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Schedule 1

FORMS

FORM 1

(Regulation 3)

APPLICATION FOR REGISTRATION

REGISTRATION OF SUPERVISED ENTITIES ACT,
CAP.12.36: SECTION 5(2)(a)

PART A

INFORMATION ON PERSON ENGAGED IN
OTHER BUSINESS ACTIVITY

1. Name of person engaged in other business activity:

2. Type of business structure (if applicable) —

1 Company

1 Partnership

1 Business Name

1 Other (Specify):

3. Category of person engaged in other business activity:

1 Attorney-at-Law

1 Accountant

1 Real Estate Agent

1 Jeweller

1 Motor Vehicle Dealer

4. Country of Incorporation/Establishment:

5. Date of Incorporation/Establishment:

6. Principal business address in Saint Lucia:

7. Mailing address in Saint Lucia (if different):

8. Website address (if applicable) & email address:

9. Are there offices located outside of Saint Lucia? If yes, please list each office and the jurisdiction below.

PART B

NATURE OF BUSINESS

(Tick all relevant boxes to describe the type of activity carried out or to be carried out by the person engaged in other business activity)

10. Attorney-at-law preparing transactions for a client in relation to the following activities —

(a) buying and selling real estate 1

(b) creating, operating or managing companies 1

(d) managing client's money, securities or other assets 1

(e) raising contributions for the creation, operation or management of companies 1

11. Accountant preparing transactions for a client in relation to the following activities —

(a) buying and selling real estate 1

(b) creating, operating or managing companies 1

(d) managing client's money, securities or other assets 1

(e) raising contributions for the creation, operation or management of companies 1

12. Real Estate Agent involved in transactions for a client concerning the buying and selling of real estate.

Predominant business activity?

1 Commercial

1 Residential

1 Other (Specify):

13. Jeweller acting as a dealer in precious metals or stones 1

14. Motor dealer providing the service of selling —

New Motor Vehicles 1

Used Motor Vehicles 1

New and Used Motor Vehicles 1

PART C

DUE DILIGENCE INFORMATION

15. State the number of employees:

16. Details of the Compliance Officer/Designated Compliance Officer

Name:

Address:

Nationality:

National Identification Card Number / Passport Number:

Telephone:

Email:

17. List the Directors of the company

Full Name

Address

Job title / role

Nationality

Date of Appointment

National Identification Card Number /
Passport Number

Contact Information

18. List the Senior Managers of the business/company

Full Name

Address

Job title / role

Nationality

Date of Appointment

National Identification Card Number /
Passport Number

Contact Information

19. List all Beneficial Owners, Partners and Principals of the business/ company

Full Name

Address

Percentage Interest

Nationality

National Identification Card Number /
Passport Number

Contact Information

Have any of the directors/senior managers ever been the subject of bankruptcy proceedings? 1 Yes 1 No

If yes, please give details:

20. Have any of the directors/senior managers ever been convicted of any financial crime including money laundering, terrorist financing, proliferation financing, fraud and drug trafficking, overseas or in Saint Lucia?

1 Yes 1 No

21. Have any of the directors/senior managers ever been arrested, detained charged, indicted or summoned to answer for any criminal offence of which the result is still pending?

1 Yes 1 No

22. If you have answered 'Yes' to either 20 or 21 please give details.

23. Is the person engaged in other business activity regulated by a foreign regulatory authority?

1 Yes 1 No

If yes, please provide the name of the foreign regulatory authority and the jurisdiction, along with a copy of the licence or registration document.

PART D

CLIENTELE INFORMATION

24. Indicate the composition of your business clientele in approximate percentage terms.

Clientele

Percentage (%)

Domestic politically exposed persons

Foreign politically exposed persons

International politically exposed persons

High net-worth individuals

Non-resident or overseas clients

Clients with foreign business

Clients that are:

1 Trusts

1 Nominees

1 Foundations

1 Other (Specify):

Clients that are:

1 Companies

1 Registered Businesses

1 Partnerships

1 Other (Specify):

Professional Intermediaries

Resident

Other (please specify)

25. State the annual gross income of the person engaged in other business activity.

$ (XCD)

26. Approximately what percentage of the revenue of the person engaged in other business activity is derived from the methods of payment in the table below?

Type of Payment

Percentage (%)

Cash

Cheque

Bank drafts

Wire transfer

Credit cards

Debit cards

Other (please specify)

PART E

ATTACHMENTS

You are required to submit the following documents with the completed form —

1. The incorporation or registration documents of the person engaged in other business activity, for example, the Certificate of Incorporation, Certificate of Registration of a Business Name and relevant registers

2. The fled corporate documents of the person engaged in other business activity, including a notice of directors, beneficial owners and shareholders

3. A certified copy of the licence, practising certificate or other professional registration document of the person engaged in other business activity

4. A copy of the Compliance Manual

5. A Certificate of Good Standing (if applicable)

6. Any other document or information required by the Authority

PART F

DECLARATION

I am authorized to file this form on behalf of the person engaged in other business activity. I declare that the information provided is true, correct and complete.

I HEREBY DECLARE that on behalf of the person engaged in other business activity

…………………….., …………………………. I wish to REGISTER with the Financial

Intelligence Authority on the grounds of being engaged in other business activity.

I am aware that under section 16 of the Registration of Supervised Entities Act it is an offence to make a false or misleading representation or submit false or misleading documents to the Financial Intelligence Authority.

I am also aware that a person engaged in other business activity that commits this offence is liable on summary conviction to a fine not exceeding $25,000 or to imprisonment for one year or both.

I understand that it is a requirement under section 15 of the Registration of Supervised Entities Act that the Financial Intelligence Authority be provided with written notice of a material change in the information required to be registered within 14 days of the supervised entity first becoming aware of the change.

Name:

Signature:

Position:

Date:

FORM 2

(Regulation 6)

APPLICATION FOR RENEWAL OF REGISTRATION

REGISTRATION OF SUPERVISED ENTITIES ACT,
CAP.12.36: SECTION 8(2)(a)

PART A	Information on Supervised Entity
Certificate No.
Date
PART B	Application
THE DIRECTOR
FINANCIAL INTELLIGENCE AUTHORITY
I, the undersigned do hereby apply for renewal of the Certificate of Registration No. dated
and granted to
(name of supervised entity)
in accordance with section 8 of the Registration of Supervised Entities Act.
I HEREBY DECLARE that on behalf of the supervised entity, there has been no material change in the status or any developments which will preclude the grant of a renewal.
*The signature of the person authorized by the supervised entity is mandatory.*
Name:
Signature:
Position:
Date:

FORM 3

(Regulation 7)

DECLARATION OF COMPLIANCE OR NON-COMPLIANCE

REGISTRATION OF SUPERVISED ENTITIES ACT,
CAP.12.36: SECTION 8(2)(b)(i)

DECLARATION OF COMPLIANCE OR NON-COMPLIANCE
Using the table below, indicate the status of your entity with respect to the regulatory requirements described.
Select either:
IN COMPLIANCE – if the supervised entity has fully satisfied the regulatory requirement;
OR
NOT IN COMPLIANCE – if the supervised entity has NOT fully satisfied the regulatory requirement.
No.	DESCRIPTION OF REGULATORY REQUIREMENT	IN COMPLIANCE	NOT IN COMPLIANCE
1	The supervised entity has a Compliance Officer or designated Compliance Officer, appointed at senior management level, with the requisite competence, authority and independence for the role.
2	The supervised entity has undertaken a money laundering, terrorist financing and proliferation financing risk assessment to enable it to identify, assess, monitor, manage and mitigate the risks associated with money laundering, terrorist financing and proliferation financing, taking into account all relevant risk factors in accordance with the Money Laundering (Prevention) Act. The results of this risk assessment are clearly documented.
3	The supervised entity has formulated, adopted, documented and implemented policies, procedures and internal controls to combat money laundering, terrorist financing and proliferation financing. These include —
3.1	- Customer due diligence measures for identifying and verifying the identity of a customer.
3.2	- Enhanced due diligence procedures with respect to high-risk persons, business relationships and transactions
3.3	- Due diligence measures to identify and verify the natural persons exercising control and ownership of a legal person or legal arrangement (the Ultimate Beneficial Owner);
3.4	- Appropriate risk management systems to determine whether a person is a politically exposed person;
3.5	- The conduct and documentation of on-going monitoring of business relationships and activity on a risk-sensitive basis;
3.6	- Adoption and implementation of systems for monitoring complex, unusual or large transactions or suspicious activities;
3.7	- The establishment of clear internal reporting procedures to facilitate the recognition and reporting of unusual and suspicious activity without delay;
4	The supervised entity has had training in anti-money laundering, counter-terrorist financing and counter-proliferation financing provided to its employees, managers and directors within the last twelve (12) months.
5	The supervised entity has had an independent anti-money laundering, counter-terrorist financing and counter-proliferation financing audit conducted to review and assess its compliance with the requirements of the Money Laundering (Prevention) Act within the last twelve (12) months.
6	The supervised entity has maintained records of all transactions and records obtained through customer due diligence procedures for a minimum of seven (7) years from the date of the relevant business or transaction or following the termination of the business relationship.
7	The supervised entity has reported to the Authority in the prescribed form, any transaction or activity that its Compliance Officer or designated Compliance Officer had reason to believe was suspicious.
8	A director or employee of the supervised entity did not disclose to a person or customer the fact that a suspicious transaction or activity report or related information has been or is being submitted to the Authority or that a money laundering, terrorist financing or proliferation financing investigation is being or has been carried out.
9	For the last twelve (12) months, the supervised entity has screened its customers against the United Nations Security Council Consolidated Sanction List and made biannual reports to the Authority in January and July, on whether or not the entity is in possession or control of any property owned or controlled by or on behalf of a terrorist group.
DECLARATION
I hereby declare, on behalf of the supervised entity
, that the above responses are true and correct.
I am aware that pursuant to section 16 of the Registration of Supervised Entities Act it is an offence to make a false or misleading representation or to submit false or misleading information or documents to the Authority and that any supervised entity that commits this offence is liable on summary conviction to a fine not exceeding $25, 000 or to imprisonment for one year or to both.
*The signature of the person authorized by the supervised entity is mandatory.*
Name:
Signature:
Position:
Date: