Legal AML Submission Form

LEGAL AML SUBMISSION FORM

This Legal AML Submission Form is made and entered into by Submitting Party Name: (Submitting Party) and Recipient Name: . Effective Date:

RECITALS

WHEREAS, the Submitting Party possesses information or reasonably suspects activity that may constitute money laundering, terrorist financing, or other illicit financial activity (the "Submission"); and

WHEREAS, the Recipient is authorized to receive, review and take appropriate compliance and reporting actions with respect to such Submissions under applicable anti-money laundering laws, regulations, and internal policy; and

WHEREAS, the Parties desire to establish the terms under which the Submission is provided, handled, retained and disclosed.

NOW, THEREFORE, in consideration of the mutual covenants set forth below, the Parties agree as follows:

1. DEFINITIONS

For purposes of this Form, the following definitions apply: "Submission" means the written or electronic information provided by the Submitting Party concerning suspected illicit activity; "Beneficial Owner" means any natural person who ultimately owns or controls the subject of the Submission in accordance with applicable law; "Supporting Documents" means any documentary evidence accompanying the Submission.

2. SUBMISSION DETAILS

AML Risk Indicators (check all that apply)

Structuring or frequent cash deposits Unusual cross-border activity
Use of shell or nominee entities Possible sanctions or PEP exposure

3. REPRESENTATIONS AND WARRANTIES

The Submitting Party represents and warrants that: (a) to the best of its knowledge the information supplied in this Submission is true, accurate and complete; (b) the Submitting Party has a reasonable basis for the suspicion or information provided; (c) the Submitting Party is authorized to provide the information and any personal data subject to applicable privacy obligations has been collected and provided in accordance with law; and (d) no representation in this Form is made for the purpose of misleading the Recipient.

The Submitting Party acknowledges that making a knowingly false or malicious Submission may violate applicable law and may subject the Submitting Party to civil or criminal penalties.

4. CERTIFICATION AND AUTHORIZATION

By signing below, the Submitting Party certifies under penalty of perjury that the information provided herein is true, correct and complete to the best of the Submitting Party's knowledge and authorizes the Recipient to: (i) investigate, verify and retain the Submission; (ii) disclose the Submission and any Supporting Documents to regulators, law enforcement, auditors, correspondent institutions, and other persons or entities as required or permitted by law; and (iii) take any compliance action deemed necessary by the Recipient, including, but not limited to, filing a Suspicious Activity Report or freezing or limiting transactional activity.

Check to confirm Submitting Party's certification: I certify the statements above are true and that I am authorized to submit this Form.

5. CONFIDENTIALITY AND DISCLOSURE

The Parties acknowledge that the Submission may contain confidential or personal information. The Recipient will treat the Submission as confidential to the extent permitted by law, but may disclose information to governmental authorities, auditors, legal counsel, other financial institutions, or as required by court order or regulation. The Recipient shall apply reasonable safeguards consistent with its policies and applicable law to protect personal data contained in the Submission.

6. RECORDS RETENTION; AUDIT

The Recipient may retain records of the Submission and related materials for the period required by applicable law and for the Recipient's compliance needs. The Submitting Party consents to the retention and, where required, the transfer of such records for regulatory or law enforcement purposes.

7. NOTICES

8. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Form shall be governed by and construed in accordance with the laws of the jurisdiction specified by the Recipient's governing policies. This Form constitutes the entire agreement between the Parties with respect to the Submission and supersedes all prior communications and understandings on the subject. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

9. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Form will be effective unless in writing and signed by authorized representatives of both Parties. The waiver of any breach shall not operate as a waiver of any subsequent breach. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

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