SCHEDULE 1(Paragraph 7(1)(a), sections 18 and 25, paragraphs 30(1)(a) and 33(1)(a), sections 39, 48, 54, 60, 64.2 and 66, paragraph 70(1)(a), section 78, subsection 131(3) and section 152)Report with Respect to Receipt of Cash
PART A
Information with Respect to Reporting Person or Entity and Place of Business Where Cash 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 or night deposit indicator
2*
Time of transaction
3*
Posting date, if different from date of transaction
4*
Type and amount of each fiat currency involved
5*
Method by which transaction conducted
6
Exchange rates used
7
Purpose of transaction
8
Source of cash involved
9
Name of every person or entity that is source of cash involved and their account number or policy number and name of the person or entity with which the account or policy is held or, if no account number or policy number, identifying number and name of the person or entity that issued it
10*
Following details of remittance of, or in exchange for, cash received:
(a)
method of remittance
(b)
if remittance is in funds, type and amount of each type of funds involved
(c)
if remittance is not in funds, type of remittance and its value, if different from amount of cash received
(d)
name of every person or entity that is involved in remittance and their account number or policy number and name of the person or entity with which the account or policy is held or, if no account number or policy number, identifying number and name of the person or entity that issued it
PART C
Account and Reference Number Information
1*
Every account number and other equivalent reference number connected to receipt of cash or remittance
1.1*
Name of person or entity with which the account is held or of person or entity that issued the reference number
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*
Type of fiat currency of account
6
Date account opened
PART D
Information with Respect to Person or Entity That Conducts Transaction That Does Not Involve Deposit into Business Account
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
In the case of a person,
(a)
their alias
(b)*
their date of birth
(c)
their country of residence
(d)
their employer’s name
10*
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 E
Information with Respect to Person or Entity That Conducts Transaction That Involves Deposit into Business Account Other than Night Deposit or Quick Drop
1*
Person’s or entity’s name
PART F
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 conducting transaction
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 G
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
Relationship of beneficiary to person or entity conducting transaction
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
