16. Company’s address (P.O. BOX not allowed): Self-explanatory
17. Telephone Number (can be more than one): Self-explanatory.
18. Main Business Line: In accordance with the main business line of the company.
19. Business License/other licenses from the competent authority: Fill out with the Type and Number of License in accordance with the Type and Number of the License owned by the company. Can be more than one.
20. Names of the Company’s Executives: Fill out according to the latest company’s Articles of Association available at PJK. The PJK may add the number of form of the Company’s Executives according to its need.
21. Names of the Owners/Majority Shareholders: Fill out according to the latest company’s Articles of Association available at PJK. The PJK may add the number of form of the Owners/Majority Shareholders according to its need.
C. Proxy Holder/Intermediary
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Filling Out No.
Description
Shall be the party authorized by or Intermediary of Account Holder to conduct transactions indicated as Suspicious Financial Transactions.
C.1. Proxy Holder/Individual Intermediary Fill out No. 22 to 32, if the enactor is Proxy Holders/Individual Intermediary.
22. Full Name: Full name of the Proxy Holder/Intermediary.
23. Nickname: Self-explanatory.
24. Sex: Self-explanatory.
25. Place and Date of Birth: Self-explanatory.
26. Nationality: Self-explanatory.
27. Full address of domicile (use of P.O. BOX not allowed): The latest domicile address and telephone number account holder.
28. Telephone Number (can be more than one): Self-explanatory.
29. Occupation : Including occupation such as student, college student, and housewife.
30. Office Address: For student/college student, fill out with the school/college address. For housewife, fill out the concerned home address.
31. Taxpayer Registration Number (NPWP): Self-explanatory.
32. Proofs of identity (can be more than one): Self-explanatory.
C.2. Proxy Holder/Corporate Intermediary Fill out No. 33 to 42, if the enactor is Proxy Holder/Corporate Intermediary.
33. Name of Company: Self-explanatory.
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Filling Out No.
Description
34. Type of Legal Entity/other Entities: Examples of type of legal entity/other entities are Limited Liability Company (PT), Limited Partnership (CV), Firm, Commercial Business, Foundation, Cooperatives, Non-Government Organization (NGO), Political Party.
35. Domicile of Legal Entity/other Entities: Fill out with the country of origin of such legal entity/other entities of account holder. For legal entity/other entities originating from Indonesia, it must be filled out with “Indonesia”.
36. Taxpayer Registration Number (NPWP): Fill out with “Not obligated to possess NPWP”, for those who are not obligated to possess Taxpayer Registration Number.
37. Company’s Address (use of P.O. BOX not allowed): Self-explanatory.
38. Telephone Number (can be more than one): Self-explanatory.
39. Main Business Line: In accordance with the main business line of the company.
40. Business License/other licenses from the competent authority: Fill out with the Type and Number of License in accordance with the Type and Number of the License owned by the company. Can be more than one.
41. Names of the Company’s Executives: Fill out according to the latest company’s Articles of Association available at PJK. The PJK may add the number of form of the Company’s Executives according to its need.
42. Names of the Owners/Majority Shareholders: Fill out according to the latest company’s Articles of Association available at PJK. The PJK may add the number of form of the Owner/Majority Shareholders according to its need.
II. DETAILS OF SUSPICIOUS FINANCIAL TRANSACTIONS 43. Type of Transactions:
Among other things securities or stock purchase transaction.
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Filling Out No.
Description
If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
44. Date of Transactions: The date of transactions that triggers the occurrence of suspicions or having the indication of Suspicious Financial Transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
45. Value of Transactions (in Rupiah): The value (in Rupiah) of transactions that triggers the occurrence of suspicions or having the indication of Suspicious Financial Transaction. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
46. Payment Instruments used: For example: Check, Clearing Account Letter, Money Transfer, and other. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
47. Does it use foreign currency? Select “Yes” or “No”.
48. Are they Walk-in Customers? Select “Yes” or “No”.
49. Accounts used for transactions: Example: Securities Regular Account or Securities Margin Account.
50. Office of Reporting PJK where transactions occur: Shall be the PJK head office or branch office where Suspicious Financial Transactions occur. If the Suspicious Financial Transaction consists of a series of several transactions, please describe them in Number 53.
51. Other PJKs related to such transactions (if any): Other PJKs related to suspicious financial transactions.
52. Third Party related to such transactions (if any): Names of other individual related to suspicious financial transactions.
53. Details and description of the Suspicious Financial Transactions:
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Filling Out No.
Description
Detail description concerning the background, data of the enactor and transactions, as well as indicators of Suspicious Financial Transaction.
54. Codes of PJK: In accordance with the code (sign) of the respective PJKs given by PPATK.
55. Name of PJK: Self-explanatory.
56. Names and signatures of PJK officials: Self-explanatory
B. Electronic Reporting
The substance and explanation about Electronic Reporting Form of Suspicious Financial Transactions are based on the explanation of the above Manual Reporting Form. The procedure for filling out Suspicious Financial Transaction Reporting Form electronically can be seen in the attached User’s Guide.
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CHAPTER 4: Time Limit for Submission of Report
1. Suspicious Financial Transaction reports shall be submitted to the PPATK by no later than 3 (three) business days after PJK knows the elements of Suspicious Financial Transactions.
2. Such 3 (three) business day period shall commence as from
the date the PJK knows the elements of Suspicious Financial Transactions to the date the Suspicious Financial Transactions is received by the PPATK. Referred to as PJK shall be the officials of PJK’s Head Office who are competent to determine the status of a transaction as Suspicious Financial Transactions. Principally, earlier reporting will improve the effectiveness of preventive action or other necessary actions. Therefore, PJK must pay attention to the time period for determining the status of a transaction as Suspicious Financial Transaction.
3. Financial Dealers deliberately not submitting such Suspicious
Financial Transaction report to the PPATK shall be subject to a minimum fine of Rp.250,000,000.00 (two hundred and fifty million rupiah) and a maximum fine of Rp.1,000,000,000.00 (one billion rupiah).
4. The date of receipt at the PPATK shall be:
a. In the event that such reporting is done manually, the date
of receipt of Suspicious Financial Transaction Reports may be:
- The date of receipt by the courier/expedition services;
or
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- The date of post office stamp; or
- The date of receipt at PPATK.
b. In the event that such reporting is done electronically, the
date shall be the submission date recorded automatically in the PPATK’s Suspicious Financial Transaction Report system.
5. Explanation concerning identification of Suspicious Financial
Transaction by PJK shall be described in detail in the Guidelines for the Identification of Suspicious Financial Transactions (Guideline II).
6. The Identification of Suspicious Financial Transaction shall be
conducted in accordance with the internal procedures of the respective PJKs. If elements of Suspicious Financial Transaction are found, the Suspicious Financial Transaction reporting must be decided and reported by the competent PJK Officials in accordance with the applicable provisions.
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CHAPTER 5: Submission Address
A. Manual Reporting Manual reporting shall be addressed to:
Indonesian Financial Transaction Reports and Analysis Center (PPATK) BI Building Kebon Sirih, 4th Floor Jl. Kebon Sirih No. 82 – 84 Jakarta 10010
B. Electronic Reporting Electronic reporting shall be conducted using user id and password provided by the PPATK by accessing PPATK’s Suspicious Financial Transaction reporting server, the address of which will be informed individually by the PPATK to the respective PJKs.
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CHAPTER 6: Reporting Methods A. Manual Reporting
1. Suspicious Financial Transaction Reports shall be sent in sealed envelopes under a special treatment considering their high level of confidentiality.
2. In the event that PJK uses courier/expedition services to
submit Suspicious Financial Transaction Reports, then the relevant PJK must pay their attention to the following:
a. Measures that can be taken to avoid possible information
abuses or mistakes that may be detrimental to the PJK, customers or public at large directly or indirectly.
b. The security aspect in facility utilization used for preparing
reports or documents.
c. Granting of authority from PJK to courier/expedition service companies to deliver reports to the PPATK.
3. PJK shall be obligated to fill out Suspicious Financial
Transaction Report forms with the required data in compliance with the available format.
B. Electronic Reporting
1. Electronic reporting of Suspicious Financial Transactions by PJK shall be conducted under a special treatment considering their high level of confidentiality.
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2. PJK must administer , user id, password, and address of Suspicious Financial Transaction reporting server under a special treatment and must take the following measures:
a. Take measures that can avoid possible violation of user id,
password, and address of Suspicious Financial Transaction reporting server or mistakes that may be detrimental to the PJK, customers or public at large directly or indirectly.
b. Heed the security aspect in facility utilization used for
preparing reports and or documents such as user id, password, computer, diskette, print-out of reports and documents in the context of reporting Suspicious Financial Transactions.
3. PJK shall fill out Suspicious Financial Transaction Report
forms with the required data in compliance with the available format.
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CHAPTER 7: Confidentiality
1. Suspicious Financial Transaction reports are very confidential documents.
2. Each PJK shall be responsible for the confidentiality of
Suspicious Financial Transaction reports. 3. The PPATK shall also be responsible for the confidentiality of
Suspicious Financial Transaction reports, since their acceptance by PPATK.
4. The directors, officials, or employees of Financial Dealers
shall be prohibited from informing financial service users or other parties directly or indirectly by any method whatsoever, about Suspicious Financial Transaction Reports being prepared or having been submitted to the PPATK.
5. Officials or PPATK, and investigators/inquirers shall be
prohibited from informing customers directly or indirectly by any method whatsoever, of Suspicious Financial Transaction Reports submitted to the PPATK or investigators.
6. The directors, officials, or employees of Financial Dealers,
officials or employees of the PPATK as well as investigators/inquirers violating the provisions as intended in items 4 and 5 above, shall be subject to a minimum imprisonment of 3 (three) years and a maximum imprisonment of 5 (five) years, and a minimum fine of Rp.100,000,000.00 (one hundred million rupiah) and a maximum fine of Rp.1,000,000,000.00 (one billion rupiah).
7. Implementation of reporting obligation by Financial Dealers in
the form of banks including submission of supporting
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documents shall be excluded from bank confidentiality provisions as intended in Law providing for bank confidentiality.
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CHAPTER 8: Miscellaneous
Inquiries related to Suspicious Financial Transaction Reports shall be addressed to PPATK to the following address: E-mail : [email protected]
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BANK
I. IDENTITY OF TRANSACTION PERFORMERA. INDIVIDUAL ACCOUNT HOLDER
1 Full Name……………………………………………………………………………………..
2 Nick name / Alias (if any)……………………………………………………………………………………..
3 Sex……………………………………………………………………………………..
4 Place & Date of Birth……………………………………………………………………………………..
5 Citizenship……………………………………………………………………………………..
6 Full address of domicile (use of P.O. BOX not allowed):……………………………………………………………………………………..……………………………………………………………………………………..……………………………………………………………………………………..
7 Telephone no. (may be more than one): ……………………………………8 Occupation
……………………………………………………………………………………..9 Address of occupation …………………………………………………………..
……………………………………………………………………………………..10 Tax ID No. ..………………………………………………………………………11 Personal Identity (may be more than one)
a. No. of ID Card ……………………………………………………………..Valid until ……………………………………………………………….
b. No. of Passport ..………………………………………………………….Valid until ……………………………………………………………….
c. No. of Driving License ……………………………………………………..Valid until ……………………………………………………………….
d. No. of Temporary Living Permit …………………………………………Valid until ……………………………………………………………….
e. No. of Student Card ………………………………………………………Valid until ……………………………………………………………….
f. Others …………………………………………………………………….Valid until ……………………………………………………………….
B. CORPORATE ACCOUNT HOLDER12 Name of Company
……………………………………………………………………………………..13 Type of Legal Entity / Other Entity
……………………………………………………………………………………..14 Domicile of Legal Entity / Other Entity
……………………………………………………………………………………..
SUSPICIOUS TRANSACTION REPORT
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SUSPICIOUS TRANSACTION REPORT
15 Tax ID No. …...………………………………………………………………16 Full address of company (use of P.O. BOX not allowed):
……………………………………………………………………………………..……………………………………………………………………………………..……………………………………………………………………………………..
17 Telephone No. (may be more than one) ……………………………………….18 Main Business Line
………………………………………………………………………………………19 Business license / other license from competent authorities
a. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
b. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
c. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
20 Name of Company's Managementa. Name ……………………………………………………………………….
Occupation ………………………………………………………………..b. Name …………………………………………………………………………
Occupation ………………………………………………………………..c. Name …………………………………………………………………………
Occupation ………………………………………………………………..21 Name of Owner/Majority Shareholder
a. Name …………………………………………………………………………b. Name …………………………………………………………………………c. Name …………………………………………………………………………
C BENEFICIAL OWNER/BROKER/PROXY/WALK-IN CUSTOMER(choose that apply to)C.1. INDIVIDUAL
22 Full Name…………………………………………………………………………………
23 Nick name / Alias (if applicable)…………………………………………………………………………………
24 Sex…………………………………………………………………………………
25 Place & Date of Birth…………………………………………………………………………………
26 Citizenship…………………………………………………………………………………
27 Full address of domicile (use of P.O. BOX not allowed):………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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SUSPICIOUS TRANSACTION REPORT
28 Telephone no. (may be more than one): ………………………………….29 Occupation
…………………………………………………………………………………30 Address of occupation ……………………………………………………
…………………………………………………………………………………31 Tax ID No. ..………………………………………………………………..32 Personal Identity (may be more than one)
a. No. of ID Card …………………………………………………………Valid until ……………………………………………………………….
b. No. of Passport ..………………………………………………………Valid until ……………………………………………………………….
c. No. of Driving License …………………………………………………Valid until ……………………………………………………………….
d. No. of Temporary Living Permit ………………………………………Valid until ……………………………………………………………….
e. Others …………………………………………………………………….Valid until ……………………………………………………………….
C.2. COMPANY33 Name of Company
…………………………………………………………………………………34 Type of Legal Entity / Other Entity
…………………………………………………………………………………35 Domicile of Legal Entity / Other Entity
…………………………………………………………………………………36 Tax ID No. …...………………………………………………………………37 Full address of company (use of P.O. BOX not allowed):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
38 Telephone No. (may be more than one) …………………………………39 Main Business Line
…………………………………………………………………………………40 Business license / other license from competent authorities
a. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
b. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
c. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
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BANK
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41 Name of Company's Managementa. Name ……………………………………………………………………….
Occupation ………………………………………………………………..b. Name ……………………………………………………………………..
Occupation ………………………………………………………………c. Name ……………………………………………………………………
Occupation ………………………………………………………………..42 Name of Owner/Majority Shareholder
a. Name ……………………………………………………………………b. Name ……………………………………………………………………c. Name ……………………………………………………………………
II DETAILS OF SUSPICIOUS FINANCIAL TRANSACTIONS43 Type of Transaction (e.g. deposit, withdrawal, transfer, TC purchase, etc)
………………………………………………………………………………………………44 Date of Transaction
……………………………………………………………………………………………45 Value of Transaction (in Rupiah) ……………………………………………………..46 Payment Instrument used
……………………………………………………………………………………………47 Is foreign exchange used ? Yes No48 Is cash used for transaction ? Yes No49 Is the party a walk-in customer? Yes No50 Account (s) used for transaction
a. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
b. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
c. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
d. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
e. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
51 Office of Reporting Bank where transaction occurs…………………………………………………………………………………………….
52 Other bank related to the transaction (if any)…………………………………………………………………………………………….
4
BANK
SUSPICIOUS TRANSACTION REPORT
53 Third party related to the transaction (if any)a. Name ….………………………………………………………………………..b. No. of account ………………………………………………………………….…
54 DETAILS AND DESCRIPTION OF SUSPICIOUS FINANCIAL TRANSACTION(served in separate pages)
III IDENTITY OF REPORTING BANK55 Code of Bank
……………………………………………………………………………………………56 Name of Bank
……………………………………………………………………………………………57 Name and signature of Bank's Officer(s)
……………………………………………………………………………………………
5
I. IDENTITY OF POLICY HOLDERA. INDIVIDUAL POLICY HOLDER
1 Full Name……………………………………………………………………………………..
2 Nick name / Alias (if any)……………………………………………………………………………………..
3 Sex……………………………………………………………………………………..
4 Place & Date of Birth……………………………………………………………………………………..
5 Citizenship……………………………………………………………………………………..
6 Full address of domicile (use of P.O. BOX not allowed):……………………………………………………………………………………..……………………………………………………………………………………..……………………………………………………………………………………..
7 Telephone no. (may be more than one): ……………………………………8 Occupation
……………………………………………………………………………………..9 Address of occupation …………………………………………………………..
……………………………………………………………………………………..10 Tax ID No. ..………………………………………………………………………11 Personal Identity (may be more than one)
a. No. of ID Card ……………………………………………………………..Valid until ……………………………………………………………….
b. No. of Passport ..………………………………………………………….Valid until ……………………………………………………………….
c. No. of Driving License ……………………………………………………..Valid until ……………………………………………………………….
d. No. of Temporary Living Permit …………………………………………Valid until ……………………………………………………………….
e. No. of Student Card ………………………………………………………Valid until ……………………………………………………………….
f. Others …………………………………………………………………….Valid until ……………………………………………………………….
B. CORPORATE POLICY HOLDER12 Name of Company
……………………………………………………………………………………..13 Type of Legal Entity / Other Entity
……………………………………………………………………………………..14 Domicile of Legal Entity / Other Entity
……………………………………………………………………………………..
SUSPICIOUS TRANSACTION REPORTINSURANCE
1
SUSPICIOUS TRANSACTION REPORTINSURANCE
15 Tax ID No. …...………………………………………………………………16 Full address of company (use of P.O. BOX not allowed):
……………………………………………………………………………………..……………………………………………………………………………………..……………………………………………………………………………………..
17 Telephone No. (may be more than one) ……………………………………….18 Main Business Line
………………………………………………………………………………………19 Business license / other license from competent authorities
a. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
b. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
c. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
20 Name of Company's Managementa. Name ……………………………………………………………………….
Occupation ………………………………………………………………..b. Name …………………………………………………………………………
Occupation ………………………………………………………………..c. Name …………………………………………………………………………
Occupation ………………………………………………………………..21 Nama of Owner/Majority Shareholder
a. Name …………………………………………………………………………b. Name …………………………………………………………………………c. Name …………………………………………………………………………
C POLICY HOLDER's PROXYC.1. INDIVIDUAL POLICY HOLDER's PROXY
22 Full Name…………………………………………………………………………………
23 Nick name / Alias (if applicable)…………………………………………………………………………………
24 Sex…………………………………………………………………………………
25 Place & Date of Birth…………………………………………………………………………………
26 Citizenship…………………………………………………………………………………
27 Full address of domicile (use of P.O. BOX not allowed):………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
2
SUSPICIOUS TRANSACTION REPORTINSURANCE
28 Telephone no. (may be more than one): ………………………………….29 Occupation
…………………………………………………………………………………30 Address of occupation ……………………………………………………
…………………………………………………………………………………31 Tax ID No. ..………………………………………………………………..32 Personal Identity (may be more than one)
a. No. of ID Card …………………………………………………………Valid until ……………………………………………………………….
b. No. of Passport ..………………………………………………………Valid until ……………………………………………………………….
c. No. of Driving License …………………………………………………Valid until ……………………………………………………………….
d. No. of Temporary Living Permit ………………………………………Valid until ……………………………………………………………….
e. Others …………………………………………………………………….Valid until ……………………………………………………………….
C.2. CORPORATE POLICY HOLDER's PROXY33 Name of Company
…………………………………………………………………………………34 Type of Legal Entity / Other Entity
…………………………………………………………………………………35 Domicile of Legal Entity / Other Entity
…………………………………………………………………………………36 Tax ID No. …...………………………………………………………………37 Full address of company (use of P.O. BOX not allowed):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
38 Telephone No. (may be more than on…………………………………………39 Main Business Line
…………………………………………………………………………………40 Business license / other license from competent authorities
a. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
b. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
c. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
3
SUSPICIOUS TRANSACTION REPORTINSURANCE
41 Name of Company's Managementa. Name ……………………………………………………………………….
Occupation ………………………………………………………………..b. Name ……………………………………………………………………..
Occupation ………………………………………………………………..c. Name ……………………………………………………………………….
Occupation ………………………………………………………………..42 Nama of Owner/Majority Shareholder
a. Name ……………………………………………………………………..b. Name ……………………………………………………………………..c. Name ……………………………………………………………………..
II DETAILS OF SUSPICIOUS FINANCIAL TRANSACTIONS43 Type of Insurance/Policy
………………………………………………………………………………………………44 Date of Transaction
……………………………………………………………………………………………45 Value of Transaction (in Rupiah) ……………………………………………………..46 Payment Instrument used
……………………………………………………………………………………………47 Is foreign exchange used ? Yes No48 Is cash used for transaction ? Yes No49 Account (s) used for transaction
a. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
b. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
c. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
d. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
e. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
50 Office of Reporting Insurance Company where transaction occurs…………………………………………………………………………………………….
51 Name of Beneficiary…………………………………………………………………………………………….
4
SUSPICIOUS TRANSACTION REPORTINSURANCE
52 Address of Beneficiary…………………………………………………………………………………………….
53 Account No. and Beneficiary Bank
54 DETAILS AND DESCRIPTION OF SUSPICIOUS FINANCIAL TRANSACTION(served in separate pages)
III IDENTITY OF REPORTING INSURANCE COMPANY55 Code of Insurance company
……………………………………………………………………………………………56 Name of Insurance company
……………………………………………………………………………………………57 Name and signature of Insurance's Officer(s)
……………………………………………………………………………………………
5
Pension Fund and Financing Institution
I. IDENTITY OF TRANSACTION PERFORMERA. INDIVIDUAL ACCOUNT HOLDER
1 Full Name……………………………………………………………………………………..
2 Nick name / Alias (if any)……………………………………………………………………………………..
3 Sex……………………………………………………………………………………..
4 Place & Date of Birth……………………………………………………………………………………..
5 Citizenship……………………………………………………………………………………..
6 Full address of domicile (use of P.O. BOX not allowed):……………………………………………………………………………………..……………………………………………………………………………………..……………………………………………………………………………………..
7 Telephone no. (may be more than on…………………………………………………8 Occupation
……………………………………………………………………………………..9 Address of occupation …………………………………………………………..
……………………………………………………………………………………..10 Tax ID No. ..………………………………………………………………………11 Personal Identity (may be more than one)
a. No. of ID Card ……………………………………………………………..Valid until ……………………………………………………………….
b. No. of Passport ..………………………………………………………….Valid until ……………………………………………………………….
c. No. of Driving License ……………………………………………………..Valid until ……………………………………………………………….
d. No. of Temporary Living Perm………………………………………………….Valid until ……………………………………………………………….
e. No. of Student Card ………………………………………………………Valid until ……………………………………………………………….
f. Others ……………………………………………………………………………..Valid until ……………………………………………………………….
B. CORPORATE ACCOUNT HOLDER12 Name of Company
……………………………………………………………………………………..13 Type of Legal Entity / Other Entity
……………………………………………………………………………………..14 Domicile of Legal Entity / Other Entity
……………………………………………………………………………………..
SUSPICIOUS TRANSACTION REPORT
Pension Fund and Financing Institution
SUSPICIOUS TRANSACTION REPORT
15 Tax ID No. …...………………………………………………………………16 Full address of company (use of P.O. BOX not allowed):
……………………………………………………………………………………..……………………………………………………………………………………..……………………………………………………………………………………..
17 Telephone No. (may be more than on………………………………………………….18 Main Business Line
………………………………………………………………………………………19 Business license / other license from competent authorities
a. Type and License N………………………………………………………………..Date of issue ………………………………………………………………..
b. Type and License N………………………………………………………………..Date of issue ………………………………………………………………..
c. Type and License N………………………………………………………………..Date of issue ………………………………………………………………..
20 Name of Company's Managementa. Name ……………………………………………………………………………
Occupation ………………………………………………………………..b. Name ……………………………………………………………………………
Occupation ………………………………………………………………..c. Name ……………………………………………………………………………
Occupation ………………………………………………………………..21 Name of Owner/Majority Shareholder
a. Name ……………………………………………………………………………b. Name ……………………………………………………………………………c. Name ……………………………………………………………………………
C BENEFICIAL OWNER/BROKER/PROXY(choose that apply to)C.1. INDIVIDUAL
22 Full Name…………………………………………………………………………………
23 Nick name / Alias (if applicable)…………………………………………………………………………………
24 Sex…………………………………………………………………………………
25 Place & Date of Birth…………………………………………………………………………………
26 Citizenship…………………………………………………………………………………
27 Full address of domicile (use of P.O. BOX not allowed):………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Pension Fund and Financing Institution
SUSPICIOUS TRANSACTION REPORT
28 Telephone no. (may be more than one): …………………………………………29 Occupation
…………………………………………………………………………………30 Address of occupation ……………………………………………………
…………………………………………………………………………………31 Tax ID No. ..………………………………………………………………..32 Personal Identity (may be more than one)
a. No. of ID Card …………………………………………………………Valid until ……………………………………………………………….
b. No. of Passport ..………………………………………………………Valid until ……………………………………………………………….
c. No. of Driving License …………………………………………………Valid until ……………………………………………………………….
d. No. of Temporary Living Permit ………………………………………Valid until ……………………………………………………………….
e. Others …………………………………………………………………….Valid until ……………………………………………………………….
C.2. COMPANY33 Name of Company
…………………………………………………………………………………34 Type of Legal Entity / Other Entity
…………………………………………………………………………………35 Domicile of Legal Entity / Other Entity
…………………………………………………………………………………36 Tax ID No. …...………………………………………………………………37 Full address of company (use of P.O. BOX not allowed):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
38 Telephone No. (may be more than one) ……………………………………….39 Main Business Line
…………………………………………………………………………………40 Business license / other license from competent authorities
a. Type and License No. …………………………………………………..Date of issue ……………………………………………………………
b. Type and License No. …………………………………………………..Date of issue ……………………………………………………………
c. Type and License No. …………………………………………………..Date of issue ……………………………………………………………
Pension Fund and Financing Institution
SUSPICIOUS TRANSACTION REPORT
41 Name of Company's Managementa. Name …………………………………………………………………
Occupation ……………………………………………………………b. Name …………………………………………………………………
Occupation …………………………………………………………c. Name …………………………………………………………………
Occupation …………………………………………………………42 Name of Owner/Majority Shareholder
a. Name …………………………………………………………………b. Name …………………………………………………………………c. Name …………………………………………………………………
II DETAILS OF SUSPICIOUS FINANCIAL TRANSACTIONS43 Type of Transaction
………………………………………………………………………………………………44 Date of Transaction
……………………………………………………………………………………………45 Value of Transaction (in Rupiah) ……………………………………………………..46 Payment Instrument used
……………………………………………………………………………………………47 Is foreign exchange used ? Yes No48 Is cash used for transaction ? Yes No49 Account (s) used for transaction
a. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
b. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
c. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
d. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
e. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
50 Office of Reporting PFS where transaction occurs…………………………………………………………………………………………….
51 Other Providers of Financial Services related to the transaction (if any)…………………………………………………………………………………………….
Pension Fund and Financing Institution
SUSPICIOUS TRANSACTION REPORT
52 Third party related to the transaction (if any)a. Nama ……………………………………………………………………………..b. No. Rekening ………………………………………………………………….…
53 DETAILS AND DESCRIPTION OF SUSPICIOUS FINANCIAL TRANSACTION(served in separate pages)
III IDENTITY OF REPORTING PROVIDER OF FINANCIAL SERVICES (PFS)54 Code of PFS
……………………………………………………………………………………………55 Name of PFS
……………………………………………………………………………………………56 Name and Signature of PFS' Officer(s)
……………………………………………………………………………………………
Securities Company, Fund Manager and Custodian Bank
I. IDENTITY OF TRANSACTION PERFORMERA. INDIVIDUAL ACCOUNT HOLDER
1 Full Name……………………………………………………………………………………..
2 Nick name / Alias (if any)……………………………………………………………………………………..
3 Sex……………………………………………………………………………………..
4 Place & Date of Birth……………………………………………………………………………………..
5 Citizenship……………………………………………………………………………………..
6 Full address of domicile (use of P.O. BOX not allowed):……………………………………………………………………………………..……………………………………………………………………………………..……………………………………………………………………………………..
7 Telephone no. (may be more than one …………………………………………………8 Occupation
……………………………………………………………………………………..9 Address of occupation …………………………………………………………..
……………………………………………………………………………………..10 Tax ID No. ..………………………………………………………………………11 Personal Identity (may be more than one)
a. No. of ID Card ……………………………………………………………..Valid until ……………………………………………………………….
b. No. of Passport ..………………………………………………………….Valid until ……………………………………………………………….
c. No. of Driving License ……………………………………………………..Valid until ……………………………………………………………….
d. No. of Temporary Living Permit ………………………………………………….Valid until ……………………………………………………………….
e. No. of Student Card ………………………………………………………Valid until ……………………………………………………………….
f. Others ………………………………………………………………………………..Valid until ……………………………………………………………….
B. CORPORATE ACCOUNT HOLDER12 Name of Company
……………………………………………………………………………………..13 Type of Legal Entity / Other Entity
……………………………………………………………………………………..14 Domicile of Legal Entity / Other Entity
……………………………………………………………………………………..
SUSPICIOUS TRANSACTION REPORT
Securities Company, Fund Manager and Custodian Bank
SUSPICIOUS TRANSACTION REPORT
15 Tax ID No. …...………………………………………………………………16 Full address of company (use of P.O. BOX not allowed):
……………………………………………………………………………………..……………………………………………………………………………………..……………………………………………………………………………………..
17 Telephone No. (may be more than one) ……………………………………….18 Main Business Line
………………………………………………………………………………………19 Business license / other license from competent authorities
a. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
b. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
c. Type and License No. …………………………………………………..Date of issue ………………………………………………………………..
20 Name of Company's Managementa. Name ………………………………………………………………………………
Occupation ………………………………………………………………..b. Name ………………………………………………………………………………
Occupation ………………………………………………………………..c. Name ………………………………………………………………………………
Occupation ………………………………………………………………..21 Name of Owner/Majority Shareholder
a. Name ………………………………………………………………………………b. Name ………………………………………………………………………………c. Name ………………………………………………………………………………
C BROKER/PROXY(choose that apply to)C.1. INDIVIDUAL
22 Full Name…………………………………………………………………………………
23 Nick name / Alias (if applicable)…………………………………………………………………………………
24 Sex…………………………………………………………………………………
25 Place & Date of Birth…………………………………………………………………………………
26 Citizenship…………………………………………………………………………………
27 Full address of domicile (use of P.O. BOX not allowed):……………………………………………………………………………………………………………………………………………………………………
Securities Company, Fund Manager and Custodian Bank
SUSPICIOUS TRANSACTION REPORT
28 Telephone no. (may be more than one): ……………………………………………29 Occupation
…………………………………………………………………………………30 Address of occupation ……………………………………………………
…………………………………………………………………………………31 Tax ID No. ..………………………………………………………………..32 Personal Identity (may be more than one)
a. No. of ID Card …………………………………………………………Valid until ……………………………………………………………….
b. No. of Passport ..………………………………………………………Valid until ……………………………………………………………….
c. No. of Driving License …………………………………………………Valid until ……………………………………………………………….
d. No. of Temporary Living Permit ………………………………………Valid until ……………………………………………………………….
e. Others …………………………………………………………………….Valid until ……………………………………………………………….
C.2. COMPANY33 Name of Company
…………………………………………………………………………………34 Type of Legal Entity / Other Entity
…………………………………………………………………………………35 Domicile of Legal Entity / Other Entity
…………………………………………………………………………………36 Tax ID No. …...………………………………………………………………37 Full address of company (use of P.O. BOX not allowed):
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
38 Telephone No. (may be more than one) ……………………………………….39 Main Business Line
…………………………………………………………………………………40 Business license / other license from competent authorities
a. Type and License No. …………………………………………………..Date of issue ……………………………………………………………
b. Type and License No. …………………………………………………..Date of issue ……………………………………………………………
c. Type and License No. …………………………………………………..Date of issue ……………………………………………………………
Securities Company, Fund Manager and Custodian Bank
SUSPICIOUS TRANSACTION REPORT
41 Name of Company's Managementa. Name …………………………………………………………………
Occupation ……………………………………………………………b. Name …………………………………………………………………
Occupation …………………………………………………………c. Name …………………………………………………………………
Occupation …………………………………………………………42 Name of Owner/Majority Shareholder
a. Name …………………………………………………………………b. Name …………………………………………………………………c. Name …………………………………………………………………
II DETAILS OF SUSPICIOUS FINANCIAL TRANSACTIONS43 Type of Transaction
………………………………………………………………………………………………44 Date of Transaction
……………………………………………………………………………………………45 Value of Transaction (in Rupiah) ……………………………………………………..46 Payment Instrument used
……………………………………………………………………………………………47 Is foreign exchange used ? Yes No48 Is he/she walk-in customer? Yes No49 Account (s) used for transaction
a. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
b. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
c. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
d. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
e. Type of account …………………………………………………………..Account holder …………………………………………………………..No. of account …………………………………………………………..
50 Office of Reporting PFS where transaction occurs…………………………………………………………………………………………….
51 Other Providers of Financial Services (PFS) related to the transaction (if any)…………………………………………………………………………………………….
Securities Company, Fund Manager and Custodian Bank
SUSPICIOUS TRANSACTION REPORT
52 Third party related to the transaction (if any)a. Nama ……………………………………………………………………………..b. No. Rekening ………………………………………………………………….…
53 DETAILS AND DESCRIPTION OF SUSPICIOUS FINANCIAL TRANSACTION(served in separate pages)
III IDENTITY OF REPORTING PROVIDER OF FINANCIAL SERVICES (PFS)54 Code of PFS
……………………………………………………………………………………………55 Name of PFS
……………………………………………………………………………………………56 Name and Signature of PFS' Officer(s)
……………………………………………………………………………………………