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: