香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
交易報告
Statement of Transactions
香港法例 第615 章《打擊洗錢及恐怖分子資金籌集條例》
Anti-Money Laundering and Counter-Terrorist Financing Ordinance,
Chapter 615
20 年 月 日 至 20
Periodic Return for the period from年

月日 的定期申報表
to(dd/mm/yyyy)(dd/mm/yyyy)

請用正楷及黑色筆填寫表格。
Please fill in the form in capital letter and black ink.
持牌人姓名 / 名稱:Name of licensee :金錢服務經營者牌照號碼:Money Service Operator Licence No.:□ 貨幣兌換業務性質:
Nature of business :Money changing□匯款Remittance□兩者Both(如適用，請加上「」號)(please 「」 if applicable)

第 1 部 – 貨幣兌換交易
Part 1 - Money Changing Transactions(A) 買入及賣出交易
Purchase and Sale Transactions
買入 Purchase款額(港元)
Amount in HKD

賣出 Sale交易宗數
No. ofTransactions

款額(港元)
Amount in HKD

交易宗數
No. ofTransactions

人民幣 RMB
其他貨幣
Othercurrencies
總數 Total:(B) 須執行客戶盡職審查(盡職審查)措施的非經常貨幣兌換交易
Occasional Money Changing Transactions requiring Customer Due Diligence (CDD) measures
成功交易的宗數拒絕個案數目#No. of Successful Transactions
No. of Rejected Cases #人民幣 RMB
其他貨幣Othercurrencies
總數 Total:# 表示客戶盡職審查措施未完成，因而拒絕交易的個案
denotes rejected transactions that due to incompletion of CDD requirements

1CED 406 (Rev. 12/2022)

香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
交易報告
Statement of Transactions
第2部–匯款交易
Part 2 – Remittance Transactions(A) 匯出的匯款交易及匯入的匯款交易
Outward Remittance Transactions and Inward Remittance Transactions
匯出的匯款
Outward Remittance款額(港元)
交易宗數
Amount in
No. ofHKD
Transactions

匯入的匯款
Inward Remittance款額(港元)
交易宗數
Amount in
No. ofHKD
Transactions(a) 其他金錢服務經營者
Other money service
operators(b) 個別人士
Individual persons(c) Others其他總數 Total: (a) + (b) + (c)(B)

須執行客戶盡職審查措施的匯款交易宗數
Number of Remittance Transactions requiring Customer Due Diligence (CDD) measures
成功交易的宗數
No. of Successful Transactions

拒絕個案數目#No. of Rejected Cases ## 表示客戶盡職審查措施未完成，因而拒絕交易的個案

denotes rejected transactions due to incompletion of CDD requirements

第3部
可疑交易報告Part 3 – Suspicious Transaction Report

曾向香港警務處聯合財富情報組報告的可疑交易報告宗數:
Number of suspicious transactions reported to the Joint Financial Intelligence Unit ofthe Hong Kong Police Force:

2
CED 406 (Rev. 12/2022)

香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
交易報告
Statement of Transactions
第 4 部 – 提交此申報表人士的聲明 (見於第 4 部內的備註)Part 4 – Declaration by the person who submits this return (see remarks in Part 4)
本人謹此聲明:I declare that:(a) 本申報表內提供的資料是真實無誤的;
the information given in this return is true and accurate;(b) 本人已閱讀此定期申報表的收集個人資料聲明，以及明白當中內容。
I have read the Personal Information Collection Statement in this Periodic Return and understandthe contents stated therein.

(*持牌人 / 獲授權的合夥人 / 董事或人士
簽署及公司印章)(姓名 (正楷))( Name in block letters )(*Signature of the licensee / authorized
person of the licensed partnership /authorized director or person of thelicensed corporation and company chop)(香港身份證號碼 /旅遊證件號碼*)(HKID No. / TravelDocuments No.* )(在持牌人業務/法團擔任的職位)(聯絡電話號碼)(日期)(Position in the Licensee’sBusiness / Corporation)(Contact Telephone No.)

(Date)

備註:
提交此申報表的人士必須是：
Remarks: The person who submits this return must be:(a) 如持牌人屬獨資經營，該獨資經營者；the sole proprietor, if the licensee is a sole proprietorship;(b) 如持牌人屬合夥，則獲每名合夥人書面授權的合夥人，並應隨附授權書；the partner authorized in writing by every partner, if the licensee is a partnership.
letter should be attached;

The authorization(c) 如持牌人屬法團，則獲董事局書面授權的董事或人士，並應隨附授權書。
the director or the person, authorized in writing by the Board of Directors, if the licensee is a corporation.
The authorization letter should be attached.

請 將填妥的交易報告定期申報表呈交 :Please submit the completed Statement of Transactions Periodic Return to:香港海關 金錢服務監理科 九龍 九龍灣常悅道 11 號 新明大廈 4 樓 402-403 室
Money Service Supervision Bureau Customs and Excise Department
Units 402-403, 4/F, Centre Parc, 11 Sheung Yuet Road, Kowloon Bay, Kowloon*請删去不適用者 Please delete as appropriate

3CED 406 (Rev. 12/2022)

香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
交易報告
Statement of Transactions

收集個人資料聲明Personal Information Collection Statement
1.

收集目的
Purpose of Collection
本申報表所提供的個人資料及任何更新資料，將會用於處理申請 / 記錄用途 / 更新紀錄 及 進行調查，藉以執行第 615 章《打擊洗錢及恐怖分子資金籌集條例》(打擊洗錢條例) 的規定。
The personal data provided in this return as well as any updates will be used for facilitating processing ofapplications / record purpose / record update and investigations for the enforcement of the Anti -Money
Laundering and Counter-Terrorist Financing Ordinance (AMLO), Chapter 615.

2.

資料轉介
Classes of Transferees
在本申報表填報的個人資料及任何更新資料，可能會向其他政府部門 / 政策局或機構披露，以履行上文
第 1 段所載的目的；或根據打擊洗錢條例第 49 條向任何第三者披露；或在法律授權或規定的情況下須作出此等披露。
The personal data you provide in this return as well as any updates of them may be disclosed to other
Government departments / bureaux or organizations for the purposes mentioned in paragraph 1 above; or any
third parties under section 49 of the AMLO; or where such disclosure is authorized or required by law.

3.

查閱個人資料
Access to Personal Data
根據《個人資料﹝私隱﹞條例》(私隱條例)的規定，你有權查閱及更正你的個人資料。查閱的權利包括有權索取此申報表內填報的個人資料的複本。根據私隱條例的規定，本署有權收取合理費用，以處理任何查閱資料要求。
You have the right of access to and correction of your personal data as provided for in the Personal Data (Privacy)
Ordinance (PDPO). Your right of access includes the right to obtain a copy of your personal data
provided in this return. In accordance with the provision of the PDPO, we have the right to charge a reasonable
fee for the processing of any data access request.

4.

個人資料的查詢Enquiries to Personal Data如欲查詢本申報表所收集的個人資料，包括查閱及更正資料要求，請聯絡：
Enquiries concerning the personal data collected by this return, including the request for access to andcorrection of personal data, should be addressed to:香港北角渣華道222號
海關總部大樓31樓
香港海關
內務行政科
內務秘書

Departmental Secretary
Office of Departmental Administration
Customs and Excise Department
31/F, Customs Headquarters Building
222 Java Road, North Point, Hong Kong.

4
CED 406 (Rev. 12/2022)