Know Your Customer (KYC) Application Form (For Individuals Only) (Please fill in ENGLISH and in BLOCK LETTERS with black ink) Resident Individual Non-Resident Individual Diplomat Foreign National Person of Indian Origin ADCB Staff CIF No. KYC No. (If available) : A/c. No. 1. Name of Applicant / Customer (As appearing in supporting identification document) Mr./Mrs./Ms./ Gender : M F T-Transgender PHOTOGRAPH Please affix the recent passport size photograph and sign across it. 2. Maiden Name (if any) : 3. Spouse Name : 4. Father s Name : 5. Mother s Maiden Name : 6. Marital Status : Married Unmarried Other 7. Date of Birth : D D M M Y Y Y Y Minor Senior Citizen 8. Country Jurisdiction of Residence* : 9. Country of Birth : Place of Birth : 10. Nationality : Indian Others (specify) Category : General OBC SC ST Others 11. Passport No. : Date of Issue : D D M M Y Y Y Y Date of Expiry : D D M M Y Y Y Y Place of Issue : 12. Valid Visa (Mandatory- NRI / Diplomat / Foreign National) : Type of Visa : Date of Issue : D D M M Y Y Y Y Date of Expiry : Place of Issue : 13. KYC Documents Details : PAN Card Election ID Driving License (Expiry Date D D M M Y Y Y Y ) NREGA Job Card Aadhar Card Diplomat ID No. 14. Form 60 / 61 : Yes No 15. Permanent Address : Address Type : Residential Business Registered Office Unspecified Landline No. (Office) : STD/ISD Country code No Mobile No. : Fax: Landline No. (Res.) : STD/ISD Country code No Email ID : (*Please refer to the enclosed annexure for state code & country code) D D M M Y Y Y Y Page 1
16. Correspondence / Mailing Address : Same as Permanent Address Address Type : Residential Business Registered Office Unspecified 18. Gross Annual Income : (Please select anyone of the appropriate slab INR / USD / AED) INR Upto INR 50,000/- INR 50,001/- to Rs. 100,000/- INR 100,001/- to Rs. 500,000/- INR 500,001/- to INR 1,000,000/- INR 1,000,001/- to INR 2,500,000/- INR 2,500,001/- to INR 5,000,000/- Above INR 5,000,000/- USD Upto USD 30,000 USD 30,001-50,000 USD 50,001-75,000 USD 75,001-120,000 Above USD 120,000 AED Upto AED 100,000 AED 100,001-165,000 AED 165,001-250,000 AED 250,001-395,000 Above AED 395,000 19. Occupation : (please tick) Landline No. (Office): STD/ISD Country code No Mobile No : Fax : Landline No. (Res) : STD/ISD Country code No E-mail ID : 17. Address where Applicant is Resident Outside India for tax purpose : Same as Permanent Address Same as correspondence address Address Type : Residential Business Registered Office Unspecified Landline No. (Office) : STD/ISD Country code No Mobile No. : Fax : Landline No. (Res.) : STD/ISD Country code No Email ID : Retired Bullion Housewife Student Service Politician Diplomat Money Service Business Real Estate Jewellery / Diamond / Gems Precious Stones Self-employed Business Professional Others (please specify) Salaried (Employed with Pvt. Ltd./Partnership/Proprietorship/Public Ltd./Public Sector/Govt./MNC/Staff ADCB) Other (Please specify) 20. Qualification : Under Graduate Graduate Post Graduate Others (Please specify) 21. Source of Fund : Salary Business Inheritance Investment Others (Please specify) (*Please refer to the enclosed annexure for state code & country code) Page 2
22. FATCA Details : 1. Are you a US Citizen (Green Card or US Passport Holder)? Yes No 2. Are you liable to pay taxes in the US? Yes No (If yes, to any of the above points 1) or 2), provide the latest W-8-BEN / W-9 form as applicable). U.S. Taxpayer Identification Number (SSN or ITIN) : In case you are declaring US person status as No but your Country of Birth is US, please provide document evidencing Relinquishment of Citizenship. If not available provide reasons for not having relinquishment certificate. 23. CRS Details : Are you liable to pay taxes outside India? Yes No If Yes : Please list all jurisdictions in which you are treated as tax resident and provide the tax identification number for each one. If you are tax resident in more than three countries, please use a separate sheet. Country of Tax Residency Taxpayer Identification Number (TIN) TIN Issue Country Reasons for not providing TIN (enter reason A, B, C or D) The TIN is the unique identifier assigned to you by the tax administration in the jurisdiction of your tax residence (usually where you are treated as a resident of the country for the purpose of income tax). Reason A - The country where you are tax resident does not issue TINs to its residents. Reason B - You are otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the table below if you have selected this reason). Reason C - No TIN is required. (Note. Only select this reason if the authorities of the country of tax residence entered above do not allow the TIN to be disclosed to third parties). Reason D - You have got no tax residence, therefore TIN is not applicable. In this case, please write "NONE" in the "Country of Tax Residency" Column. Please explain in the following boxes why you are unable to obtain a TIN if you selected "Reason B" above. 1 2 3 24. Additional Information : i) Have you any other Banking relationship with ADCB-UAE/India? Yes No If Yes CIF No.: ii) Have you any other relationship with associate / family member having any Banking relationship with ADCB-UAE/India? Yes No If Yes CIF No.: Branch iii) Expected Account activity (INR / USD / AED - P.M.) : Cash Domestic Non-Cash Wire Transfer Page 3
25. Please tick, if applicable: Politically Exposed Person Related to Politically Exposed Person Politically Exposed Persons(PEP): PEPs are individuals who are or have been entrusted with prominent public functions in a foreign country. Examples of PEPs include, but, not limited to: (i) Heads of States or of Governments (ii) Senior politicians (iii) Senior government/judicial (iv) Senior executives of state-owned corporations (v) important political party officials (vi) Senior Indian Diplomatic personnel posted outside the country. The term PEP also include the families and close associates of the PEPs mentioned. Families: The families includes close family members such as spouses, children, parents and siblings and may also include other blood relatives and relatives by marriage. Close associates: The term closely associated persons in the context of PEPs includes close business and personal advisors / consultants to the PEP as well as persons who obviously benefit significantly from being close to such a person. 26. Detail of Related Person : Addition of Related Person KYC Number of Related Person (if available ) Deletion of Related Person Related Person Type : Guardian of Minor Assignee Authorized Representative Name : 27. KYC Documents Details : PAN Card Election ID Driving License (Expiry Date D D M M Y Y Y Y ) NREGA Job Card Aadhar Card Diplomat ID No. 28. Related Person Address : Address Type Residential Business Registered Office Unspecified Landline No. (Office) : STD/ISD Country code No Mobile No. : Fax : Landline No. (Res.) : STD/ISD Country code No Email ID : (*Please refer to the enclosed annexure for state code & country code) DECLARATION I/we hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I/we am/are aware that I/we may be held liable for it. I/we confirm that the details submitted above are for updating the Bank's records and abide by Terms and Conditions as applicable from time to time. I/we agree and undertake to notify the Bank within 30 days if there is a change in any information which I/we have provided to the Bank. I/We hereby consent to sharing KYC details/receiving information to/from Central KYC Registry, through SMS/Email on the above registered number/email address. (i) Under penalty of perjury, I certify that: 1. I am an applicant taxable as a US person under the laws of the United States of America (US) or any state or political subdivision thereof or therein, including the District of Columbia or any other states of the U.S., (ii) an estate the income of which is subject to US federal income tax regardless of the source thereof. (This clause is applicable only if the account holder is identified as a US person) 2. I am an applicant taxable as a tax resident under the laws of country outside India. (This clause is applicable only if the account holder is a tax resident outside of India) (ii) I understand that the Bank is relying on the information provided herein for the purpose of determining the status of the applicant named above in compliance with FATCA / CRS. The Bank cannot offer any tax advice on CRS or FATCA or its impact on the applicant. I shall seek advice from any professional tax advisor for any tax related query. (iii) I agree that as may be required by domestic regulators / tax authorities, the Bank may also be required to report reportable details to CBDT or close or suspend my account (as may be necessary). Date Place : Signature / Thumb Impression of Applicant Page 4
State Code & Country Code Annexure Page 5
KYC Documents Checklist KYC Application Form FATCA Details: W8 BEN/ W9 (if applicable) 2 In case of Mailing/ Correspondence address of the close relative (Applicant/ Customer) e.g. wife, son, daughter and parents etc. are not avialable, then provide proof as per KYC Documents Checklist mentioned above in Section (B) & (C) of their close relatives living alongwith. 6 For related person please provided documents as per point B. Signature of Applicant / Customer Page 6