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    Edeclaration of Source Funds Form

    Uploaded by

    Raymond Williams
    This document is a large transaction declaration of source and use of funds form from a bank in Anguilla. It requires customers conducting large transactions over $10,000 to provide identification details, information on the source and intended use of funds, and to declare that the funds were legitimately acquired. The customer must sign to authorize the bank to disclose this information to regulators or law enforcement if requested. The bank reserves the right to decline any transaction if all sections of the form are not completed.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Edeclaration of Source Funds Form

    Uploaded by

    Raymond Williams
    16 views2 pages
    This document is a large transaction declaration of source and use of funds form from a bank in Anguilla. It requires customers conducting large transactions over $10,000 to provide identification details, information on the source and intended use of funds, and to declare that the funds were legitimately acquired. The customer must sign to authorize the bank to disclose this information to regulators or law enforcement if requested. The bank reserves the right to decline any transaction if all sections of the form are not completed.

    Original Title

    eDeclaration-Of-Source-Funds-Form

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    This document is a large transaction declaration of source and use of funds form from a bank in Anguilla. It requires customers conducting large transactions over $10,000 to provide identification details, information on the source and intended use of funds, and to declare that the funds were legitimately acquired. The customer must sign to authorize the bank to disclose this information to regulators or law enforcement if requested. The bank reserves the right to decline any transaction if all sections of the form are not completed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    16 views2 pages

    Edeclaration of Source Funds Form

    Uploaded by

    Raymond Williams
    This document is a large transaction declaration of source and use of funds form from a bank in Anguilla. It requires customers conducting large transactions over $10,000 to provide identification details, information on the source and intended use of funds, and to declare that the funds were legitimately acquired. The customer must sign to authorize the bank to disclose this information to regulators or law enforcement if requested. The bank reserves the right to decline any transaction if all sections of the form are not completed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    P.O.

    BOX 44
    LARGE TRANSACTION DECLARATION OF SOURCE
    THE VALLEY, AI-2640 USE OF FUNDS FORM
    ANGUILLA, BWI

    NAME OF CUSTOMER/COMPANY TYPE OF TRANSACTION - DEBIT BRANCH/TRANSIT # DATE SINGLE TRANSACTION

    MULTIPLE TRANSACTIONS
    PHYSICAL ADDRESS TYPE OF TRANSACTION CURRENCY AMOUNT

    CUSTOMER INDENTIFICATION
    ACCOUNT NUMBER(S):

    FOR AN Customer/Tax Identification # / Social Security #: Nationality/Resident Status:


    INDIVIDUAL
    OCCUPATION or TYPE OF BUSINESS COMPLETE THIS Passport # / Drivers License #: Expiry Date (DD/MM/YYYY): Date of Birth (DD/MM/YYYY):
    SECTION
    FOR A COMPANY Business License. # Date of Incorporation Country of Incorporation
    COMPLETE THIS Company Incorporation #
    TELEPHONE #: SECTION

    Complete this section if the individual presenting the transaction is other than the customer:
    Name of Individual presenting the transaction Customer/Tax Identification # / Social Security #: Date of Birth

    Passport # / Drivers license #: Expiry Date (dd/mm/yy): Nationality/Resident Status

    PHYSICAL ADDRESS: Address Line 1 Address Line 2 Address Line 3

    Telephone #: Occupation:

    Signature of individual if other than customer _____________________________ Capacity in which you are signing ______________________________________
    Provide evidence of authorization to sign on behalf of the customer

    RBM0026-2016/11 Page 1 of 2
    BENEFICIARY OF FUNDS ___________________________________________________________________________________________________________

    DECLARATION:
    I/We declare that the source of these funds is _____________________________________________________________________________________________
    __________________________________________________________________________________________________________________________________

    I/We declare that the funds would be used for _____________________________________________________________________________________________


    __________________________________________________________________________________________________________________________________

    TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF, THE INFORMATION PRESENTED IN THIS LARGE TRANSACTION DECLARATION OF SOURCE/USE OF FUNDS FORM AND ANY ANNEXURES THERETO IS
    TRUE AND ACCURATE AND THAT THE FUNDS RELATIVE TO THE ABOVE ACCOUNT(S) WERE LEGITIMATELY ACQUIRED.

    __________________________________
    CUSTOMER’S SIGNATURE

    IN ACCORDANCE WITH THE ANTI-MONEY LAUNDERING & TERRORIST FINANCING REGULATION AND CODE AND THE BANK’S AML POLICY AND PROCEDURES, BEFORE ACCEPTING DEPOSITS, FUNDS
    FOR TRANSFER OR FOR THE PURCHASE OF ANY CURRENCY/PRODUCT/SERVICE, IT IS REQUIRED THAT THE BANK BE SATISFIED AS TO THE SOURCE OF FUNDS AND USE OF FUNDS BEFORE
    PROCESSING TRANSACTIONS.

    THE BANK RESERVES THE RIGHT TO DISCLOSE THIS INFORMATION TO BANK REGULATORS AND/OR LAW ENFORCEMENT AUTHORITIES UPON REQUEST.

    OFFICE USE ONLY / AUTHORISATION:

    ______________________________ ________________________________________
    TRANSACTION TAKEN BY AUTHORIZING OFFICER
    All sections of this form must be completed before authorizing

    TRANSACTION ACCEPTED

    TRANSACTION DECLINED REASON:_____________________________________________________________________________________________________________________________________

     NB: This form must be completed for all transactions US$10,000 and over or the equivalent in any currency and for any amount that might be required from time to time.
    RBM0026-2016/11 Page 2 of 2

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