SUPPLEMENTARY INFORMATION FORM INSTITUTIONS & NON-INDIVIDUAL ACCOUNT ZENITH

Transcription

1 SUPPLEMENTARY INFORMATION FORM INSTITUTIONS & NON-INDIVIDUAL ACCOUNT ZENITH

2 ENTITY & ACCOUNT INFORMATION Full Legal Name of Customer Account Number Tax Iden fica on Number (TIN) Business Registra on Number Business Website/ Address En ty Type Nature of Business Key Personnel & Beneficial Ownership [ ] Sole Proprietorship [ ] Accoun ng/audit Services [ ] Informa on Technology [ ] Partnership [ ] Agriculture, Forestry & Fishing [ ] Investment Advisory [ ] Limited Liability Company [ ] Commerce & Finance [ ] Legal Services [ ] Public Company [ ] Construc on [ ] Manufacturing [ ] External Company [ ] Educa on [ ] Mining & Quarrying [ ] Yes [ ] No Is the customer licensed as a free zones enterprise under the Ghana Free Zones Act? [ ] Trust, Nominee or Fiduciary [ ] Electricity, Gas & Water [ ] Other Professional Services [ ] Yes [ ] No Is the customer listed on any stock exchange? [ ] Embassy/Diploma c Mission [ ] Energy [ ] Real Estate Please provide reference No.: [ ] Parastatal (including MDAs) [ ] Health Care [ ] Religious Organisa ons [ ] Yes [ ] No Is the customer or any of the beneficial owners or directors a poli cally exposed person (PEP) or [ ] Guarantee Company: NGO, [ ] Transporta on, Storage & [ ] Hospitality closely associated with one? Please provide name(s) and designa ons of each PEP: Founda on etc Communica ons [ ] Unincorporated Society, [ ] Other (please specify) Club or Associa on Account Specifica ons Poli cally Exposed Persons (PEPs)are individuals who are or have been entrusted with prominent public func ons both in Ghana and foreign countries and those associated with them. Purpose of Account Source of Funds Foreign Countries with which Business is Conducted [ ] Salary Processing [ ] Commissions [ ] Salary List top four (4) countries [ ] Business/Transac onal [ ] Dividends [ ] Family & Friends [ ] Savings & Investment [ ] Business Income [ ] Rental Income [ ] Conduct single transac on [ ] Personal Savings [ ] Inheritance/Gi [ ] Access to banking services [ ] Other (please specify) [ ] Trust funds per trust deed [ ] Security/Safe keeping Authorised Signatory Signature Date [ ] Facilita on of third party payments [ ] Reciept of inflows from [ ] Other (please specify) Authorised Signatory Signature Date FOR BANK USE ONLY An cipated # of Trans./Month An cipated Amount/Month Indicate customers FATCA Status and Risk Score Deposits Withdrawals [ ] US Person [ ] Non US Person [ ] Recalcitrant [ ] PFFI [ ] NPFFI [ ] 0-10 [ ] 0-10 [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5 [ ] [ ] Deposits Note: An Enhanced Due Diligence (EDD) form must be completed and approved by senior management for applicants achieving [ ] [ ] scores of 4 or 5. [ ] > 50 [ ] > 50 Withdrawals Documents Obtained [ ] Completed Key Personnel Informa on Form [ ] Completed Beneficial Ownership Form Beneficial Ownership* [ ] Graphical Sketch of Loca on [ ] Enhanced Due Diligence Form (where applicable) [ ] We are the beneficial owners of the funds in the account [ ] Non Ci zen Ghana Card (where applicable) [ ] Residence Permit (where applicable) [ ] We are holding the funds in the account on behalf of a third party [ ] Work Permit (where applicable) [ ] Valid GIPC cer ficate (where applicable) [ ] We are holding the funds in the account on behalf of more than one third party * Beneficial owner means (a) a natural person(s) who ul mately owns or controls a customer and or (b) the person who has the ul mate effec ve control over a legal person or arrangement (e.g. shareholders, trustees etc) and relevant third par es Dear Valued Customer, we would be most grateful if you would take a li le me to provide us with the requested supplementary informa on to enable us update our records in accordance with addi onal requirements specified by the Central Bank. Your coopera on is greatly appreciated! Kindly find overleaf forms for (i) Key Personnel and (ii) Beneficial Owners to be completed for each Principal Officer/Signatory/Director and Beneficial Owner, respec vely. Other Informa on Checked and Processed by: Rela onship Manager:

3 GRAPHICAL SKETCH OF LOCATION Provide a direc onal sketch of direc ons to the customer's loca on. You may also provide other descrip ve informa on that will assist in iden fying the customer's loca on.

4 KEY PERSONNEL INFORMATION: PRINCIPAL OFFICERS/SIGNATORIES/DIRECTORS Full Legal Name: Key Person I Key Person II Key Person III Other Names: Mother's Maiden Name: Date of Birth: (mandatory) D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y Place of Birth/TIN: Place of Birth Tax Iden fica on Number Place of Birth Tax Iden fica on Number Place of Birth Tax Iden fica on Number Sex: [ ] Male [ ] Female [ ] Male [ ] Female [ ] Male [ ] Female Iden fica on Type: [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] NIA Card [ ] SSNIT Card [ ] NIA Card [ ] SSNIT Card [ ] NIA Card [ ] SSNIT Card ID Number/Issuing Country ID Number Issuing Country ID Number Issuing Country ID Number Issuing Country ID Issue/: Issue Date Issue Date Issue Date Residence Permit No: (if applicable) Permit No Permit No Permit No Ci zenship/hometown: Ci zenship Hometown Ci zenship Hometown Ci zenship Hometown Occupa on/job Title: Occupa on Job Title Occupa on Job Title Occupa on Job Title Residen al Address (including important landmarks) & Metropolitan, Municipal District Assembly Area (MMDA) Personal Phone No: City, Region & Country MMDA City, Region & Country MMDA City, Region & Country MMDA Address: Key Person Status: Tick all applicable boxes [ ] Principal Officer [ ] Signatory [ ] Director [ ] Principal Officer [ ] Signatory [ ] Director [ ] Principal Officer [ ] Signatory [ ] Director I hereby a est that the above informa on is true and complete. Signature Signature Signature Verified by: (For Bank Use Only)

5 KEY PERSONNEL INFORMATION: PRINCIPAL OFFICERS/SIGNATORIES/DIRECTORS Full Legal Name: Key Person IV Key Person V Key Person VI Other Names: Mother's Maiden Name: Date of Birth: (mandatory) D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y Place of Birth/TIN: Place of Birth Tax Iden fica on Number Place of Birth Tax Iden fica on Number Place of Birth Tax Iden fica on Number Sex: [ ] Male [ ] Female [ ] Male [ ] Female [ ] Male [ ] Female Iden fica on Type: [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] NIA Card [ ] SSNIT Card [ ] NIA Card [ ] SSNIT Card [ ] NIA Card [ ] SSNIT Card ID Number/Issuing Country ID Number Issuing Country ID Number Issuing Country ID Number Issuing Country ID Issue/: Issue Date Issue Date Issue Date Residence Permit No: (if applicable) Permit No Permit No Permit No Ci zenship/hometown: Ci zenship Hometown Ci zenship Hometown Ci zenship Hometown Occupa on/job Title: Occupa on Job Title Occupa on Job Title Occupa on Job Title Residen al Address (including important landmarks) & Metropolitan, Municipal District Assembly Area (MMDA) Personal Phone No: City, Region & Country MMDA City, Region & Country MMDA City, Region & Country MMDA Address: Key Person Status: Tick all applicable boxes [ ] Principal Officer [ ] Signatory [ ] Director [ ] Principal Officer [ ] Signatory [ ] Director [ ] Principal Officer [ ] Signatory [ ] Director I hereby a est that the above informa on is true and complete. Signature Signature Signature Verified by: (For Bank Use Only)

6 BENEFICIAL OWNERSHIP Beneficial Owner I Beneficial Owner II Beneficial Owner III Full Legal Name: Kindly provide details for each beneficial owner or shareholder with a holding of 10% or greater Na onality/country of Incorpora on.: Date of Birth: Iden fica on Type: ID No./Company Reg. No.: D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] NIA Card [ ] SSNIT Card [ ] NIA Card [ ] SSNIT Card [ ] NIA Card [ ] SSNIT Card Tax Iden fica on No: Current Permanent Residen al Address: Personal Phone Number: Address: Nature of Business: % Shareholding: Name of Spouse: Spouse's Address: For corporate shareholders: Name of Ul mate Beneficial Owner: Names of Affiliated En es:

7 BENEFICIAL OWNERSHIP Beneficial Owner IV Beneficial Owner V Beneficial Owner VI Full Legal Name: Kindly provide details for each beneficial owner or shareholder with a holding of 10% or greater Na onality/country of Incorpora on.: Date of Birth: Iden fica on Type: ID No./Company Reg. No.: D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] Driver's License [ ] Voters ID Card [ ] Passport [ ] NIA Card [ ] SSNIT Card [ ] NIA Card [ ] SSNIT Card [ ] NIA Card [ ] SSNIT Card Tax Iden fica on No: Current Permanent Residen al Address: Personal Phone Number: Address: Nature of Business: % Shareholding: Name of Spouse: Spouse's Address: For corporate shareholders: Name of Ul mate Beneficial Owner: Names of Affiliated En es:

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