Individual Account Opening Form

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PLEASE COMPLETE THIS FORM IN ITS ENTIRETY IN BLOCK LETTERS ONLY
▪ To comply with our obligations under the Proceeds of Crime Act, Chap. 11.27 (as amended), the Financial Obligations
Regulations, 2010 (as amended) and the Foreign Account Tax Compliance Act (FATCA), ANSA Bank Limited (ABL) is mandated
to request the information contained therein.

SECTION 1.0 Account Type

Branch Date
Account Number (Bank use only) Account Number (Bank use only) Product Class (Bank use only)

Product/ Service required

 Savings Account  Current Account  Fixed Deposit
 Cheque Book  ATM/ Debit Card  Online Banking

Purpose of account
Expected Monthly Deposit
Sources of Deposits
Number / Frequency of Expected Deposits
Please indicate how you would like to receive account statements:

 Send via email:……………………………………………………………………………

SECTION 1.1 Main Applicant Information

Title Given Name(s) Surname

CIF # (Bank use only) Date of Birth Gender Marital Status

 Male  Female

Nationality Citizenship Other Citizenship

-- -- --

ID Type ID Number Issue Date Expiry date

Residence Street Address City/ Town Country of Residence

--

Mobile Number Home Number Work Number

Email Address

Employment status Gross Income Salary frequency

Current Employer Previous Employer (if at current employer <2years)

Occupation
Employer’s Name
Street Address
City/ Town
Period of Employment From: To: present date From: To:

Primary Reference Secondary Reference

Full Name
Street Address
City/ Town
Telephone Contact
Relationship

ANSA Bank Limited FORM# GRC-101 (revised Oct-2024) Page 1 of 8

SECTION 1.2 Joint Applicant Information

Title Given Name(s) Surname

CIF # (Bank Use Only) Date of Birth Gender Marital Status

 Male  Female

Nationality Citizenship Other Citizenship

-- -- --

ID Type ID Number Issue Date Expiry date

Residence Street Address City/ Town Country of Residence

--

Mobile Number Home Number Work Number

Email Address

Employment status Gross Income Salary frequency

Current Employer Previous Employer (if at current employer <2years)

Occupation
Employer’s name
Street Address
City/ Town
Period of employment From to current date From To

Primary Reference Secondary Reference

Full Name
Street Address
City/ Town
Telephone Contact
Relationship

SECTION 1.3 Self-Employment Details (Omit this section if not applicable)

Name of Business

Nature of Business

1. List of products and services provided by the company.

Business address

Business # Fax # Email

Last annual earnings Last Annual Profit # of employees

2. Are you an Attorney-at-law, Accountant or Independent Legal Professional involved in the following on behalf of clients?
a) Buying and selling of real estate;  Yes  No
b) Managing of client money, securities, and other assets;  Yes  No
c) Management of banking, savings, or securities accounts;  Yes  No
d) Organisation of contributions for the creation, operation or management of companies;  Yes  No
e) Creation, operation or management of legal persons or arrangements, and buying or selling of  Yes  No
business entities.

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3. Are you involved in any of the following activities involving real estate?
- Buying and/ or selling or leasing land and any interest in land or any buildings thereon;  Yes  No

4. Are you involved in any of the activities listed below?  Yes  No

 Internet Gambling  Motor Vehicle Sales or Leasing  Gaming Houses
 National Lotteries  Jewellery dealer  Art Dealer
 Cash Intensive trade  Pool Betting

5. If the answer to any question from 2 – 4 above is yes, then the following is required: (please indicate which are provided)
 Proof of Registration with Financial Intelligence Unit of Trinidad & Tobago.
 Confirmation letter indicating that a Compliance Program exists and is in line with the Proceeds of Crime Act, Chap: 11.27

6. The following items may also be required

• Registration certificate (mandatory if business is registered)
• Professional licensure required for doctors, lawyers, accountants, farmers (farmer’s badge), taxi operators (taxi badge) and
vendors & food caterers (food badge)
• Financials in the form of management accounts for the last three (3) years if in operation for more than three (3) years; or
estimates of income for three (3) years if in operation for less than three (3) years;
• Bank statements for the past six (6) months (if applicable)

SECTION 1.4 Guardian Consent (Required if Applicant is a Minor)

Father * Mother * Legal Guardian**

* (Father or Mother) Submit document evidencing relationship with minor

** (Court appointed Guardian) In case of Legal Guardian, please submit attested copy of the court appointment letter, affidavit
etc. to support

I shall represent the said minor in all future transactions of any description in the above account until the said minor attains the
age of eighteen. I will indemnify the Bank against the claim of the above minor of any withdrawal/ transactions made by me in
his/her account.

……………………………………………………….
Signature

SECTION 1.5 Politically Exposed Person (PEP) Attestation (tick ‘Yes’ where applicable to you)
a) Have you ever been entrusted with a prominent public function, local or foreign (either currently or in the past) as stated
below?  Yes  No
 Head of State  Head of Government  Senior Member of Legislature  Military Official
 Senior Politician  Senior Government Official  Judicial Official  Political Party Official
 Executive State-Owned Enterprise  Prominent Position in an International Organisation

If yes, please provide details

b) Are you an immediate family member (spouse, parent, sibling, child) or close personal or professional associate of anyone
in the categories in ‘a’ above?  Yes  No
If yes, please provide details

SECTION 1.6 Foreign Account Tax Compliance Act (FATCA) Information (tick ‘Yes’ where applicable to you)
The Government of the United States of America passed a law in March 2010 under the Foreign Account Tax Compliance Act
(FATCA) requiring disclosure on the existence of all accounts held by United States nationals and of any persons or entities to
which the following indicia are applicable. Please tick where appropriate pertaining to your U.S. status.

a) Are you a permanent resident of the United Stated of America (USA) or a USA Citizen (i.e.  Yes  No
Holder of a US Green card or US Passport)
b) Do you possess a US mailing address?  Yes  No
c) Was your place of birth in the USA?  Yes  No
d) Do you have a US “in care of” or “hold mail” address or a P.O. address as your primary  Yes  No
address?
e) Have you granted a power of attorney or signatory authority to a person with a USA address?  Yes  No
f) Have you provided standing order instructions to transfer funds to an account maintained in  Yes  No
the USA or directions received from a USA address?

A. FATCA CERTIFICATION FOR NON-US PERSONS

I certify that:
a. I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of
all the income to which this form relates,
b. The person named under the section entitled ‘Identity Information’ on this form is not a U.S. person,

ANSA Bank Limited FORM# GRC-101 (revised Oct-2024) Page 3 of 8

 c. The person named under the section entitled ‘Identity Information’ on this form is a resident of the treaty country where
they indicated tax is paid (if any) within the meaning of the income tax treaty between the United States and that country,
and
I agree that I will advise ANSA Bank Limited immediately of any changes relating to my U.S. status.

………………………………………………………………………………………………….. ………………………………………………………..
Signature/Signature of beneficial owner Date
(or individual authorized to sign for beneficial owner)

B. FATCA CERTIFICATION FOR US PERSONS

If you are a US person and answered “yes” to the Assessment of US Indicia noted above, then:
I certify that:
a. The Taxpayer Identification Number (TIN) provided is correct, and
b. I am a U.S. person.
c. I have completed an Internal Revenue Service (IRS) US Form W-9- Request for Taxpayer Identification Number and
Certification  YES  NO
d. I have renounced my US Citizenship and have completed an IRS W-8BEN Form – Certificate of Foreign Status of Beneficial
Owner for US Tax Withholding  YES  NO
Copies of all accompanying evidence in support should be attached to the declaration.
I agree that ANSA Bank Limited can provide to the United States Internal Revenue Service and to any relevant tax authority (or
any party authorized to act on behalf of such an authority) any of the information provided in this section or any information
that may be required to be provided by law to the United States Internal Revenue Service or other relevant tax authority relating
to my account(s) held.

………………………………………………………………. ………………………………………………………..…………….. ……………………………………..

Signature of US Person Taxpayer Identification Number (TIN) Date

********Please obtain approval of the Compliance Officer********

SECTION 1.7 Connected/ Related Party Information

Are you a major shareholder, partner or director in a business entity that is an existing customer of  Yes  No
ANSA Bank Ltd?
If yes, please provide details

Are you a Director/ 1Officer of any company in the ANSA McAl Group?  Yes  No
If yes, please provide details

Are you a spouse (including common law), parent, sibling, child or spouse’s child of a Director/  Yes  No
Officer of any company in the ANSA McAl Group?
If yes, please provide details

SECTION 1.8 Signing Authority

Signing Instructions  Singly /  Any two jointly /  All jointly

Name of Primary Account Holder Signature of Primary Account Holder

Name of Joint Account Holder Signature of Joint Account Holder

Name of Joint Account Holder Signature of Joint Account Holder

Name of Joint Account Holder Signature of Joint Account Holder

1
Section 4 of the Companies Act of Trinidad and Tobago, an “Officer”, in relation to a body corporate means—
i) the Chairman, Deputy Chairman, President or Vice-President of the Board of Directors; ii) the Managing Director , General Manager, Comptroller, Secretary or Treasurer; or iii) any
other person who performs for the body corporate functions similar to those normally performed by the holder of any office sp ecified in paragraph (a) or (b) and who is duly appointed
to perform such functions
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SECTION 1.9 Debit Card Undertaking

I wish to apply for ANSA Bank Limited Debit Card.

 I authorize ANSA Bank Limited to issue a Debit ATM Card to me.
 I further unconditionally and irrevocably authorize you to debit my account annually for Debit Card fees/charges.

I confirm that I am the sole account holder or have the required mandate to operate the account linked to the Debit Card singly
and that I am older than 18 years of age. I acknowledge that the PIN must not be shared and indemnify ABL from any issues that
may occur if I divulged my PIN. I accept the responsibility for my Debit Card and agree not to make and claims against ANSA Bank
Limited in respect thereto.

Signature of Main Applicant Date signed Signature of Joint Applicant Date signed

SECTION 1.10 Terms & Conditions and Customer Declaration (Please tick boxes)
 1. I/We wish to be informed about the various features/ products and promotional offers made by the Bank from time to time.
 2. Please issue cheque book and recover charges from my/ our account.
 3. I/We have read, understood and agree to abide by the Bank’s rules relating to the conduct of the above accounts /services
/ products which are displayed on the website and contained in the brochures of the Bank. Account will be operated and
balance along with interest payable as per operational instructions given above.
 4. I/We understood that in the event of the death of the depositor(s), premature termination of term deposit would be allowed
without any penal charges to the claimant(s) after following the due procedure.
 5. I/We also agree to maintain the minimum/ average quarterly balance which the Bank may prescribe as the minimum balance
to be maintained and any other charges stipulated by the Bank. I/We understand that any charges in this respect will be
noticed by the Bank on its website and also will be displayed on the notice board of the branches one month in advance.
 6. I/We confirm I/ We will not commit one or any of commingling indicators, I/We understand that the practice of commingling
is prohibited under the Proceeds of Crime Act No. 55 of 2,000. I/We understand that ANSA Bank Limited, in its sole discretion,
is at liberty to terminate the said account should I/We be in breach of any commingling indicators.
 7. I/We confirm that I/We was/were entirely free to have this document reviewed and be independently advised as to the
content and legal effect. I/We confirm same was not required.
 8. I/ We also agree that ANSA Bank Limited can disclose the contents of this application and other related information and
transactions on accounts linked to me/us to ANSA Merchant Bank Ltd (AMBL) and any current or future financial services
companies which are subsidiaries of AMBL including ANSA Securities Limited, ANSA Merchant Bank (Barbados) Limited,
Trinidad and Tobago Insurance Limited, TATIL Life Assurance Limited and Colonial Fire & General Insurance Company Limited.
 9. I/ We understand that approval of this application is contingent on verification of all information given and authorize ABL to
obtain and share further information with credit bureaus and other credit grantors as permitted by law.
 10. I/ We understand that TTD deposits are insured with the Deposit Insurance Corporation, for each account up to
TT$200,000.00 and apportioned accordingly for joint accounts.
 11. I/ We also agree that, if any such declarations made by me/us are found to be incorrect, intentionally misleading, or
fabricated, then ABL shall be entitled to terminate the account relationship with immediate effect.
 12. Should my/our provision of any false/misleading information result in any suits, claims, demands and damages of
whatsoever kind or nature arising against ANSA Bank Limited, I/We FULLY AGREE to defend, indemnify, protect and hold
harmless ANSA Bank Limited.
 13. I/We confirm that the company has not been or is not in the process of being dissolved, struck-off, wound-up, terminated
or placed under receivership or liquidation.
 14. I/We understand that ABL reserves the right to review the operation of all accounts. If an account is found to be operated
in a manner that does not meet the Bank's standards or terms of use or relevant/applicable laws, rules and regulations, the
Bank may, at its discretion, close the account without prior notice.
 15. Should any of my/our circumstances change during the course of the banking/business relationship which would result in a
change to the information herein provided, I/We will provide updated information and/or documentation to ANSA Bank
Limited within thirty (30) days of such change

The Borrower agrees that ANSA Bank Limited (the Bank) may at any time without notice apply any credit balance (whether or not
then due and in whatever currency) which is at any time held in any of your accounts towards the satisfaction of:
a) any fees, loss, damage or expense suffered by us, as a result of our provision and/or your use of our services, or
b) any sum you owe under a credit card, mortgage, overdraft or other agreement within ANSA Bank Limited.
If such balances are in different currencies, the Bank may convert either balance at the then prevailing market rate of exchange
for the purpose of the set-off.
Any exercise by the Bank of its rights of set-off shall not limit or affect any other rights or remedies available to it.

……………………………………………………………………………………. …………………………………………………………………………………….
Signature of Main Applicant Signature of Main Co-applicant

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SECTION 1.11 Branch Attestation
1. Prospective Customer Existing Customer T24 Customer ID

2. Compliance Approval is required for any customer in the categories below. Indicate which applies
 POLITICALLY EXPOSED PERSON  REAL ESTATE AGENT  INFORMAL WORKER
 FOREIGN RESIDENT  LAWYER (Private practice)  INTRODUCED BUSINESS
 ESTATE EXECUTOR/ ADMINISTRATOR  ACCOUNTANT (Private practice)
 POWER OF ATTORNEY  NOTARY

3. Customer Risk Assessment

Risk Rating % Score Risk Rating % Score Risk Rating % Score
 HIGH RISK  MEDIUM RISK  LOW RISK
 PEPH  PEPM  PEPL

4. Has the customer’s identity been verified in line with the required standards and true copies of documents obtained?
 Yes  No

………………………………………………………….. …… …………………………………………………………………………………… .…......................................

Name of Officer (Block letters) Officer’s Signature Date

………………………………………………………….. …… …………………………………………………………………………………… .…......................................

Name of Manager (Block letters) Manager’s Signature Date

SECTION 2.1 Loan Requirements (Omit if not required)

Statement of Affairs
Assets (Cash Investments & Amount Liabilities (Loans, Balance Instalment
Other e.g., Motor vehicles, Mortgages, Credit Cards all
Real Estate, etc.) other debts & to whom owing)

Total 0.00 Total 0.00 0.00

Net Worth 0.00

Loan Purpose

Amount Required Interest Rate

Downpayment Tenor in months
Insurance premium Negotiation Fee
Principal Loan Amount Instalment Amount

DSR Calculations
Source of Income Expenses
Salary (Aggregate) Mortgage
Bonuses/ Commissions Rent
Rental Property Income Personal Loan
Investment Income Credit Cards
Other Income ABL Loan
Total Income 0.00 Total Expenses 0.00
DSR (%) 0.00%

ABL Exposure After Proposed Liabilities

Loan Number Loan Balance Collateral Instalment

Total 0 Total 0
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 Proposed Security
Description of Security Estimated Mkt Value/ FV Bank Charge Taken

SECTION 2.2 Loan Recommendation/ Conditions Precedent

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SECTION 2.3 Disbursements

………………………………………………… ……………………………………………………………. ………………………..

Recommended by Officer’s Signature Date

SECTION 2.4 Credit Approval

A credit decision is taken as follows:  APPROVED  DECLINED

There is reasonable assurance of repayment  Yes  No There is sufficient equity  Yes  No

There is sufficient collateral  Yes  No

Manager’s Name Manager’s Name

Signature of Manager Signature of Manager

Date Approved Date Approved

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