Introductory BSA/AML Examiner School, Atlanta, CA

BANK SECRECY ACT Data Form for Businesses

SECTION B (This section must always be completed for any new (less than 90 days) transaction accounts)

What is the source of the initial deposit into this account? (Please circle one of the choices below) Transit Check Cash Wire Transfer from another NSB account Loan Proceeds

Direct Deposit

What is purpose of this account? General Operating Funds

Payroll - only

Accounts Payable - only Savings - specific item

Accounts Receivable - only

Lottery Funds - only Savings - general

Savings - sweep account funds - only

Philanthropic

Escrow funds/IOLTA

Landlord/Tenant

Political campaign

Estate settlement

Other ____________________________________________________

Please indicate the type, dollar amount(s) and volume of transactions you plan to conduct on this new account?

If yes, please indicate the expected average monthly value of this type of transaction

If yes, please indicate the expected # of transactions per month

Will you conduct this type of transaction? (Y or N)

Type of Transaction

$50,001 or greater Please provide

$10,001 - $20,000

$20,001 - $30,000

$30,001 - $40,000

$40,001 - $50,000

Less than $10,000

explanation below

Cash Deposits Cash Withdrawals

Incoming ACH Transfers Outgoing ACH Transfers

Incoming Domestic Wire Transfers Outgoing Domestic Wire Transfers Incoming Foreign Wire Transfers* Outgoing Foreign Wire Transfers* Check Deposits Check Withdrawals Purchase NSB Official Checks or Money Orders ATM Deposits ATM Withdrawals *If you intend to send or receive foreign wires, please indicate the countries involved: ________________________________________

Additional notes pertaining to anything stated on this form:

Revised February 5, 2016