Subject: *
Independent Review Other Need

Business Name: *


Contact Name: *


Email Address: *


Phone: *


Street Address:


City, State and Zip-code:


Level of Urgency:
Select one. Our initiative to seek assistance Bank(s) has requested (ASAP) Regulatory action

Brief description of business activities: *


Independent Review:
Select one. This will be our first one. Replacing prior relationship

FinCEN Registration as MSB?
Select one. Have never registered with FinCEN FinCEN registration expired Current FinCEN registration

Check Cashing?
Select one No; we do not cash checks Yes; no state license or registration required (Principal) Registered or Licensed check casher (Principal) Yes; cash checks as an Agent

Sale of Money Orders or Travelers Checks?
Select one. No; not a Principal or Agent Agent for money orders or travelers checks Principal Check Seller with state license Principal Check Seller; state license not required

Sale of Stored Value Cards?
Select One Not applicable / No sale of stored value Agent; sells stored value Principal for stored value

Money Transfer Services:
Select One Not applicable Agent of money transmitter Principal money transmitter w/state license(s) Principal, state license(s) not required

BSA/AML Policies, Procedures and Controls:
Select one. Nonexistent or minimal May need some improvements Complete, well developed, current

Number of business locations:
Select one. 1 - one 2 - two 3 - 5 6 - 10 11 or more

Number of employees:
Select one. 1 - 5 6 - 25 26 - 100 over 100

Agents and Foreign Counterparties:
Select one. Not applicable yes, Agents. yes, Foreign Counterparties Agents AND Foreign Counterparties