MORTGAGES
INVESTMENTS
KNOW YOUR CUSTOMER FORM (NEW CUSTOMERS) - INDIVIDUALS
1. CLIENT IDENTIFICATION INFORMATION
1.
2.
Single
Married
Divorced
Widowed
Common Law
Separated
Male
Female
Investment customers who are citizens or lawful permanent
residents of the United States, please complete U.S. Taxpayer Form
Spouse's name:
Spouse's dob:
Spouse's Occupation:
Resident
Non-Resident
Local
Foreign
Banker's reference from foreign bank
Credit Support
Do you hold residency status in a country other than Trinidad & Tobago? (Yes or No)
If Yes please indicate which country/countries
NATIONAL IDENTIFICATION CARD
NO.
COUNTRY OF ISSUE:
EXPIRE DATE (mm/dd/yy):
DRIVER's PERMIT
NO.
COUNTRY OF ISSUE:
EXPIRE DATE (mm/dd/yy):
PASSPORT
NO.
COUNTRY OF ISSUE:
EXPIRE DATE (mm/dd/yy):
Please provide two (2) forms of valid photographic identification
PERMANENT ADDRESS (Must not be a P.O. Box)
Proof of address provided (Y/N):
MAILING ADDRESS (If different from Permanent Address):
Please provide proof of address (Utility Bill (FLOW, TSTT land line, WASA or T&TEC) or copy of correspondence from a Government
office such as the Board of Inland Revenue or National Insurance Board)
2. EMPLOYMENT INFORMATION
EMPLOYMENT NAME & ADDRESS (If retired, state last employer)
Type of business activity:
OCCUPATION:
Length of service:
Salaried
Alimony
Pension
Self-Employed
Other
If OTHER please provide details:
Resident
Non-Resident
Local
Foreign
If OTHER please provide details:
≤ $25,000
$50,001 - $100,000
$25,001 - $50,000
< $100,000
Please provide Job Letter/Pay slip/Other documentary evidence
FOR INVESTMENTS CUSTOMERS:
Please indicate estimated annual account activity (TT$):
HMB/KYC-1 v2.2 effective 2424.07.27
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3. BENEFICIAL OWNER(S)
Who will be the beneficial owner of the account?
Self
Other
If Other please provide name(s) and relationships:
(Note: A separate Know Your Customer form must be completed for each person identified)
4. CONNECTED PARTIES
1. Are you a Director/Officer of Home Mortgage Bank?
Yes
No
2. Are you a relative of a Director/Officer of Home Mortgage Bank?
Yes
No
If Yes please provide name(s) and relationships:
(“Relative” means the spouse (including common-law), parents, siblings or children of that person and the parents, siblings and additional children of the person’s spouse)
5. POLITICALLY EXPOSED PERSONS
A "politically exposed person (PEP)" means a person who is or was entrusted with important public functions such as —
(a) a senior official in the executive, legislative, administrative or judicial branch of government, whether elected or not;
(b) a senior official of a major political party;
(c) a senior executive of a government-owned commercial enterprise;
(d) a senior military official;
1. Are you currently or formerly a person mentioned in items (a) to (d)?
Yes
No
If "Yes" Please give details
2. Are you an immediate family member of a person mentioned in items (a) to (d) meaning the spouse (includes ex-spouse), parents, siblings or children of that person and the parents, siblings and additional children of the person’s spouse?
Yes
No
If "Yes" Please give details
3. Are you a close personal or professional associate of a person mentioned in items (a) to (d)?
Yes
No
If "Yes" Please give details
4. Are you A Foreign PEP?
Yes
No
If "Yes" Please give details
5. Are you an International Organization PEP?
Yes
No
If "Yes" Please give details
See KYC Form guidelines for further explanations.
6. DECLARATION
Check applicable statement:
i. I am neither a citizen (including dual citizenship) nor a lawful permanent resident of the United States.
ii. I am a citizen (including dual citizenship) or a lawful permanent resident of the United States.
I confirm that the information provided in this form is true and accurate as at the date below.
For Individuals, if the account is jointly held, a separate Know Your Customer Form must be completed for each account holder. In the case of a sole trader, the Principal/Owner is to sign this form. The Bank reserves the right to request additional information, if necessary.
FOR OFFICIAL USE ONLY
RECEIVED BY:
SIGNATURE:
DATE:
Checked against UN1267 list by Compliance Officer
Yes
No
Client’s name appears on UN1267 list
Yes
No
COMPLIANCE OFFICER SIGNATURE:
RISK RATING:
RECOMMENDED BY:
APPROVED BY:
COMMENTS:
HMB/KYC-1 v2.2 effective 2424.07.27
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HMB/KYC-1 v2.2 effective 2424.07.27
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