Please complete this form if one or more of the following applies to you or your business: you are a reporting entity that only provides an item 31 and/or 32 designated service you are a remittance network provider that only provides an item 32A designated service you are a reporting entity that only provides an item 54 designated service you are a reporting entity that is licensed to operate no more than 15 electronic gaming machines and do not provide any other designated services you did not provide a designated service in the 2016 reporting period (1 January to 31 December 2016). Please note: If you or your business are no longer a reporting entity - you must submit an RE Roll Removal Request form (available in the Business Profile of your AUSTRAC Online account). If you or your business have not enrolled on the Reporting Entities Roll with AUSTRAC - you need to contact the AUSTRAC Contact Centre on 1300 021 037 (a local call within Australia) or email firstname.lastname@example.org. If none of the paragraphs above apply to you or your business - you must complete a 2016 AML/CTF compliance report form, available by logging in to your AUSTRAC Online account. Note: If you sold the business in 2016 but provided a designated service during that year you are still required to provide a 2016 AML/CTF compliance report. *Person: * Business and trading names: * AUSTRAC reference (the reference number on your letter or email, if applicable): HINT: Type the reference exactly as it appears on your letter to ensure AUSTRAC can correctly identify you.* Contact name and title: * Contact phone number (include area code): Declaration Please select ONE of the options below and complete any additional information as prompted. I/my business am/is not required to lodge a compliance report for the 2016 reporting period (1 January 2016 to 31 December 2016) because we (tick the most applicable): are not a reporting entity because no designated service was provided in the 2016 reporting period and we have submitted a request to be removed from the Reporting Entities Roll. are a reporting entity, but did not provide a designated service in the 2016 reporting period. hold an Australian financial services licence (AFSL) and the only designated service provided was to make arrangements for a person to receive another designated service. sold the business during 2016 and have submitted a request to be removed from the Reporting Entities Roll. Date of sale* (DD/MM/YYYY): Contact details of new owner: ceased business during 2016 and have submitted a request to be removed from the Reporting Entities Roll. Date business ceased* (DD/MM/YYYY): merged or were acquired by another business during 2016. Date of merger/acquisition* (DD/MM/YYYY): Contact details of controlling entity: are a member of the following designated business group and another member of the group has lodged the group's 2016 AML/CTF compliance report: Name of designated business group: Other (please specify): * Note: If you provided a designated service during 2016 you still need to provide an AML/CTF compliance report for that year. I declare that: I am/have been authorised in writing to submit this form on behalf of the reporting entity; and I have updated the Reporting Entities Roll information for the reporting entity; and the information provided by me in respect of the reporting entity is true, accurate and complete.