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Part A

Source Log

Date: DD/MM/YYYY [to be updated on June 30th and December 31st of each year]

Identifying Name Project(s) Information Expected/Provided Payment Terms Cumulative Payments (USD)
Fozzy Bear Informax Information on X printing facilities in France
Payments per Schedule 1, Part 2 of MCSA with handling Consultant
Flash Bandit Deep Drill, Delivery Well
Distribution channels in X market
500 USD per verifiable tip of X.

Part B

Source Identity Form

Background Information:  
Identifying Name:  
Position/job function:  
Employed since:  
Personal Affiliations:  
Is the Source a Government Official (as defined below)?
Is the Source related to in any way or employed by a Government Official?
Source Verification:  
How long have you known the Source?
Have you verified Source details provided above?
Name of Source Handler:  

The term “Government Official” means any officer or employee of, or person acting on behalf of (i) a government or one or more of its department, agencies, or Government Instrumentalities, or (ii) a Public International Organization; or any official party or candidates for political office.

If you are not sure if someone is government official, please consult with your Sponsor. Note that in some contexts, interactions with close family members of a Government Official may be treated as interaction with that Government Official.

Part C

Source Payment Form

Source Identifying Name:  
Amount of Payment (*):  
Nature of Payment:  
Date of Payment:  

I confirm that I made the above-mentioned payments and advised the Source that the payment may be taxable income that must be reported to the appropriate tax authorities.

(*) If a single (one-time) payment exceeds 5,000 USD or a series of smaller payments reaches 5,000 USD during the calendar year, I further confirm that I have performed the U.S. Office of Foreign Asset Control (OFAC) Sanctions List check using this link - and that this Source is not in the Sanctions List.

Name of Source Handler:  
Signature of Source Handler: