Proceeds of Crime (Disclosure) Order

PROCEEDS OF CRIME (DISCLOSURE) ORDER, 2010 PUBLISHING DETAILS Arrangement of Paragraphs Arrangement of Paragraphs Paragraph DISCLOSURE Paragraph 1 In exercise of the power conferred by section 143 of the Proceeds of Crime Law, 2008, the Governor in Cabinet makes the following Order — Citation This Order may be cited as the Proceeds of Crime (Disclosure) Order, 2010. Form of disclosure A disclosure pursuant to section 136 or 137 of the Law shall be made in the form prescribed in the Schedule to this Order. Offence A person who wilfully makes or causes to be made, in the form prescribed in the Schedule to this Order, a declaration which he knows to be false or fraudulent commits an offence and is liable on summary conviction to a fine of five thousand dollars or to imprisonment for a term of two years, or to both. (Paragraph 2) DISCLOSURE CONFIDENTIAL FINANCIAL REPORTING AUTHORITY Delivery Address: 80E Shedden Road 3rd Floor, Elizabethan Square, Phase IV George Town, Grand Cayman Tel No. 945-6267 Fax No. (345) 945-6268 Mailing Address: P.O. Box 1054 Grand Cayman KY1 - 1102 SUSPICIOUS ACTIVITY REPORT Note: This form should preferably be typed using arial 12 point font. Date of this Report: Date of Original Report (if applicable): FRA Case No. (if known): Nature of service(s) provided to the individual and / or entity that is the subject of this report: Address of Reporting Entity: Reference of Reporting Entity: Name of Reporting Entity:

REPORTING ENTITY DETAILS: Other signatories on the account. (Please include relevant KYC details): Other Information: Date of Issue: Place of Issue: Identification Document Number: Identification Document Type: (i.e. passport, driver’s license etc.) E-Mail: Fax No.: Telephone No: Zip/Postal Code: Country State/Province City/Town Street No. and Name: Address(es): PO Box: Occupation/Profession: Nationality: Place of Birth: Date of Birth: Gender: First Name: Surname:

SUBJECT(S) OF REPORT (Legal Entities) Note: Please attach additional sheets as necessary. Entity Type (company, trust, partnership, charity, other): Name of Entity: Jurisdiction of Incorporation/Registration: Date of Incorporation/Registration: Purpose of Entity: Registered Office Address (or address of Trustee or General Partner etc.): Business Address (if different from registered office address): NOTE: Please include relevant information for entity type (i.e. settlor and beneficiary information for a trust). For each of the following which is a natural person please provide the information noted in Section 2. Other signatories on the account: (Please include relevant KYC details): Other Information: Address(es): Name(s):

REASON FOR SUSPICION Note: Please include relevant details including date business relationship established/declined, source of funds, value of assets currently held if any and nature of the suspicion. Attach additional sheets as necessary. Made in Cabinet the 2nd day of March, 2010. Kim Bullings Clerk of the Cabinet.