Introductory BSA/AML Examiner School, Atlanta, CA

BANK SECRECY ACT Data Form for Businesses

_________________________ _______________________ ______________ __________________ Business Name Taxpayer Identification Number Account Number CIF#

Description of Business: ______________________ __________________________________________________________ SECTION A (This section must always be completed) ATM: Is an ATM operated on your premises? =NO =YES location: ___________________________ If yes, we require a copy of your disclosure approval from Vermont Department of Financial Regulation. How many ATMs do you own or operate? _________ Do you service the ATM(s) operated on your premises? =NO =YES If yes, what is the source of cash replenishment? =Withdrawal from NSB Account =Other ATM Vendor =Cash held within business (i.e. cash registers) Lottery Tickets: Do you sell lottery tickets? =NO =YES If yes, is more than 50% of your profit derived from income from the sale of lottery tickets? =NO =YES Money Service Business: A Money Service Business (MSB) is required to comply with Bank Secrecy Act laws and we are required to request documentation of registration with FinCEN and with the State of Vermont if applicable. For any person, on any day, in one or more transactions, for more than $1,000 cash (aggregated), do you: 1. Cash checks?-------------------------------------------------------------------------------------------- =NO =YES 2. Redeem traveler’s checks, money orders, or prepaid access cards/gift cards? ----------------- =NO =YES 3. Exchange currency for currency or monetary instruments? -------------------------------------- =NO =YES 4. Issue or sell traveler’s checks, money orders, or prepaid access cards/gift cards?------------- =NO =YES For any person, on any day, in one or more transactions, for any amount , do you: 5. Accept and transmit currency or are you engaged as a business in the transfer of funds? ---- =NO =YES If you answered YES to any of the above, you may be an MSB or an agent of an MSB . If you need information or assistance, refer to the website http://www.fincen.gov/financial_institutions/msb/ or call 1-800-949-2732. If you are an MSB , we require a copy of your correspondence confirming your registration as an MSB with FinCEN. If you are an agent of an MSB , we require a copy of the contracts/agreements you have with the principal money service business. Money Transmitter: If you answered YES to numbers 4 or 5 and you are not an agent 1 for a money transmitter, are you registered with the State of Vermont as a Money Transmitter? =NO =YES Check Cashing: If you cash checks, what types do you cash? =payroll =third party =commercial enterprises =out of state checks =government checks Check Casher Requirements . If you receive $500.00 or more in check cashing fees within a 30-day period of time and you are not a registered Money Transmitter or an agent of a registered Money Transmitter, you may be required to register as a Check Casher with the State of Vermont. Are you? =NO =YES Internet Gambling: Is your business engaged in Internet gambling of any kind? =NO =YES Third Party Payment Processors (TPPP): Do you process ACH transactions for another company? =NO =YES If you are TPPP , we require a copy of your signed ACH authorization agreements between you and your client(s). 2

Marijuana Related Activities: Is your business engaged in marijuana related activities(including medical marijuana)? =NO =YES

Virtual Currency: Does your business process virtual currency (i.e. Bitcoin) transactions? =NO =YES

1 Agent refers to a business that acts as a representative for another (i.e. an agent may sell checks issued by and drawn on an account of a bank). 2 The agreement will be shared with NSB Compliance for further review. NSB reserves the right to request additional information if needed.

Revised February 5, 2016