SCHEDULE 1(Paragraph 12(1)(a), sections 17 and 21, paragraph 28(1)(a), sections 33.1, 35, 38, 39.2 and 39.6, paragraph 40(1)(a), section 47 and subsections 52(1) and (3))Large Cash Transaction Report
PART A
Information on Place of Business Where Transaction Occurred
1*
Type of reporting person or entity, as described in paragraphs 5(a) to (h), (k) and (l) of the Act, and, if reporting person or entity is referred to in paragraph 5(i) or (j) of the Act, type of business, profession or activity of reporting person or entity, as described in sections 16, 34, 37, 45 and 46 of these Regulations
2*
Identification number of place of business where transaction occurred (e.g., institution’s identification number, licence number or registration number), if applicable
3*
Full name of reporting person or entity
4*
Full address of place of business where transaction occurred
5*
Name and telephone number of contact person
PART B
Information on Transaction
1*
Date of transaction or night deposit indicator
2
Time of transaction and, for a transaction for which the date is provided in item 1, the posting date (if different from the date of the transaction)
3*
Posting date for a transaction for which night deposit indicator is provided in item 1, if date of transaction is not provided
4*
Purpose and details of the transaction, including amount of transaction and currency of transaction
5*
Disposition of funds, amount of disposition, currency of disposition and, if applicable, name and number of each other institution and name, account number and policy number of each other person or entity
6*
Method by which the transaction is conducted (in branch or office, ABM, armoured car, mail deposit, courier or other)
PART C
Account Information (if applicable)
1*
Account number
2*
Branch number or transit number
3*
Type of account (personal, business, trust or other)
4*
Full name of each account holder
5*
Type of currency of the account
PART D
Information on Person Conducting Transaction That Is Not a Deposit into a Business Account (if applicable)
1*
Person’s full name
2*
Client number provided by reporting person or entity, if applicable
3*
Person’s full address
4
Person’s personal telephone number
5
Person’s country of residence
6*
Person’s type of identifier (e.g., driver’s licence, birth certificate, provincial health insurance card — if such use of the card is not prohibited by the applicable provincial law — or passport) and identifier number
7*
Place of issue of person’s identifier (province or state, country)
8*
Person’s date of birth
9
Person’s business telephone number
10*
Person’s occupation
PART E
Information on Person Conducting Transaction That Is a Deposit into a Business Account Other than a Night Deposit or a Quick Drop (if applicable)
1*
Person’s full name
PART F
Information on Entity on Whose Behalf Transaction Is Conducted (if applicable)
1*
Entity’s full name
2*
Entity’s incorporation number and place of issue of its incorporation number, if applicable
3*
Entity’s type of business
4*
Entity’s full address
5
Entity’s telephone number
6
Full name of each person — up to three — who is authorized to bind the entity or act with respect to the account
PART G
Information on Person on Whose Behalf Transaction Is Conducted (if applicable)
1*
Person’s full name
2*
Person’s full address
3
Person’s personal telephone number
4
Person’s business telephone number
5
Person’s type of identifier (e.g., driver’s licence, birth certificate, provincial health insurance card — if such use of the card is not prohibited by the applicable provincial law — or passport) and identifier number
6
Place of issue of person’s identifier (province or state, country)
7
Person’s date of birth
8
Person’s occupation
9
Person’s country of residence
10
Relationship of person conducting the transaction to the person on whose behalf the transaction is conducted
