Report a Financial Crime

This form has been prepared by the Financial Intelligence Unit and is subject to the Money Laundering and Terrorism (Prevention) Act, Chapter 104 of the laws of Belize. All information provided is strictly confidential and will not be disclosed in any way unless it is determined that it is suitable for investigations by the appropriate authority. The Financial Intelligence Unit does not guarantee that an arrest or prosecution will be carried out as a result of any suspicious activity reported.

Financial Intelligence Unit
Disclosure Form
4998 Coney Drive Plaza, P.O. Box 2197, Belize City Belize
Telephone No.: 223-2729/0596, Fax No.: 223-2351, Email: fiu.belize@fiubelize.org

[A] Disclosing Individual
Name:
Full Address:
Telephone No:
E-mail Address:

[B]Subject(s) of Disclosure – Individual
Full Name: (Individual)
Date and Place of Birth:
Identification (form and number):
Occupation:
Full Address:
Telephone No:

[C]Subject(s) of Disclosure – Company
Company Name:
Type of Business:
Full Address:
Telephone No.:
Fax No.:
E-mail Address:
Identification Documents (e.g., certificate of incorporation, memorandum and articles of association, etc. if available):

[D] Beneficial Owner(s)
(of the assets being the subject(s) of disclosure – if different from the subject(s) of disclosure above)
Full Name:
Date and Place of Birth (Individual):
Type of Business/Occupation:
Full Address:
Telephone No. (Work):
Telephone No. (Home):
Fax No.:
E-mail Address:

[F] Suspicious Activity Information Explanation/Description
Explanation/description of known or suspected violation of law or suspicious activity.
Provide below a chronological and complete account of the possible violation of law, including what is unusual, irregular or suspicious about the transaction, using the following checklist as you prepare your account. If necessary, continue the narrative on a duplicate of this page.

Date range of the suspicion.
Explain who benefited, financially or otherwise, from the transaction(s) or activity(ies), how much, and how.
Any evidence of cover-up or evidence of an attempt to deceive federal or state examiners or others.
Indicate where the possible suspicion took place.
Indicate whether there is any related litigation; if so, specify.
Recommend any further investigation that might assist law enforcement authorities.
Indicate whether any information has been excluded from this report; if so, why?
If you are correcting a previously filed report, describe the changes that are being made.

For reports involving money value, include whether cash and/or monetary instruments were involved. If so, provide the amount, if known, and/or description of the instrument (for example, bank draft, letter of credit, money order, traveler’s checks, wire transfers sent or received, cash, etc.).

The capital of Brazil?