Period that this report covers: [specify]

Note: This is the period referred to as “during the year” or “at the end of the year” by this form.

The reporting entity’s legal name:

Registered or company incorporation number (or equivalent):

FSPR number (if applicable):

Registered charity number (if applicable):

Trading name(s):

Street name and number:

Suburb/town:

City:

Postcode:

Street name and number or PO Box:

Suburb/town:

City:

Postcode:

AML/CFT compliance officer (full name):

AML/CFT contact telephone number:

AML/CFT contact email address (if available):

Website (if available):

Is this reporting entity a branch or a subsidiary? Yes/No

If yes, specify: [branch/subsidiary]

In what country is your largest owner based? [country]

Number of physical branch office locations in New Zealand (exclude agent’s office locations). If none, record nil: [number/nil]

Number of New Zealand subsidiaries (or nil): [number/nil]

If known, number of physical branch office locations outside New Zealand (or nil): [number/nil/unknown]

Number of subsidiaries outside New Zealand (or nil): [number/nil]

Does your risk assessment meet the requirements of section 58 of the Act?

Meets all/Meets some/Meets none*

If your risk assessment meets only some of the requirements of section 58 of the Act, please list all subsections that it is not fully compliant with (eg, sections 58(1), 58(2)(a)–(h), 58(3)(a)–(c)) (use commas to separate each entry): [list]

When was the most recent internal review of the risk assessment completed? [date]

Has the risk assessment been independently audited?

Yes/No*

If yes to 4.4, when was the most recent audit of the risk assessment completed? [date]

If yes to 4.4, did the most recent audit of the risk assessment highlight any deficiencies?

Yes/No*

If yes to 4.4 and 4.6, have you made the changes identified as being necessary in the most recent audit?

Yes, complete/Not yet complete*

During the year, did you make available a new activity regulated by the Act (eg, a new product, service, or channel)?

Yes/No*

If yes to 4.8, before making this activity available, did you assess the ML/TF risk?

Yes/No*

Does your AML/CFT programme meet the requirements of section 57 of the Act?

Meets all/Meets some/Meets none*

If your AML/CFT programme meets only some of the requirements of section 57 of the Act, please list all paragraphs that it is not fully compliant with. Use commas to separate each entry: [list relevant paragraphs from section 57(a) to (l)]

When was the most recent internal review of the programme completed? [date]

Has the programme been independently audited?

Yes/No*

If yes to 5.4, when was the most recent audit of the programme completed? [date]

If yes to 5.4, did the most recent audit of the programme highlight any deficiencies?

Yes/No*

If yes to 5.4 and 5.6, have you made the changes identified as being necessary in the most recent audit?

Yes, complete/Not yet complete*

Do you have procedures to identify and verify the identity of—

Do you have exception handling procedures for issues related to customer due diligence (CDD) (eg, clause 4 of the Amended Identity Verification Code of Practice 2013)?

Yes/No*

Outside a DBG, do you outsource any CDD requirements to third parties (as set out in sections 32 to 34 of the Act)?

Yes/No*

Are your reporting entity’s AML/CFT transaction monitoring and account monitoring processes best described as electronic, manual, or a combination of both

Electronic/Manual/Electronic and manual*

Estimate the value and number of all transactions settled by your reporting entity during the year. Add the number of receipts and payments together, record the total number, and repeat for value—

Gross number of transactions: [number]

Gross value of transactions (NZD): $[amount]

If your reporting entity offers the products and services listed in the table below, enter “yes” and estimate the proportion of annual revenue of your business during the year:

Estimate the number of customers your reporting entity had a business relationship with during the year: [number]

How many customers (question 7.1 above) are classified as politically exposed persons (PEP)? (Include your customers that are beneficially owned, controlled by, or for the benefit of a PEP.) [number]

How many customers (question 7.1 above) are a trust or another vehicle for holding personal assets? [number]

How many customers (refer question 7.1 above) are non-residents? [number]

Estimate, as at the end of the reporting period, the percentages of the following types of customers:

Estimate the proportion of your new customers who were accepted via the following methods during the year:

For this section,—

Count your relationships with all entities for the purpose of establishing accounts, authenticating instructions, and providing payment or other clearing-related services and provide the results in the following table:

Using your answers to the question in 6, estimate the gross value and number of transactions settled during the year for the following (add all receipts and record the total):

Identify the sub-sector(s) that your reporting entity belongs to: issuer of securities/licensed supervisors/fund managers/brokers and custodians/financial advisers/derivative issuers/DIMS providers/peer-to-peer lenders/equity crowd funding service providers/other (specify in the notes section in Part 6)*

Refer to your previous answer to question 7.4 (“how many of your total customers are non-resident customers?”). List the top 5 countries (high to low in descending order) according to where the largest numbers of your non-resident customers are: [list]

Name the 3 countries your business receives the most transactions from, and estimate the average monthly number of inward transactions:

Name the 3 countries your business sends the most transactions to, and estimate the average monthly number of outward transactions:

Do you provide the following payment methods? If yes, estimate the average monthly value of all transactions settled during the year (Enter nil or value):

Estimate the total number of safe deposit boxes you currently have in use: [number]

Estimate the average number of times these boxes are accessed each month: [number]

Have you been granted any ministerial exemption that is subject to conditions?

Yes/No*

Please provide a description of your compliance with all conditions on any such exemption.

Period that this report covers: [specify year]

Note: This is the period referred to as “during the year” or “at the end of the year” by this form.

Reporting entity’s legal name:

Type of entity (natural person, company, partnership, other legal person, trust):

Registered or company incorporation number, or equivalent (if applicable):

Trading name(s) (if different from legal name):

Street name and number:

Suburb or town:

City:

Postcode:

Street name and number or PO Box:

Suburb or town:

City:

Postcode:

Full name of reporting entity’s compliance officer:

Reporting entity’s AML/CFT contact email address (if available):

Reporting entity’s AML/CFT contact telephone number (if available):

Reporting entity’s website (if available):

What sector(s) best describe your business activities. Select 1 or more of the following:

Is your reporting entity a branch or a subsidiary of an offshore parent? Yes/No*

If “yes”, specify: [branch or subsidiary]

In what country is your largest owner based [specify]. If your reporting entity does not have a clear owner, in what country is your largest beneficial owner based? [specify]

How many people work for your reporting entity? [specify]

Number of physical branch/office locations in New Zealand (exclude agent’s branch location): [specify number]

Number of New Zealand subsidiaries: [specify number]

If known, number of physical branch/office locations outside New Zealand: [specify number or state “unknown”]

Number of subsidiaries located or incorporated outside New Zealand: [specify number]

Are you a member of a DBG? *Yes/No [If you answer No then complete Part 2 and the rest of this form as applicable]

If you answered “yes” to 4.1, are you completing Part 2 on behalf of the DBG? *Yes/No [If you are not completing the form for the DBG, please note the legal name of the DBG reporting entity completing Part 2 for you. Then leave the rest of Part 2 blank and go to Part 3. You are required to answer all other parts of this form.]

Does your risk assessment meet the requirements of section 58 of the Act? Meets all/Meets some/Meets none*

If your risk assessment meets only some of the requirements of section 58 of the Act, list all subsections that it is not fully compliant with (eg, section 58(1), 58(2)(a) to (h), or 58(3)(a) to (c)): [list, using commas to separate each entry]

When was the most recent internal review of your risk assessment completed? [date]

Has your risk assessment been independently audited? Yes/No*

If you answered “yes” to 5.4, when was the most recent audit of your risk assessment completed?: [date]

If you answered “yes” to 5.4, did the most recent audit of your risk assessment highlight any deficiencies? Yes/No*

If you answered “yes” to 5.4 and 5.6, have you made the changes identified as being necessary in the most recent audit? Yes, complete/Not yet complete*. If you answered “not yet complete” please explain: [insert detailed explanation]

During the year, did you introduce a new service or activity regulated by the Act (eg, a new product, service, or channel) that is not considered in your risk assessment. Yes/No*

Does your AML/CFT programme meet the requirements of section 57 of the Act?

Meets all/Meets some/Meets none*

If your AML/CFT programme meets only some of the requirements of section 57 of the Act, list all paragraphs that it is not fully compliant with. Use commas to separate each entry: [list relevant paragraphs from section 57(1)(a) to (l)]

When was the most recent internal review of your programme completed? [date]

Has your programme been independently audited? Yes/No*

If you answered “yes” to 6.4, when was the most recent audit of your programme completed? [date]

If you answered “yes” to 6.4, did the most recent audit of your programme highlight any deficiencies? Yes/No*

If you answered “yes” to 6.4 and 6.6, have you made the changes identified as being necessary in the most recent audit? Yes, complete/Not yet complete*. If you answered “not yet complete”, please explain: [insert detailed explanation]

Do you have procedures to identify and verify the identity of—

Do you have exception handling procedures for issues related to customer due diligence (CDD)? (eg, clause 4 of the Amended Identity Verification Code of Practice 2013). Yes/No*

Outside a DBG, do you outsource any CDD requirements to third parties (as set out in sections 32 to 34 of the Act)? Yes/No*

Do you use electronic processes to fulfil the statutory requirement to monitor accounts as required under section 31 of the Act? Yes/No*

Do you act as a formation agent of legal persons or arrangements? Yes/No*

If you answered “yes”, estimate how many of the following you have formed in the last year. Circle the estimated number.

Companies: 0: 1–10: 11–100: 101–999: 1 000+

Trusts (excluding charitable trusts): 0: 1–10: 11–100: 101–999: 1 000+

Partnerships (including limited partnerships): 0: 1–10: 11–100: 101–999: 1 000+

Charities (including charitable trusts and other charitable entities): 0: 1–10: 11–100: 101–999: 1 000+

Other: [specify]

Do you act as, or arrange for a person to act as, a nominee director or nominee shareholder or trustee in relation to legal persons or legal arrangements? Yes/No*

If you answered “yes”, estimate the number of nominee directorship roles your reporting entity holds: [number]

If you answered “yes”, estimate the number of nominee shareholder roles your reporting entity holds: [number]

If you answered “yes”, estimate the number of trustee roles your reporting entity holds: [number]

Do you provide a registered office or a business address, a correspondence address, or an administrative address for a company, or a partnership, or any other legal person or arrangement** Yes/No*

If you answered “yes”, estimate the number of companies, partnerships, or other legal persons or arrangements that your reporting entity provides these services to. Circle the estimated number.

Companies: 0: 1–10: 11–100: 101–999: 1 000+

Trusts (excluding charitable trusts): 0: 1–10: 11–100: 101–999: 1 000+

Partnerships (including limited partnerships): 0: 1–10: 11–100: 101–999: 1 000+

Charities (including charitable trusts and other charitable entities): 0: 1–10: 11–100: 101–999: 1 000+

Do you manage client funds (other than sums paid as fees for professional services), accounts, securities, or other assets? Yes/No*

If you answered “yes”, estimate the value of funds managed in the last year. Circle the estimated value.

0: $1–999,999: $1,000,000–$9,999,999: $10,000,000–$49,999,999: $50,000,000 and over

Do you provide real estate agency work (within the meaning of section 4(1) of the Real Estate Agents Act 2008) to effect a transaction (within the meaning of section 4(1) of that Act)? Yes/No*

Specify which of the following services you engage in or give instructions on behalf of a customer to another person for:

Estimate the total value of the transactions listed in 7.6 above (excluding your professional fees) for the last year. Circle the total estimated value.

0: $1–999,999: $1,000,000–$9,999,999: $10,000,000–$49,999,999: $50,000,000 and over

Note: It is optional to complete section B, but you are encouraged to do so as it provides the Department of Internal Affairs with valuable information.

Select whichever of the following activities you provide:

Do you accept cash (physical currency or bearer negotiable instruments)? Yes/No*

If you answered “yes”, estimate what percentage of your business involves cash: [percentage]

Do you send/receive funds from other countries (including the payment of fees either on your own behalf or on behalf of someone else)? Yes/No*

If you answered “yes”, estimate the total value of transactions for the past year: Circle the estimated total value of transactions for the past year.

0: $1–999,999: $1,000,000–$9,999,999: $10,000,000–$49,999,999: $50,000,000 and over:

List your 3 most common products and/or services (described in sections A to C above):

Estimate how many customers you conducted CDD on this year in the course of carrying out activities regulated by the Act: [estimate number]

Estimate how many of the customers referred to in question 8.1 above are—

• classified as politically exposed persons (PEP). (Include your customers that are beneficially owned or are controlled by, or for the benefit of, a PEP): [number]

• a trust or another vehicle for holding personal assets: [number]

• an overseas government body: [number]

• a New Zealand resident individual: [number]

• a New Zealand resident entity (including companies, partnerships, trusts, charities, and other incorporated or unincorporated entities): [number]

• a non-resident individual: [number]

• a non-resident entity (including companies, partnerships, trusts, charities, and incorporated societies): [number]

Indicate whether you use the following methods to carry out CDD on new customers who requested new activities subject to the Anti-Money Laundering and Countering Financing of Terrorism Act 2009 during the annual reporting year. If so please indicate the most common method.

Do you incorporate companies or form trusts or other legal structures or arrangements in jurisdictions outside NZ? Yes/No*

If the answer to 9.1 above is “yes”, please select the 3 most common jurisdictions in which you incorporate companies, or form trusts or other legal structures or arrangements: [select from drop down list]

Do you handle the receipt and transmission of customer/client money? Yes/No*

Do you manage customer/client bank accounts? Yes/No*

For your customers and clients who are overseas corporations with shares in bearer form, do your policies provide for maintaining the physical control of those bearer-shares to ensure that ownership of the corporate entity does not change without your knowledge? Yes/No/N/A*

Do you provide AML/CFT regulated services to other DNFBPs in New Zealand?

Yes/No/Unknown if customers are DNFBPs*

Do you provide AML/CFT regulated services to other DNFBP equivalents located overseas?

Yes/No/Unknown if customers are DNFBP equivalents*

When providing AML/CFT regulated services, do you use intermediaries or agents within New Zealand? Yes/No*

When providing AML/CFT regulated services, do you use intermediaries or agents based overseas? Yes/No*

If you answered “yes” to question 9.9, list the overseas countries your intermediaries are based in: [list]

Have you received cash as part of a real estate transaction? Yes/No*

If you answered yes, how often in the last year? How much? NZ$[amount]

Are you providing residential property sales or services? (eg, people buying homes)

Yes/No*

Are you providing commercial property sales or other services?

Yes/No*

If you answered “yes” to both 9.12 and 9.13, what is the estimated split between residential and commercial property sales and services? [percentage]

Have you been granted any ministerial exemption that is subject to conditions? Yes/No*

Provide a description of your compliance with all conditions on any such exemption.

Period that this report covers: [specify year]

Start date:

End date:

Reporting entity’s legal name:

FSPR number (if applicable):

Trading name(s):

Street name and number:

Suburb/town:

City:

Postcode:

Street name and number or PO Box:

Suburb/town:

City:

Postcode:

Full name of AML/CFT compliance officer:

AML/CFT contact telephone number:

AML/CFT contact email address (if available):

Website (if available):

Number of each type of physical location in New Zealand: [specify number]

Number of branches: [specify number]

Number of agents: [specify number]

Combined number of PubTABs and ClubTABs: [specify number]

Number of other types of locations: [specify number]

Number of New Zealand subsidiaries: [if none, enter 0]

Number of physical locations outside New Zealand: [if none, enter 0]

Number of subsidiaries outside New Zealand: [if none, enter 0]

Does your risk assessment meet the requirements of section 58 of the Act?

Meets all/Meets some/Meets none*

If your risk assessment meets only some of the requirements of section 58 of the Act, please list all subsections that it is not fully compliant with (eg, sections 58(1), 58(2)(a) to (c), 58(3)(a) to (c)). [Use commas to separate each entry.]

When was the most recent internal review of the risk assessment completed?

[DD/MM/YY]

Has the risk assessment been independently audited? Yes/No*

If yes to 4.4, when was the most recent audit of the risk assessment completed?

[DD/MM/YY]

If yes to 4.4, did the most recent audit of the risk assessment highlight any deficiencies? Yes/No*

If yes to 4.4 and 4.6, have you made the changes identified as being necessary in the most recent audit? Yes, complete/Not yet complete*

During the year, did you make available a new product, service, or channel?

If yes to 4.8, before making this product, service, or channel available, did you assess the ML/TF risk? Yes/No*

Does your AML/CFT programme meet the requirements of section 57 of the Act?

Meets all/Meets some/Meets none*

If your AML/CFT programme meets only some of the requirements of section 57 of the Act, please list all paragraphs that it is not fully compliant with. (list relevant paragraphs from section 57(a) to (i)). [Use commas to separate each entry.]

When was the most recent internal review of the programme completed? [DD/MM/YY]

Has the programme been independently audited? Yes/No*

If yes to 5.4, when was the most recent audit of the programme completed? [DD/MM/YY]

If yes to 5.4, did the most recent audit of the programme highlight any deficiencies? Yes/No*

If yes to 5.4 and 5.6, have you made the changes identified as being necessary in the most recent audit? Yes, complete/Not yet complete*

Do you have procedures to identify and verify the identity of—

Do you have exception handling procedures for issues related to customer due diligence (CDD) (eg, clause 4 of the Amended Identity Verification Code of Practice 2013)? Yes/No*

Do you outsource any CDD requirements to third parties (as set out in sections 32 to 34 of the Act)? Yes/No*

Are your reporting entity’s AML/CFT transaction monitoring and accounting monitoring processes best described as electronic, manual, or a combination of both? [Electronic/Manual/Both*]

Estimate the value and number of all transactions completed by your reporting entity during the year. Add the number of receipts and payments together, record the total number, and repeat for value.

Gross number of transactions: [number]

Gross value of transactions (NZD$): [amount]

If your reporting entity offers any of the following products and services, specify the value of your annual revenue received from that product or service:

Name the 3 countries your business receives the most transactions from, and estimate the average monthly number of inward transactions:

Name the 3 countries your business sends the most transactions to, and estimate the average monthly number of outward transactions:

Do you provide the following payment methods? If yes, estimate the average monthly value of all transactions settled during the year [enter 0 or value]:

Estimate the number of customers your reporting entity had a business relationship with during the year: [number]

Estimate the number of customers that carried out occasional transactions through your reporting entity during the year: [number]

Estimate, as at the end of the reporting period, the numbers of the following types of customers:

Estimate the number of your new customers who were accepted via the following methods during the year:

Estimate the value of transactions during the year for each of the following methods:

I confirm that I have the authority to submit this report on behalf of the reporting entity. I have reviewed the answers and information and I confirm that I am satisfied that, to the best of my knowledge, after undertaking all reasonable inquiries, all answers are true and correct.

Reminder: Under section 103 of the Anti-Money Laundering and Countering Financing of Terrorism Act 2009, a person commits an offence if, without reasonable excuse, the person provides information to an AML/CFT supervisor knowing that information to be false or misleading in any material respect. (See section 103 of the Act).

Yes, I agree:

Date:

Signature:

Full name:

Position or job title: