Money Laundering Internal Report Form (Jan24)

IMPORTANT If you suspect money laundering or terrorist financing submit this report without delay to the firm’s MLRO. Also, telephone to advise that a report is being made. Do not inform anyone else. It may be an offence to disclose that this report has been made.

CLIENT DETAILS

Our reference/ file number……………Is the matter within the AML regulated sector? Yes/ No

Name ….………………………………………………………………Date of Birth: ……………………………………

Aliases / Trading / Business Name ……………………………..………………………………………………………………………………………………………..

Address ………………………………………………………………..……………………………………………………………………..

…………………..…………………………………………….. Telephone No. …….……………………………

If beneficial owner exists who is not the client:

(a) Name of beneficial owner ………………………………..…………………………………………………

(b) Address of beneficial owner ………………………………………..…………………………………………

…………………………………………………………………………….…..……………………………………………………..

Evidence of identity of client / beneficial owner attached: YES/NO (give details):

…………………………………………………………………………………………….…………………………………………

Name and address of introducer (if any) ……………….……………………………………………………………

INFORMATION/SUSPICION

Concisely summarise details of the transaction, (including details of the criminal property such as value and location, source of funds, other parties, etc)

…………………………………………………………………………………………………………………………………………

Are there any specific timescale that we need to consider (for example completion, dates stated within the contract). If yes, please provide details.

…………………………………………………………………………………………………………………………………………

Reason for Suspicion (including who is the subject of suspicion (is the client a victim or a suspect?), how are they involved, nature of criminal conduct if known, when and how did the circumstances arise/ are planned to happen, funds believed to be suspect, information that causes suspicion)

…………………………………………………………………………………………………………………………………………

Is a PEP involved in the transaction? Yes/ No

Is any high-risk jurisdiction involved or sanctions? If yes, please provide details.

…………………………………………………………………………………………………………………………………………

Do you seek consent to proceed with a matter possibly involving criminal property? Yes/No

Other Comments …………………………………………………………………………………………………………………

In submitting this report, I understand my obligations:

a) to take no further action in the matter unless authorised by you in writing; and
b) not to disclose the contents of this report to the client or anyone else unless authorised by you in writing.

Name of person reporting …………………………………….

Signed ………………………………………….. Date ……………..

MLRO USE

Date / time received …………………….……………

Date of review: …………………………………

Actions taken/ any comments

………………………………………………………………………………………………………………………

January 2024

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