Application Form Multi Currency Account (EUR USD RMB) With this form you can apply for the Multi Currency Account. Please pay attention: the Multi Currency Account can not process Direct Debit transactions and does not facilitate automatic Standing Orders. If you only like to save online we refer you to our website www.icbc.co.nl to apply for the Internet Saving package with registered counter account online. Please complete this form with block letters. Incomplete forms will not be processed. 1 Personal Details Accountholder(s) Accountholder 1 Accountholder 2 Gender Male Female Male Female Initials First names Nickname Prefix Surname Date of Birth Place of Birth Country of Birth Marital status Proof of Identity Nationality Type of ID proof Passport Residence permit Passport Residence permit Number ID proof Issue date Expiry date Issuing city Issuing country TAX Number Street name House number + Affix Zip code Country Street name House number + Affix Zip code EU-ID card NL Driving license EU-ID card NL Driving license Residential Address Postal address if different from residential address 1 / 7
Country Other contact details Telephone number Fax number E-mail address 2 Personal Characteristics and Preferences How do you know ICBC? Expected use of account? Multiple answers possible. Domestic payments International Payments To which countries do you expect to transfer funds? Domestic payments International Payments To which countries do you expect to transfer funds? Incoming payments What is the expected origin/ source of the incoming payment? (Salary, Saving, etc) Incoming payments What is the expected origin/ source of the incoming payment? (Salary, Saving, etc) From which countries do you expect to receive funds? From which countries do you expect to receive funds? _ Cash deposit and withdrawals Saving Others, please explain briefly: _ Cash deposit and withdrawals Saving Others, please explain briefly: For which employer or in which sector do you work? What is your (public) position? 3 Which additional products and agreements do you wish? UnionPay Debit Card Yes No Not possible with joint Accounts Internet Banking Yes No (please complete part 4) Yes No (please complete part 4) Do you wish to receive Yes No Yes No 2 / 7
our newsletters/ Usually our newsletters and advertisements will be sent by e-mail. If you do not like to receive advertisements? this information it may still occur that you receive information if ICBC Amsterdam is legally obliged to inform you. If you did apply for Internet Banking you can manage the settings below yourself online. You can continue with declaring and signing ICBC Amsterdam. If you did not apply for Internet Banking we request you to complete part 4 Bank statements and Easy Saving. 4 Bank statements and Easy Saving Bank statements instead of Internet Banking ICBC Amsterdam is legally obliged to inform its customers about the mutations/ transaction history of their accounts. This is one of the reasons we give Internet banking to your availability. If you choose not to apply for Internet Banking Please indicate below in which frequency and manner you like to receive your bank statements. Debit Card without Internet Banking If you do not want to apply for Internet Banking but do apply for the UnionPay Debit Card, we recommend you to choose a high frequency of bank statements so that you are able to monitor your account movements timely. Registration of your e-mail address is required. If you dispute any transaction it is your responsibility to inform the Bank as soon as possible! Easy Saving Easy Saving gives you the possibility to install a limit on your current account. Any balance which exceeds the limit will, during our end-of-the-day processing, automatically be transferred to your callable ICBC saving account. Accountholder 1 Accountholder 2 Bank statements By mail by E-mail By mail by E-mail Only month end frequency possible Daily Weekly Monthly Month end Only month end frequency possible ICBC Amsterdam Account number: Easy Saving No Yes Desired limit: 5 Declare and signing ICBC Amsterdam Daily Weekly Monthly Month end (To be complete by bank) Currency: EUR USD RMB By signing I agree with the General Banking Conditions and ICBC Amsterdam Terms and Conditions Retail Customers Date Place Signature 1 Signature 2 3 / 7
Self-certification form to establish US tax status Registration of your personal data Financial institutions are legally required to verify whether their clients are U.S. persons. As a financial institution we therefore have to ask you several questions. If you are a U.S. person we are legally bound to report your data to the Dutch tax authorities. The Dutch tax authorities will report this data to the United States tax authorities. Several definitions in this form are underlined. Please find an explanation of these terms in the glossary. 1. General Information 1a First and middle Initials 1b Title 1c Last name 1d Date of birth dd-mm-yy 1e Account numberr/iban 2. Liable to tax in the United States? 2a Are you a US Person? Yes please proceed with 2b (You may be liable to tax in the United States. Therefore, we are legally bound to report your data to the Dutch tax authorities. The Dutch tax authorities will report this data to the United States tax authorities.) No please proceed with 2c 2b Please provide your US TIN? please proceed with 3 2c Is your place of birth located in the United States? Yes Please attach the following documents to the form: A copy of a valid passport (not a driver s licence), and A copy of a Certificate of loss of nationality of the United States. No Please attach a copy of a valid passport/identification card to the form. 3. Declaration and signature I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct and complete. I declare that I will inform the financial institution within 30 days about any changes that may occur in above-mentioned information. Signatory date dd-mm-yy Full name Signature 4 / 7
*Self-certification form to establish US tax status (Please use this form for the second accountholder) Registration of your personal data Financial institutions are legally required to verify whether their clients are U.S. persons. As a financial institution we therefore have to ask you several questions. If you are a U.S. person we are legally bound to report your data to the Dutch tax authorities. The Dutch tax authorities will report this data to the United States tax authorities. Several definitions in this form are underlined. Please find an explanation of these terms in the glossary. 1. General Information 1a First and middle Initials 1b Title 1c Last name 1d Date of birth dd-mm-yy 1e Account numberr/iban 2. Liable to tax in the United States? 2a Are you a US Person? Yes please proceed with 2b (You may be liable to tax in the United States. Therefore, we are legally bound to report your data to the Dutch tax authorities. The Dutch tax authorities will report this data to the United States tax authorities.) No please proceed with 2c 2b Please provide your US TIN? please proceed with 3 2c Is your place of birth located in the United States? Yes Please attach the following documents to the form: A copy of a valid passport (not a driver s licence), and A copy of a Certificate of loss of nationality of the United States. No Please attach a copy of a valid passport/identification card to the form. 3. Declaration and signature I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct and complete. I declare that I will inform the financial institution within 30 days about any changes that may occur in above-mentioned information. Signatory date dd-mm-yy Full name Signature 5 / 7
Glossary Certificate of loss of nationality of the United States A Certificate of loss of nationality of the United States is considered proof that United States citizenship has been terminated. A United States citizen can file a request for this certificate with the United States government. Upon receipt of this certificate the person will no longer be considered a United States citizen. There are other certificates to prove a person s loss of nationality. For more information please visit www.travel.state.org and search for Loss of citizenship and nationality. IBAN IBAN is an abbreviation of International Bank Account Number. This account number is constructed in the same manner in every country. The number consists of various elements including the following information: the country code (NL for the Netherlands); a control number (two digits); the code of the bank (four characters in the Netherlands); one or more zeros; and the account number The IBAN consists of 18 characters in the Netherlands. Passport / Identification card This document certifies the identity of an individual. This document must be issued by a recognised government institution. In order to establish the residence and nationality of the individual, a valid copy of one of the documents below should be attached to this form: (Dutch or other country) passport; Dutch driver s licence; Identification card issued by a member state of the European Union. A foreign driver s licence is not a permitted form of identity certificate for this form. U.S. person When are you considered a U.S. person? As an individual, you are a U.S. person if one of the following situations is applicable to you: You are a citizen of the United States You are a resident of the United States (including the following U.S. territories: Puerto Rico, Guam or the U.S. Virgin Islands). You currently possess or have previously been in the possession of a U.S. green card. Please consult your tax advisor to determine which type of U.S. green card may qualify you as a U.S. person. Please visit www.irs.gov for more information about U.S. green cards. In which other cases could an individual be considered a U.S. person? As an individual, you could be considered a U.S. resident and therefore a U.S. person if you have spent 183 days or more in the United States during the past three years, including at least 31 days in the current calendar year. The days are calculated as follows: All days in the United States in the current year; and 1/3 of the days in the United States of the last year; and 1/6 of the days in the United States of the year before last year. When are you considered a United States citizen? You are a United States citizen if one of the following situations applies to you: 1 You were born in the United States. 2 You were born in Puerto Rico. 3 You were born in Guam. 4 You were born in the U.S. Virgin Islands. 5 You became a naturalized United States citizen. 6 At least one of your parents is a United States citizen. In this case other requirements must be met to be considered a United States citizen. Please refer to www.irs.gov for these requirements. When is a person liable to tax as a U.S. person? If you satisfy the requirements to be considered a U.S. person, you could be liable to tax in the United States. However, there may be exceptions. For example, a student visa or diplomatic status could provide an exemption for certain tax liabilities. There could potentially be additional circumstances where a person could be liable to or exempt from tax in the United States. Please note the items mentioned above should not be considered an exhaustive list. Please consult your tax advisor or go to www.irs.gov for more information. U.S. TIN (U.S. federal taxpayer identification number) The Taxpayer Identification Number (TIN) is your personal identification number for tax administration purposes with the United States tax authorities (IRS), this is also known as a as U.S. federal taxpayer identification number. There are several types of U.S. TINs: For residents and citizens of the United States the Taxpayer Identification number is the Social Security Number (SSN). This is the United States equivalent of the Burgerservicenummer (BSN). You can request a social security number via IRS form SS-5 or www.irs.gov. Non-U.S. individuals who are United States taxpayers can request an Individual Tax Identification Number (ITIN via IRS form W-7 or www.irs.gov. More information about identification numbers and the process to request these numbers is available on www.irs.gov 6 / 7
Important Do not forget: Your proof of identification (needs to be valid for at least another 90 days) Proof of your tax number A recent proof of your resident address (not older than 3 months) E.g. a letter from the tax authority, a bank statement of another Dutch bank, or a letter/ extract from your municipality. A completed and duly signed Self-cerification form to establish US tax status Retail Customer (FATCA) form(s) 7 / 7