Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694500124962.pdf (Antigua and Barbuda)
Terrorist Property Report (Prevention of Terrorism Act 2005) Submit this form when completed to the Director of the Ofﬁce of National Drug and Money Laundering Control Policy (ONDCP), Camp Blizard, Antigua.
Tel: 268 562-3255; Fax: 268 460-8818; email: director@ondcp.gov.ag Financial institutions should use this form to: (1) Make a report of property in its possession or control which is owned or controlled by or on behalf of a terrorist* or terrorist group* as required by section 34(1)(a) of the Prevention of Terrorism Act 2005 (PTA 2005); (2) Report information regarding a transaction or proposed transaction in respect of property owned or controlled by or on behalf of a terrorist* or terrorist group* as required by section 34(1)(b) of the PTA 2005; (3) Make terrorist* property reports every three (3) months as required by section 34(3) of the Prevention of Terrorism Act 2005 (PTA 2005); (4) Report transactions related to the commission of a terrorist act as required by section 34(4) of the PTA 2005; *A terrorist or terrorist group is one that has been so declared by Order made by the Attorney General under section 3 of the PTA 2005, or by the Minister of Foreign Affairs under section 4 of the PTA 2005.
Date of report / / day month year Time of report : am/pm hour minute Please type or print and tick boxes be- low as appropriate PART A – Financial Institution making report 1.

Name ................................................................................................................ 2.

Street Address ................................................................................................................ 3.
City ................................................................................................................ 4.

Country ................................................................................................................ 5.

Type of ﬁnancial institution A.

B.

Bank Other (state type) ......................................................... 6.

Telephone ................................................. 7.

Fax ........................................................... 8.
Email ........................................................ PART B – Reason(s) for ﬁling this report 9.

This is a: Report of terrorist property to be made every 3 months by a ﬁnancial institution, pursuant to section 34(3) of the Prevention of Terrorism Act 2005.

The ﬁnancial institution named in Part A above Is Is not in possession or control of property owned or controlled by or on behalf of a terrorist group.
( if answered “Is ” continue onto Part C; if answered “Is not” please go to Part G and sign and submit the Report to the Director of ONDCP).

Report of property owned or controlled by a terrorist or terrorist group which has recently been discovered to be in the possession or control of the ﬁnancial institution named in Part A above, made pursuant to section 31(1)(a) of the Prevention of Terrorism Act 2005.
Report regarding a transaction or proposed transaction in respect of property which is owned or controlled by or on behalf of a terrorist group, made pursuant to sectin 31(1)(b) of the Prevention of Terrorism Act 2005.

Report of a transaction which there are reasonable grounds to suspect is related to the commis- sion of a terrorist act, pursuant to section 34(4) of the Prevention of Terrorism Act 2005.

PART C – Person(s) of concern Details of the declared terrorist/terrorist group (“speciﬁed entity”) 10.
Name .............................................................................................................. 11.

Address .............................................................................................................. 12.

City .............................................................................................................. 13.

Country .............................................................................................................. 14.
Citizenship ..............................................................................................................

Details of the preson who owns or controls the property on behalf of the declared ter- rorist/terrorist group (“speciﬁed entity”) mentioned above (if applicable) 15.

Name .............................................................................................................. 16.
Address .............................................................................................................. 17.

City .............................................................................................................. 18.

Country .............................................................................................................. 19.
Citizenship .............................................................................................................. PART D – Property involved 20.

Type of property A.

Cash B.

Bank account C. Insurance policy D. Money order E. Real estate F. Securities G. Traveller’s cheques H. Other (describe) .......................................................................... 21.
Property value (actual or approximate) .............................................................................................................. 22.

How did the ﬁnancial institution named in Part A come into possession or control of this property?

............................................................................ ....................................................................................................................... Account information 23.
Account number .............................................................................................................. 23.

Type of account A.

Personal B.

Business C. Savings D. Chequing E. CD F. Trust G. Safe Deposit Box H. Other .................................................................................. 24.

Details of each account holder (1) Name ..............................................................................................................
Address ..............................................................................................................

Citizenship .............................................................................................................. (2) Name ..............................................................................................................

Address ..............................................................................................................
Citizenship .............................................................................................................. (3) Name ..............................................................................................................

Address ..............................................................................................................

Citizenship .............................................................................................................. 25.
Details of each signatory to the account (1) Name ..............................................................................................................

Address ..............................................................................................................
Citizenship .............................................................................................................. (2) Name ..............................................................................................................

Address ..............................................................................................................
Citizenship .............................................................................................................. (3) Name ..............................................................................................................

Address ..............................................................................................................

Citizenship .............................................................................................................. 26.
Date account opened ....................................................................................................................... 27.

Status of account A.

Active B. Inactive C. Dormant Part E - Nature of transaction involved 28.
Type of transaction or proposed transaction: deposit other (describe) .................... ....................................................................................................................................................................... wire transfer withdrawal Part F - Reasons for suspicions relating to property or transaction 29.
Give reasons for suspecting that the property described in Part D above is owned or controlled by or on behalf of a declared terrorist or terrorist organisation (“speciﬁed entity”) (continue on separate sheet if necessary) ....................................................................................................................................................................... ....................................................................................................................................................................... ...................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... 30.
Give reasons for suspecting that the transaction or proposed transaction described in Part E above is either related to terrorist property or concerned with the commission of a terrorist act (continue on sepa- rate sheet if necessary) ................................................................................................................................ ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ...................................................................................................................................................................... Part G - Reporting Ofﬁcer - Details and Declaration 31.
Identiﬁcation of Compliance Ofﬁcer or authorised ofﬁcer submitting this report: Name: Position: Ofﬁce address: Telephone: Fax: email: 32.

Declaration.

I declare the information contained in this report to be correct to the best of my knowl- edge, information and belief.

Date (dd/mm/yyyy): SIGN HERE Signature of Compliance Ofﬁcer or authorised ofﬁcer Ofﬁcial Use Only Comments Report No.

Case Ofﬁcer