Suspicious Transaction Form

Customer account number(s) affected:

Date or date range of suspicious activity:

Total $$ amount involved:

Relationship to Financial Institution:

Accountant Attorney Customer Officer Appraiser Employee
Agent Borrower Director Shareholder Broker
Other

Summary characterization of suspicious activity:

BSA Structuring/Anti-Money Laundering Check Fraud Wire Fraud
Check Kiting Identity Theft Terrorist Financing Debit Card Fraud
Counterfeit Check Credit Card Fraud Terrorist Financing Computer Intrusion
Other

Narrative

Please answer the following questions to describe in detail the suspicious transaction(s):

Who is conducting the suspicious activity? Include occupation, position or title within the business, the nature of the suspect’s business and length of relationship with the financial institution.

What instruments or mechanisms are being used to facilitate the suspect transaction(s)? Identify and describe the transactions raising the suspicion of the bank. For example, cash deposits and/or withdrawals, wires or electronic transfers (ATM/ACH), checks & other monetary instruments, etc.

When did the suspicious activity take place? Indicate if the activity was a one-time occurrence and identify the date or if a pattern of activity occurred over a span of time, state when the activity first initiated and describe the activity during the duration.

Where did the suspicious activity take place? Include the branch/department location or locations within the institution where the activity occurred and include the name of branch, office or department and street address for each location. Also identify all account numbers & types of accounts affected by the transactions/activity.

Why does the institution think the activity is suspicious? Explain why the activity or transactions is unusual for the customer; consider the types of products and services offered by your institution and the nature and normally expected activities of similar customers. Be sure to include any relevant information about the suspicious customer activity that the institution has in its files and forward that information to the BSA Officer.

How did the suspicious activity occur? Describe the method of operation of the subject conducting the suspicious activity. In a concise, accurate and logical manner, describe how the suspect transaction or pattern of transactions was committed.

Please fax copies of any additional documentation to the BSA officer at (979) 589-2725.

Disclosures

In order for us to process your request correctly, we may need to contact you to verify some of the information or request additional documentation. When you submit this request, you certify that everything stated above is true and accurate.

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