Application Form – to be completed by the Beneficial Owner
Joint or Individual Account / If joint application, please provide one form per person on account.Title
Surname
First Name(s)
Previous Names/Maiden Name
Date of Birth
Place of Birth
Permanent Address
How long have you resided at this address? If less than 3 years please provide on an additional sheet all addresses resided in for the last 3 years.
Where are you domiciled for tax purposes?
Nationality (Including Dual Nationality if applicable)
Tax Identification Number
Social Security Number
Passport Number
Contact Number
Email Address
Current Employment
Employer’s Business Name
Asset(s) to be stored (if known)
US Status Declaration (to be completed by all applicants
Are you a US Citizen?Do you hold a US green card?
Have you ever lived in the US?
Do you own a US property
Are you a US tax payer?
Those persons who certify that they are a US person, please return the Form W-9 with this Form.
Those persons who certify that they are not a US person, please return the Form W-8BEN with this Form.
Are Instructions in place or likely to be for transfer of funds to US accounts or directions regularly received from a US address?Is there in place a Power of Attorney or signatory authority granted to a person(s) with US address?
Financial Information
The Guernsey Financial Services Commission requires that we take all precautions to prevent the laundering of monies for the purposes of Terrorism or Crime (theHandbook for Financial Services Businesses on Countering Financial Crime and Terrorist Financing and as such Network Securities Ltd is required by Law to determine the source of wealth & funds that you have used to purchase the “Deposit” that is to be stored with Network Securities Limited. We may also at times in the future, at trigger points, be required to request additional information.
Please provide an explanation in relation to the source of funds used to purchase the assets being deposited with Network Securities Limited. Please note we may request documentary evidence to support this. Please refer to Appendix 1 of this Form for instruction on details required.
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Verification of your Identity
As with the financial information, in order to be compliant with our local fiduciary authority regulations, we are required by law to confirm that you are who you say you are and where you live. To enable us to do this, we require the following information:
(1) A Certified Copy of current passport or National Identity card.*
(2) Original or Certified copy of Proof of Permanent Residential Address (not more than 3 months old).
Authorised examples include:
· Utility Bills (not mobile telephone);
· Personal Tax Assessment;
· Statement of Bank Account/Credit Card Accounts;
· Local Tax Bill.
*For dual nationality passport holders, please provide a certified copy of each passport.
The documents must be certified by an authorised individual operating in an equivalent jurisdiction to Guernsey. For these purposes, an authorised individual should be one of the following:
Lawyer, Chartered Accountant, Serving Police or Customs Officer, Notary Public ‘Member of Judiciary, Senior Civil Servant, Actuary, an Embassy, Consulate or High Commissioner of the country of issue of the document, Director, Officer or Manager of a regulated financial services business (e.g. Bank Manager).
Additional information may be required in some cases.
In addition to this, the certifier should also provide the following information:
Full Name: ______
Position Held: ______
Telephone Number: ______
Permanent Address: ______
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Business stamp:
Disclaimer / Declaration
By signing and dating this document, you, as the Beneficial Owner, hereby confirm the following:
· All information given by you is true;
· You confirm that you are not involved in any criminal or money laundering activity and the funds used to purchase your deposit are not derived from any illegal activities;
· You authorise Network Securities Limited to obtain independent verification of any information you have supplied.
Beneficial Owner Name: ______
Signature: ______
Date: ______
Appendix 1 – Guidance for Source of Funds
Savings from Employment Income / · Annual income and bonuses this year and last year
· Nature of Employer’s business
· Employer’s name/address / · Last 3 months pay slips, or
· Confirmation from Employer of income and bonuses for last 2 years, or
· Bank Statements that clearly show receipt of the most recent 3 months regular salary payments from the named employer, or
· Latest accounts if self employed.
Maturing Investments or Encashment Claim / · Amount received
· From which company
· Date received
· How long held / · Letter/contract note from previous investment company giving notification of proceeds of maturing investment/ claim
Share Sale / · Sale value of shares sold
· Description of shares/funds
· How sold (i.e. through stockbroker or bank etc.) and name/address
· Date of sale
· How long each investment held / · Legal sale document(s) (e.g. contract notes)
Property Sale / · Sale value of property sold
· Full address of property sold
· How sold (i.e. through agent, by auction, private sale , including name/address )
· Date of sale
· How long property held / · Signed letter from Solicitor
· Completed sale contract
Company sale or sale of an interest in company / · Name & address of Company
· Total sale price
· Applicant’s share
· Nature of business
· Date of sale / · Signed letter from Solicitor, or
· Signed letter from UK Regulated Accountant, or
· Copy of contract of sale and sight of investment monies on Bank Statement
Inheritance / · Total amount received
· Name of benefactor
· Relationship to benefactor
· Date received / · Grant of Probate (with a copy of the will) which must include the value of the estate, or
· Bank Statements or
· Solicitor’s letter
Loan / · Amount of loan
· Why required
· Name & address of Loan Provider
· Date of loan / · Loan agreement or
· Recent loan statements
Gift / · Total amount
· Details of benefactor
· Reason for gift
· Relationship to benefactor
· Source of donated funds / · Letter from donor confirming details of gift and acknowledging the source of the donated funds
· Based on the SOW specified, the donor needs to provide supporting documentation as per the provisions of this table
Company Profits / · Copy of latest accounts, or
· A letter from a Regulated Accountant giving details of company profits over the last 2 years
Other income sources / · Nature of Income
· Amount
· Date Received
· Received from whom / · Appropriate supporting documentation, or
· Signed letter detailing funds from a Regulated Accountant
Network Securities is registered in Guernsey. No. 49267
Registered Office: Network House, 3 Jubilee Terrace, South Esplanade, St Peter Port, Guernsey, GY1 1AH