SOURCE OF FUNDS

Date of Declaration *

Transaction Date

Name of Client: *

Address of Client: *

Occupation or Business: *

Fax Number

Telephone - #1 *

Telephone - #2

Amount: *

TTD Equiv:

Transaction Type: SingleMultiple

Transaction Method: *

Cash

Cheque / Draft

Wire / ACH

IF CLIENT IS AN INDIVIDUAL, COMPLETE THIS SECTION

ID/PP/DP #:

Date of Expiry:

Date of Birth:

Status: ResidentNon-Resident

IF CLIENT IS AN INSTITUTION, COMPLETE THIS SECTION

It is expected that an authorised officer of the institution shall make the required declaration. Their details should be entered here under “representative employee”

Incorporation / Reg. No.:

Date of Incorporation / Reg.:

Country of Incorporation / Reg.:

Name of Representative Employee:

Location of Employee:

Position / Title:

ID/PP/DP #:

Date of Expiry:

Date of Birth:

Status: ResidentNon-Resident

Telephone:

Email Address:

IF CLIENT IS BEING REPRESENTED BY A THIRD PARTY, COMPLETE THIS SECTION

This section is to be completed if the person filling out the form is acting in a fiduciary capacity for the client (e.g. power of attorney, financial advisor, notary public, trustee, receiver etc.)

Name of Individual &/or Company:

Ind:

Co:

Physical Address:

Relationship to Client:

Date of Birth &/or Incorporation:

Birth:

Incorp:

ID/PP/DP #:

Date of Expiry:

Incorporation No. (if appl.):

Telephone:

Email Address:

NB: Your declaration as to the source of funds should be made after you have made inquiry and to the best of your knowledge and belief, the funds were not derived from, or are being employed in, any illegal transaction by the individual or institution for whom you now act.

DECLARATION OF SOURCE OF FUNDS
In accordance with legislation and regulatory guidelines, and as a matter of company policy, Firstline must verify the source of your funds and we may request that you provide further detail or accompanying documentation to your declaration. Please cooperate with us. Firstline is a member of a group of companies and the information shared here may be disclosed to other members of the group or to regulatory or law enforcement authorities as may be requested.

Proceeds from:

Business Trade