Monthly Suppression of Terrorism and Canadian Sanctions Report 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. Please refer to the CSA Guide to Monthly Suppression of Terrorism and Canadian Sanctions Reporting, and to CSA Staff Notice 31-352 for further guidance regarding this report. Name of Registrant/Exempt Dealer/Exempt Adviser: Address: 1 CONFIDENTIAL when completed Revised: February 22, 2018 Date of filing of this report: ___ /___ /___ (dd / mm / yy) Monthly period covered in this report: ________ / _____ (see Note 2) (month) / (year)
If you have a POSITIVE REPORT to file, check “YES”, then fill out page 3 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”. NIL REPORT 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 2 If you have a NIL REPORT to file, check “NO”, then sign the certificate on page 2 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”. E-mail Telephone Date (dd/mm/yyyy):
POSITIVE REPORT If you have checked the “Yes” box above, please complete the table below and the certificate at the end of this form. Definitions: “Designated Person” has the meaning ascribed to it in the CSA Guide to Monthly Suppression of Terrorism and Canadian Sanctions Reporting. “Monthly STCS Reports” means monthly Suppression of Terrorism or Canadian sanctions reports, as described in CSA Staff Notice 31-352. “Number of Accounts” means the number of accounts, policies or contracts associated with a Designated Person. “Property” includes assets under administration (both discretionary and non-discretionary). Type of Dealing with Designated Person Number of Accounts Property Value (Canadian $) (see Note 2) (see Note 3) Property Cash, cash equivalents, demand and term deposits Securities (bonds, debentures, commercial paper, treasury bills, mutual fund units, common and preferred shares, and derivatives) Life Insurance and Annuity products with cash surrender value (cash surrender value) Other property, including real estate Property Totals 3
Type of Dealing with Designated Person Number of Accounts Property Value (Canadian $) (see Note 2) (see Note 3) Loans Mortgages, overdrafts, credit card balances, term loans, lines of credit balances, other indebtedness Insurance Life insurance policies with no cash surrender value (face value) Annuity products with no cash surrender value (monthly income) Property & casualty insurance policies (policy limit) Group Benefit plans such as medical or dental plans (policy limit for Listed Person or Listed Entity) Total POSITIVE REPORT 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 E-mail Telephone Date (dd/mm/yyyy): 4
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 by e-mail or electronic form to your principal regulator no later than the fourteenth (14 th ) day of each calendar month. If such a 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). Please see Appendix A of this form for the e-mail address or link to the electronic form designated by each of the CSA regulators for this purpose. You must review your records on a continuing basis for any dealing with Designated Persons. You must consult with the CSA Guide to Monthly Suppression of Terrorism and Canadian Sanctions Reporting 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. * For reports filed with the OSC as the principal regulator, you will need to complete and submit the electronic form if your firm’s name appears on the drop-down menu in the electronic form. If your name does not appear you will need to email your report to UNReports@osc.gov.on.ca. 1. The information required in this report is required pursuant to section 83.11 of the Criminal Code (Canada) and other Canadian federal legislation requiring Monthly STCS Reports. 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. 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. 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. 5
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. This report is a consolidated report. You must include information reported by your subsidiaries. 7. This report is cumulative. Information reported in the previous month must continue to be reported on the form for the current month unless the person in whose name the property is identified is no longer subject to the reporting requirements in a Monthly STCS Report. 8. 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. 9. All amounts and numbers provided must be entered in the table. Appendices that refer to additional information are not acceptable unless they provide clarifying information relating to data in the table. Reminder: The Criminal Code (Canada) and other Canadian federal legislation requiring Monthly STCS Reports will generally require every person in Canada and every Canadian outside of Canada to disclose forthwith to the Commissioner of the Royal Canadian Mounted Police and /or 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 that Act are also required to report to FINTRAC. 6
Appendix A List of CSA Regulators E-mail Addresses, Websites, and inquiry details for Monthly Reporting (Please send the reports to the principal regulator only) Alberta Northwest Territories Prince Edward Island Alberta Securities Commission Government of the Northwest Territories Steven D. Dowling, Acting Director Web: www.albertasecurities.com Office of Superintendent of Securities Consumer, Corporate and Financial Services Division Questions: email@example.com Department of Justice Justice and Public Safety E-mail to: firstname.lastname@example.org Web: Government of Prince Edward Island https://www.justice.gov.nt.ca/en/divisions/legal- T: (902) 368-4551 British Columbia registries-division/securities-office/ C: (902) 314-7627 British Columbia Securities Commission Questions: 867-767-9305 F: (902) 368-5283 Web: www.bcsc.bc.ca E-Mail to: email@example.com E-mail to: firstname.lastname@example.org Questions: 604 899-6667 E-mail to: email@example.com Nova Scotia Québec Nova Scotia Securities Commission Autorité des marchés financiers Manitoba Web: www.gov.ns.ca/nssc/ Web: www.lautorite.qc.ca The Manitoba Securities Commission Questions: 902 424-4592 Questions: 1 877 525-0337 Web: www.mbsecurities.ca E-Mail to: firstname.lastname@example.org E-mail to: email@example.com Questions: 204-945-2548 e-mail to: firstname.lastname@example.org Nunavut Saskatchewan Government of Nunavut Financial and Consumer Affairs Authority of New Brunswick Office of Superintendent of Securities Saskatchewan Financial and Consumer Services Department of Justice Web: www.fcaa.gov.sk.ca Commission of New Brunswick Web: www.justice.gov.nu.ca Questions: 306-787-9397 Web Site: www.fcnb.ca Questions: 867 975-6590 E-mail to: email@example.com Questions : 506 658-3060 E-mail to: firstname.lastname@example.org Email : email@example.com or CorporateRegistrations@gov.nu.ca Yukon Office of the Yukon Superintendent of Securities Newfoundland and Labrador Ontario Web: https://yukon.ca/ Financial Services Regulation Division Ontario Securities Commission Questions: 867-667-5466 Department of Service NL Web: www.osc.gov.on.ca E-mail to: firstname.lastname@example.org Web: www.servicenl.gov.nl.ca Eform: link Questions: 709 729-2595 Questions: 416 593-8314 or 1-877-785-1555 Email to: email@example.com E-mail to: UNReports@osc.gov.on.ca 7
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