I,

....................................................................................................................................

(Name)

........................................................................................................................................

........................................................................................................................................

........................................................................................................................................

(Contact address, telephone number and fax number)

........................................................................................................................................

........................................................................................................................................

........................................................................................................................................

(Business/employment address, telephone number and fax number)

In my capacity as

...........................................................................................................

of

...................................................................................................................................., hereby

report as follows:

a)

Particulars of the person against whom the suspicion has been formed

Full names:

..........................................................................................................

Identity/passport number:

.....................................................................................

Nationality:

..........................................................................................................

Occupation:

..........................................................................................................

Residential address in the Republic:

.....................................................................

...............................................................................................................................

Business/employment address:

............................................................................

...............................................................................................................................

Telephone numbers:

i) work:

..........................................................................

ii) home:

..........................................................................

b)

Particulars of the transaction or other action whereby the property concerned came into my possession (including date and place thereof)

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c)

Particulars of the property in respect of which the suspicion has been formed

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d)

Grounds on which the suspicion rests

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e)

List of documentation and other proof available in respect of the transaction or other action (paragraph (b)), and grounds (paragraph (d))

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f)

Copies of the following documentation, directly relevant to the suspicion and the grounds on which it rests, are attached:

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Signed at ........................................ this ................ day of............................................

........................................................................

(Signature of person making the report)