Counter-Terrorist Referral Form for Charities

If you have, or develop, information that leads you to believe that an exempt organization, a potential or actual recipient of charitable resources or services, or associated organization(s) or individual(s) may be engaged in suspicious financial activity related to terrorism or in any other activity relating to terrorism or terrorist support, please complete this form and attach any additional explanations and/or documents that may support your referral.

Please provide your contact information (optional):

Agency/Office :
Point of Contact:
Address:
Phone:

Description of Suspicious Activity (please provide as much detail as possible):