Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697797303509.pdf (Dominica)
MINISTRY OF TOURISM & LEGAL AFFAIRS FINANCIAL INTELLIGENCE UNIT (Section 31 of the Money Laundering (Prevention) Regulations S.R.O.

of 2013) DomFIU Form (CR1) DATE (Date of Travel) Cash Transportation Report (Complete all parts that apply) _____________/_____________/_____________ mm dd yyyy PART I 1.

Last Name: Persons (s) Involved in Cash Transportation 2.

First Name: 3.

Middle Name: 4.

Nationality: 5.

Passport No.

: 6.

Date of Issue (mm/dd/yyyy): 7.

Date of Expiry (mm/dd/yyyy): 8.


Address: (number, street, and Apt.

or Suite No., City, State, Zip Code, Country) 9.

Country of Birth: 10.

Occupation/Profession: PART II Amount and Type of Cash.

(Check all boxes that apply) 11.

Total Cash/Value of Negotiable Instrument:______________________________________________________ 12.
Currency:☐ Euro (€) ☐ US (US) ☐ EC (XCD) ☐ Pound (£) ☐Other (Specify):______________________________________________________________________________ PART III Financial Institution Where Transaction (s) Was Conducted 13.

Name of Financial Institution: 14.

Address of Financial Institution (Number, Street, and Apt.

or Suite No., City, State, Zip Code, Country): 15.

Date of Transaction(mm/dd/yyyy): 16.

Approximate Date of Transaction (mm/dd/yyyy): 17.

Account No.

(s) Associated with Transaction: 18.


Account Type: a.

__________________________________ ☐Savings ☐Checking ☐Fix Deposit b.

__________________________________ ☐Other: ________________________________________ PART IV Other Person (s) on Whose Behalf Cash is Being Transported 19.

Last Name: 21.

Middle Name: 20.

First Name: 22.

Place of Birth: 23.

Date of Birth (mm/dd/yyyy): 24.

Relationship: (Indicate extent of your relationship with the person named in this Part): 25.
Address of Individual (number, street, and Apt.

or Suite No., City, State, Country): PART V Source & Intended Use of Funds / Declaration : I certify that all statements I have made in this declaration are true, correct and complete.

I understand that failure to make a full declaration is an offence and can result in seizure of the cash, fines and or imprisonment.
I further declare that to the best of my knowledge and belief that the cash was not derived from or is intended for use in any illegal activity.

……………………………………………….. ....…………………………………………….. Signature Date (mm/dd/yyyy): PART VI For Official Use Only 26.

Received by (Customs Officer): 27.

Signature: 28.

Date (mm/dd/yyyy): 29.

FIU Informed: ☐ Yes ☐No 30.

Date Informed: (mm/dd/yyyy): 31.

Received by (FIU Officer): 32.

Signature: 33.

Date (mm/dd/yyyy): 34.

Entered in Database: ☐ Yes ☐No 35.


Date Entered in Database (mm/dd/yyyy): 36.

Verified by: DomFIU Form (CTR1)