SCHEDULE 4(Paragraph 7(1)(d), sections 19 and 26, paragraphs 30(1)(f) and 33(1)(f), sections 40, 49, 55, 61 and 67, paragraph 70(1)(d), section 79, subsection 131(3) and section 152)Report with Respect to Receipt of Virtual Currency
PART A
Information with Respect to Reporting Person or Entity and Place of Business Where Virtual Currency Is Received
1*
Person’s or entity’s name
2*
Type of person or entity, as described in any of paragraphs 5(a) to (h.1) and (k) of the Act, or, if person or entity is referred to in paragraph 5(i), (j) or (l) of the Act, type of prescribed business, profession or activity referred to in that paragraph
3*
Identification number assigned to person or entity by Centre
4*
Number that identifies place of business
5*
Address of place of business
6*
Contact person’s name
7
Contact person’s email address
8*
Contact person’s telephone number
PART B
Information with Respect to Transaction
1*
Date of transaction
2*
Time of transaction
3*
Type and amount of each virtual currency involved
4*
Method by which transaction conducted
5*
Exchange rates used
6*
Transaction identifiers, including sending and receiving addresses
7
Purpose of transaction
8
Source of virtual currency, if obtained in the ordinary course of business
9
If obtained in the ordinary course of business, name of every person or entity that is source of virtual currency involved and their account number or policy number or, if no account number or policy number, identifying number
10*
Following details of remittance of, or in exchange for, virtual currency received:
(a)
method of remittance
(b)
if remittance is in virtual currency, type and amount of each virtual currency involved
(c)
if remittance is not in virtual currency, type of remittance and its value, if different from amount of virtual currency received
(d)
name of every person or entity involved in remittance and their account number or policy number or, if no account number or policy number, identifying number
PART C
Account and Reference Number Information
1*
Every account number and other equivalent reference number connected to receipt of virtual currency or remittance
2*
Type of account
3*
Branch number, institution number and similar numbers connected to account or reference number
4*
Name of each account holder
5*
User name of each account holder
6*
Type of fiat currency or virtual currency of account
7
Date account opened
PART D
Information with Respect to Person Who Conducts Transaction and Who Is Client of Reporting Entity
1*
Person’s name
2
Person’s alias
3*
Person’s date of birth
4*
Person’s address
5
Person’s country of residence
6
Person’s email address
7
Person’s telephone number
8*
Nature of person’s principal business or their occupation
9*
Identification number assigned to person by reporting person or entity
10*
Type of document or other information used to identify person, or to verify their identity, and number of document or number associated with information
11*
Jurisdiction and country of issue of document or other information
12
Name of person’s employer
13
Type of device used by person who conducts transaction online
14
Number that identifies device
15
Internet Protocol address used by device
16
Person’s user name
17
Date and time of person’s online session in which request is made
PART E
Information with Respect to Person Who Conducts Transaction and Is Not Client of Reporting Entity
1
Person’s name
2
Person’s alias
3
Person’s date of birth
4
Person’s address
5
Person’s country of residence
6
Person’s email address
7
Person’s telephone number
8
Nature of person’s principal business or their occupation
9
Identification number assigned to person by reporting person or entity
10
Type of document or other information used to identify person, or to verify their identity, and number of document or number associated with information
11
Jurisdiction and country of issue of document or other information
12
Name of person’s employer
13
Type of device used by person who conducts transaction online
14
Number that identifies device
15
Internet Protocol address used by device
16
Person’s user name
17
Date and time of person’s online session in which request is made
PART F
Information with Respect to Entity That Conducts Transaction and Is Client of Reporting Entity
1*
Entity’s name
2*
Entity’s address
3
Entity’s telephone number
4*
Nature of entity’s principal business
5*
Identification number assigned to entity by reporting person or entity
6*
Name of each person — up to three — who is authorized to bind entity or to act with respect to account
7*
Type of document or other information used to identify entity, or to verify its identity, and number of document or number associated with information
8*
Jurisdiction and country of issue of document or other information
9*
Entity’s registration or incorporation number and jurisdiction and country of issue of that number
10
Type of device used by entity that conducts transaction online
11
Number that identifies device
12
Internet Protocol address used by device
13
Entity’s user name
14
Date and time of entity’s online session in which transaction is conducted
PART G
Information with Respect to Entity That Conducts Transaction and Is Not Client of Reporting Entity
1
Entity’s name
2
Entity’s address
3
Entity’s telephone number
4
Nature of entity’s principal business
5
Identification number assigned to entity by reporting person or entity
6
Name of each person — up to three — who is authorized to bind entity or to act with respect to account
7
Type of document or other information used to identify entity, or to verify its identity, and number of document or number associated with information
8
Jurisdiction and country of issue of document or other information
9
Entity’s registration or incorporation number and jurisdiction and country of issue of that number
10
Type of device used by entity that conducts transaction online
11
Number that identifies device
12
Internet Protocol address used by device
13
Entity’s user name
14
Date and time of entity’s online session in which transaction is conducted
PART H
Information with Respect to Person or Entity on Whose Behalf Transaction Is Conducted
1*
Person’s or entity’s name
2*
Person’s or entity’s address
3
Person’s or entity’s email address
4
Person’s or entity’s telephone number
5
Nature of person’s or entity’s principal business or their occupation
6
Identification number assigned to person or entity by reporting person or entity
7
Type of document or other information used to identify person or entity, or to verify their identity, and number of document or number associated with information
8
Jurisdiction and country of issue of document or other information
9*
Relationship of person or entity to person or entity that requests transfer
10
In the case of a person,
(a)
their alias
(b)
their date of birth
(c)
their country of residence
(d)
their employer’s name
11
In the case of an entity,
(a)
name of each person — up to three — who is authorized to bind entity or to act with respect to account
(b)
its registration or incorporation number and jurisdiction and country of issue of that number
PART I
Information with Respect to Beneficiary
1*
Beneficiary’s name
2*
Beneficiary’s address
3
Beneficiary’s email address
4
Beneficiary’s telephone number
5
Nature of beneficiary’s principal business or their occupation
6
Identification number assigned to beneficiary by reporting person or entity
7*
Type of document or other information used to identify beneficiary, or to verify their identity, and number of document or number associated with information
8*
Jurisdiction and country of issue of document or other information
9
Beneficiary’s user name
10
If beneficiary is a person,
(a)
their alias
(b)
their date of birth
(c)
their country of residence
(d)
their employer’s name
11*
If beneficiary is an entity,
(a)
name of each person — up to three — who is authorized to bind entity or to act with respect to account
(b)
its registration or incorporation number and jurisdiction and country of issue of that number
