Monthly Suppression of Terrorism and UN Sanctions Report Suppression of Terrorism - Report under section 83.11 of the Criminal Code of Canada (Criminal Code) and section 7 of the Regulations Implementing the United Nations Resolutions on the Suppression of Terrorism (UN SupTerror) and section 5.1 of the United Nations Al-Qaida and Taliban Regulations (UN Al-Qaida) and UN Sanctions - Report under subsection 11(2) of the Regulations Implementing the United Nations Resolution on Iran (UN Iran) or subsection 11(2) of the Regulations Implementing the United Nations Resolution on the Democratic People’s Republic of Korea (UN NKorea) Name of Registrant/Exempt Dealer/Exempt Adviser: Address: 1 CONFIDENTIAL when completed Revised July 30, 2010 Date of filing of this report: ____ /____/____ (dd / (mm) / yy) Monthly period covered in this report: ____ /____/____ (see Note 2) (dd / (mm) / yy) to ____ /____/____ (dd / (mm) / yy)
Type of Registration or Exempt Dealer/Exempt Adviser: (check all applicable Exempt Adviser categories): If you have a POSITIVE REPORT to file, check “YES”, then fill out page three of this form, sign the certificate section at page 4 and file this report. Yes The above Registrant/Exempt Dealer/Exempt Adviser has accounts in the name of a Designated Person*, or has contracts with a Designated Person, or possesses or controls property that is owned or controlled by or on behalf of a Designated Person. *Please refer to the definitions at page 3 for the definition of “Designated Person”. Certificate The Undersigned certifies that, to the best of his/her knowledge, and after having made reasonable enquires, the information contained in this report is correct. Name Signature Title Telephone Date ____________________________________________________________________________________________________________ 2 Exempt Dealer Exempt Market Dealer (Registered) Investment Dealer Investment Fund Manager ** Mutual Fund Dealer Portfolio Manager Restricted Dealer Restricted Portfolio Manager Scholarship Plan Dealer Other ______________________ ** only required to file if also in the business of dealing and/or advising in securities If you have a NIL REPORT to file, check “NO”, then sign the certificate section below and file this report. No The above Registrant/Exempt Dealer/Exempt Adviser does not have an account in the name of a Designated Person*, or have a contract with a Designated Person, or possess or control property that is owned or controlled by or on behalf of a Designated Person. *Please refer to the definitions at page 3 for the definition of “Designated Person”. (dd/mm/yyyy):
If you have checked the “Yes” box above, please complete the table below and the certificate at the end of this form. Definitions: “Number of Accounts” means the number of accounts, policies or contracts associated with a Designated Person. “Designated Person”, for purposes of the Suppression of Terrorism report, refers to the persons and entities listed as of the end of the month prior to the date of the report. The listing consists of the names of listed entities under the Criminal Code, listed persons under the UN SupTerror and those persons and entities covered by the UN Al-Qaida which have been combined into the list currently posted on the Office of the Superintendent of Financial Institutions (OSFI) website: http://www.osfi-bsif.gc.ca . For purposes of the UN Sanctions report, “Designated Person” has the meaning assigned to it under section 1 of the UN Iran (see list of Designated Persons under the UN Iran, on the OSFI website) or section 1 of the UN NKorea (see list of Designated Persons under the UN NKorea on the OSFI website) “Property” has the meaning assigned to it under the Criminal Code, the UN SupTerror and the UN Al-Qaida, and under section 1 of the UN Iran and section 1 of UN NKorea and includes assets under administration (both discretionary and non-discretionary). SUMMARY OF PROPERTY (see Note 3) Type of Property Number of Accounts Property Value (Canadian $) (see Note 2) (see Note 3) Suppression of Terrorism UN Sanctions Suppression of Terrorism UN Sanctions (combined list for (list $ for UN (combined list for Criminal (list $ for UN Iran Criminal Code, UN Iran and UN Code, UN SupTerror and and UN NKorea) SupTerror and UN Al- NKorea) UN Al-Qaida) Qaida) Cash, cash equivalents, demand and term deposits Securities (bonds, debentures, commercial paper, treasury bills, mutual fund units, scholarship plan units, common and preferred shares and derivatives). Loans (including, mortgages, overdrafts, credit card balances, term loans, lines of credit and other indebtedness) Annuities (cash surrender value/monthly income) Life insurance policies Property & casualty insurance policies (policy limit) Other property, including real estate Total 0 0 $0.00 $0.00 3
Certificate The Undersigned certifies that, to the best of his/her knowledge, and after having made reasonable enquires, the information contained in this report is correct and, if applicable, any property summarized has been frozen and the relevant account details have been reported to the Royal Canadian Mounted Police and the Canadian Security Intelligence Service and, if applicable, the Financial Transactions and Reports Analysis Centre of Canada, and in respect of any foreign operations, to foreign law enforcement officials, as appropriate. Name Signature Title Telephone Date (dd/mm/yyyy) ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Instructions: This report must be filed by every entity that is authorized under provincial legislation to engage in the business of dealing in securities, or to provide portfolio management or investment counselling services (“Registrants/Exempt Dealers/Exempt Advisers”) (see Note 1). The report must be sent to the e-mail address that has been set up to receive these reports of your principal regulator no later than the fourteenth (14 th ) day of each calendar month. Please see Appendix A of this form for the e-mail address designated by each of the CSA regulators for this purpose. If such day falls on Saturday, Sunday or statutory holiday, the report is due on the next business day. The reporting month is the month on which the report is based (e.g. for the report due on December 14, the reporting month would be November). You must review your records on a continuing basis for any dealing with Designated Persons. You must consult the updated combined list of names for UN SupTerror and the list of names under the UN Iran and UN NKorea, posted on the OSFI website http://www.osfi-bsif.gc.ca before filing the report. Notes: These Notes are provided as general information only. They do not constitute legal advice, and are not intended to replace the laws referred to in this report. You should refer to these laws for full details regarding your obligations. 1. The information required in this report is required pursuant to section 83.11 of the Criminal Code, section 7 of the UN SupTerror, section 5.1 of the UN Al-Qaida, and subsection 11(2) of the UN Iran and subsection 11(2) of the UN NKorea. Reports must be filed by all entities authorized under provincial legislation to engage in the business of dealing in securities or to provide portfolio management or investment counselling services. Members of the Investment Industry Regulatory Organization of Canada (IIROC) are requested to use the appropriate reporting forms issued by, and file those forms with, IIROC. 4
2. All reports must cover continuous dates and there must be no gaps in the reporting periods starting with the first day of each month and ending with the last day. The report is cumulative; therefore, you must continue to include information reported in a previous report, provided that the information remains unchanged. 3. All amounts must be stated in Canadian dollars. NOTE: If the original amount of the property frozen is denominated in a currency other than Canadian dollars, then the Canadian dollar equivalent should be reported using the same rate of exchange that was in effect on the date that the property was originally frozen and reported to law enforcement. 4. You must include information from any branches located outside Canada. 5. This is an aggregate report of dealings that Registrants/Exempt Dealers/Exempt Advisers have with Designated Persons. Do not append personal information or account or policy information. Such information must be directed, if applicable, to the Royal Canadian Mounted Police, the Canadian Security Intelligence Service, and if applicable, the Financial Transactions and Reports Analysis Centre of Canada (FINTRAC) and, in respect of any foreign operations, to foreign law enforcement officials. 6. If there are no assets frozen, you may file a NIL report by checking the “No” box on page 2 to confirm this. This includes situations where you may be seeking clarification from the authorities about whether an account holder is in fact a Designated Person; in other words you may file a NIL report where you have not made a determination that you are dealing with a Designated Person. There is no need to report numbers of accounts where you are still seeking clarification from the authorities. Reminder: Section 83.1 of the Criminal Code, section 8 of the UN SupTerror, section 5.2 of the UN Al-Qaida, section 12 of the UN Iran and section 12 of the UN NKorea require every person in Canada and every Canadian outside of Canada to disclose forthwith to the Commissioner of the Royal Canadian Mounted Police and the Director of the Canadian Security Intelligence Service (a) the existence of property in their possession or control that they know or have reason to believe is owned or controlled by or on behalf of a Designated Person, and (b) information about a transaction or proposed transaction in respect of a property in their possession or control that they know or have reason to believe is owned or controlled by or on behalf of a Designated Person. In addition, under the Proceeds of Crime (Money Laundering) and Terrorist Financing Act, persons subject to Part 1 of that Act are also required to report to the FINTRAC. 5
Appendix A List of CSA Regulators E-mail Addresses, Websites, and inquiry details for Monthly Reporting (Please send the reports to the e-mail address of your principal regulator only- Attention: UN Reports) Alberta Northwest Territories Prince Edward Island Alberta Securities Commission Government of the Northwest Territories Superintendent of Securities Web: www.albertasecurities.com Office of Superintendent of Securities Office of the Attorney General Questions: registration@asc.ca Department of Justice Web: www.gov.pe.ca/securities E-mail to: unreports@asc.ca Web: Questions: 902 368-4542 www.justice.gov.nt.ca/SecuritiesRegistry E-mail to: kptummon@gov.pe.ca British Columbia Questions: 867 920- 3318 British Columbia Securities Commission E-Mail to: SecuritiesRegistries@gov.nt.ca Québec Web: www.bcsc.bc.ca Autorité des marchés financiers Questions: 604 899-6667 Nova Scotia Web: www.lautorite.qc.ca E-mail to: mstreport@bcsc.bc.ca Nova Scotia Securities Commission Questions: 1 877 525-0337 Ext 4748 Web: www.gov.ns.ca/nssc/ E-mail to: Sylvie.Lacroix@lautorite.qc.ca Manitoba Questions: 902 424-4592 The Manitoba Securities Commission E-Mail to: MURPHYBW@gov.ns.ca Saskatchewan Web: www.msc.gov.mb.ca Saskatchewan Financial Services Commission Questions: 204-945-5195 or Nunavut Web: www.sfsc.gov.sk.ca paula.white@gov.mb.ca Government of Nunavut Questions: 306 787-9397 e-mail to: unreports@gov.mb.ca Office of Superintendent of Securities E-mail to: registrationsfsc@gov.sk.ca Department of Justice New Brunswick Web: www.justice.gov.nu.ca Yukon New Brunswick Securities Commission Questions: 867 975-6590 Department of Community Services Yukon Web: www.nbsc-cvmnb.ca E-mail to: theffernan@gov.nu.ca Corporate Affairs (C-6) Questions: 506 658 3060 or CorporateRegistrations@gov.nu.ca Superintendent of Securities E-mail to: nrs@nbsc-cvmnb.ca Web:www.community.gov.yk.ca/corp/secureinvest.html Ontario Questions: 867 667-5225 Newfoundland and Labrador Ontario Securities Commission E-mail to: corporateaffairs@gov.yk.ca Securities NL Web: www.osc.gov.on.ca Financial Services Regulation Division Questions: 416 593-8314 or 1-877-785-Department of Government Services 1555 Web: www.gs.gov.nl.ca E-mail to: UNReports@osc.gov.on.ca Questions: 709 729-0959 Email to: scon@gov.nl.ca 6
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