Model for Declaration of Suspicious Operation or Transaction

Declaration of Suspicious Operation or Transaction Reserved for the Declarant Enter the name and logo of the declarant Confidential Reserved for the CTAF

I- Declarant
Legal name:
First and Last Name:
Profession/Title:
E-mail:
Tel: Fax:
Address:
II- Correspondent
Name & First Name:
Tel: Fax:
E-mail:
III- Object of the Declaration
 Suspicious operation or transaction potentially linked directly or indirectly to funds originating from illicit acts classified by law as misdemeanors or felonies.  Suspicious operation or transaction potentially linked directly or indirectly to the financing of persons, organizations, or activities related to terrorist offenses stipulated by Organic Law No. 2015-26 of 07/08/2015.  Attempted suspicious operation or transaction potentially linked directly or indirectly to funds originating from illicit acts classified by law as misdemeanors or felonies.  Attempted suspicious operation or transaction potentially linked directly or indirectly to the financing of persons, organizations, or activities related to terrorist offenses stipulated by Organic Law No. 2015-26 of 07/08/2015.  Inability to verify the client's identity or where identification data are insufficient or manifestly fictitious, in accordance with the last paragraph of Article 108 of Organic Law No. 2015-26 of 07/08/2015.  Complementary suspicion declaration to a prior suspicion declaration

• Reference and date of the prior suspicion declaration:
  IV- Client 1 (Object of the Declaration)
   Regular
   Occasional
  Physical Person
  Name:
  First Name:
  Date of Birth:
  Place of Birth: City Country:
  Nationality:
  National Identity Card No. (attach copy):
  Passport No. (attach copy):
  Other reference no. (specify document type):

The suspicion declaration covers only one client Declaration of Suspicious Operation or Transaction under Article 125 of Organic Law No. 2015-26 of 07/08/2015 concerning the fight against terrorism and the repression of money laundering References for submission of the DS by the declarant Case reserved for the CTAF Reference of submission of the DS

Marital Status:
First and Last Name of Spouse:
National Identity Card No. (if applicable):
 Resident
 Non-resident
Current Professional Activity:
Main Address:
Other Addresses:
Legal Entity
Legal Name:
Trade Name or Logo:
Legal Form:
Corporate Purpose:
Sector:
Activity:
Date of Creation:
Commercial Register No.:
Tax ID Number:
 Resident
 Non-resident
Address:
City:
Postal Code:
Country:
Tel:
Fax:
E-mail:
Website:
Manager(s) or Executive(s)

Name & First Name	Date of Birth	Country of Birth	Identification Document No. (CNI/Passport)	R/NR	Role

Principal Shareholders or Partners

Name & First Name	Date of Birth	Country of Birth	Identification Document No. (CNI/Passport)	R/NR	Shareholding Percentage	Voting Rights Percentage	Role

Client's Agent/Legal Representative (physical or legal client):
Name:
First Name:
Date of Birth:

Place of Birth: City Country:
Nationality:
National Identity Card No.:
Passport No.:
Other reference no. (specify document type):
Current Professional Activity:
Address:
Mandate or other deed: (specify)
Date:
Document attached to client file:  yes  no
Other legal constructions:
Name of the legal construction:
Form of the legal construction:
Deed of creation of the legal construction:
Address:
Constituent of the legal construction:
Name and First Name:
Date and place of birth:
National Identity Card No.:
Passport No.
Beneficiaries of the legal construction:

Name & First Name	Date of Birth	Country of Birth	Identification Document No. (CNI/Passport)	Role	Shares Held in Capital	Voting Rights Percentage

V- Beneficial Owner of the Operation or Transaction Name:
First Name:
Date of Birth:
Place of Birth: City Country:
Nationality:
National Identity Card No.:
Passport No.:
Other reference no. (specify document type):
VI- Other Persons Involved in the Operation or Transaction or in the Facts Related Physical Persons

Name & First Name	Date of Birth	Identification Document No. (CNI/Passport)	Type of Link

Related Legal Entities (companies, associations and other legal constructions)

Company Name	Legal Form	Commercial Register No.	Type of Link

VII- Financial Information
Accounts

Account Type	Date of Opening	Account No. (RIB/RIP or IBAN)	Dinar/Currency	Balance at the date of the DS

Suspicious Operation(s) or Transaction(s)
 Executed operation or transaction
 Unexecuted operation or transaction

Nature of the Operation or Transaction	Date	Amount and Currency of the Operation or Transaction	Corresponding Bank(s) or Other Institutions Concerned	Other Information

VIII- Analysis of Facts & Money Laundering and/or Terrorism Financing Indicators To be indicated:
 all elements enabling clear identification of the suspicion motivating the DS  all objective elements underlying the suspicion (synthesis of operations, movements and unusual characteristics / development of facts, operational characteristics / specification of the presumed origin and destination of funds subject to suspicion, client behavior)  factors and circumstances that (led to the suspicion) revealed the presumed links of declared operations or transactions with ML/TF.  conclusions leading to the emergence of suspicion. _______________________________________________________________________________________

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_______________________________________________________________________________________ _________________________________________________ (add as many sheets as necessary) IX- Attachments to the Declaration (attach documents necessary for DS review, including:

Label	Check (X)	Document Format	Declarant's Observations
The legal relationship file and identification documents of concerned persons (client, beneficiary, beneficial owner) and "KYC" sheet specifying ML/TF risk.	(X)	Paper or Electronic
Operations related to account movements or executed operations: 1-Bank and financial statements 2-Accounting documents, Swift, client orders, bank checks…	(X)	Excel / PDF
Documents related to the DS and facts (Contracts, foreign currency import declaration, foreign currency exit authorization, documents from financial service providers)	(X)	Paper or Electronic
Other Documents	(X)	Paper or Electronic

Signature of Correspondent2:
Signature of Authorized Declarant3
Date of Declaration:
Date of Declaration:

Concerns banking and financial institutions
Concerns designated non-financial professions