Financial Intelligence Centre (Prescribed Thresholds) Regulations, 2016

1. Check all box(es) that apply: a. Amends Prior Report b. Multiple Persons c. Multiple Transactions Individual’s Last Name or Company’s Name: __________________________________ First Name: ___________________________________________________________

4. Middle Name: __________________________________________________________

5. Date of Birth: (DD/MM/YYYY) __________/_____________/________

8. Profession/Nature of business: _____________________________________________ 8th July, 2016 Statutory Instruments 605

9. Identify Type: NRC Passport Driver’s License TPIN Number a. b. c. Identification Number: ___________________________________________ Identification issued by: ___________________________________________ Place of Issue: ___________________________________________________

10. Physical Address* a. b. c. d. Property Number and Street Name: __________________________________ Residential Area:__________________________________________________ Town: __________________________________________________________ Provincial & Country: _____________________________________________

12. Postal Address:___________________________________________________ Telephone: _________________________ Mobil:_________________________ Fax:______________________ II. INDIVIDUAL(S) CONDUCTING TRANSACTION(S) (IF OTHER THAN ABOVE) If Section II is left blank or incomplete, check the box(es) below to indicate the reason(s) a. c. d. Armored Car Service Night Deposit or ATM Multiple Transactions b. e. Mail Deposit or Transportation Conducted on Own Behalf Individual's Last Name or Company's Name: ___________________________ First Name: ____________________________________________________ Middle Name: ___________________________________________________ Date of Birth: (DD/MM/YYYY) _________/__________/_______ Gender: F M Doing Business as: ______________________________________________ Profession/Occupation/Nature of business: ___________________________ Identify Type: NRC Passport Driver's License TPIN Number

20. a. b. c. Identification Number: ____________________________________________ Identification issued by: ___________________________________________ Place of Issue: ___________________________________________________

21. Physical Address* a. b. c. d. Property Number and Street Name: __________________________________ Residential Area: _________________________________________________ Town: _________________________________________________________ Provincial & Country: ____________________________________________

22. Postal Address: _______________________________________________________ 606 Statutory Instruments 8th July, 2016

23. Telephone: _________________________ Mobil:___________________________ Fax:_____________________ If box 1a above for Amend prior report is checked, please provide the reference number for the CTR to be amended

24. CTR Reference Number: _________________________________________________ If box 1a above for Amend prior report is checked, please provide the reference number for the CTR to be amended

31. PART B: TRANSACTION DETAILS CHECK ALL BOXES THAT APPLY Place of Transaction*: _____________________________________________ Date of Transaction*:DD/MM/YYYY _______/ ________/ _______ Total cash in (K)*: ________________________________________________ Total cash out (K):________________________________________________ Foreign Currency Amount and Type (specify): _________________________ Account Number(s) Affected*: ______________________________________ Transaction Type* Negotiable Instrument(s) Purchased Negotiable Instrument(s) Cashed Deposit(s) Withdraws(s) Other (specify): …………………………………… PART C: REPORTING ENTITY DETAILS* NATURE OF BUSINESS Micro Finance Institution Insurance Broker Lotteries Motor Vehicle Dealer Motor Vehicle Dealer Precious Metal Dealer Leasing Company Bureau de Change Real Estate Ag. Legal Practitioner Insurance Building Society Money Remitter Real Estate Dev. Accountant/Auditor Pension Commercial Bank Casino Stock Broker Tax Consultant Development Finance Other (Specify): _________________________________________________________ Reporting Entity Name*: __________________________________________________ Physical Address: ________________________________________________________ 8th July, 2016 Statutory Instruments 607 Compliance/Reporting Officer Name: _________________________________________________________________ Position: _______________________________________________________________ Tel. No.: Email Address: __________________________________________________________ If different from Compliance/ReportingOfficer Name: _________________________________________________________________ Address: _______________________________________________________________ Tel. No.: Landline: +260 Mobile: +260 Email Address: __________________________________________________________ Are there any attachments accompanying this form? Yes NO (If yes, please specify):____________________________________________________ …………………………… MM/DD/YYYYY _______/ _______/ _____ Signature Date: A. B. CHIWANDA, Minister of Finance LUSAKA 17th June, 2016 [ MF/IDM.101/1915] 608 Statutory Instruments 8th July, 2016