CUSTOMER INFORMATION SHEET (INDIVIDUAL)
RM NO.:
Last Name First Name Middle Name Suffix
Date of Birth (mm-dd-yyyy) Place of Birth (City, Country) Citizenship
Sex
Male Female
Marital Status
Single Married Others:_________
Mother’s Maiden Name ID Presented (ID type, number)
Mobile (+Country Code-Area Code-Tel.no.) Landline (+Country Code-Area Code-Tel.no.) Email Address
Address
(House/Lot/Block/Unit no., Floor & Building , Street, Subdivision/Barangay/Village)
District/Town City/Municipality/Province Country Zip Code
Employer / Business Name Nature of Work (Job Title)
employment
Source of Income/Wealth
FATCA DECLARATION
I am not a U.S. Person I am not a U.S. Person but with U.S. Indicators I am a U.S. Person
U.S. Place of Birth (1 & 2)
U.S. Telephone Number (1)
U.S. Address (1)
power of attorney or signatory authority
granted to a person with a U.S. address (1)
Standing instructions to transfer funds
to an account maintained in the U.S. (1)
“in-care-of” or “hold mail” U.S. address (1)
1. W8 BEN
2. Any of the following:
Certificate of Loss of US Nationality
Written explanation of not having such
certificate despite the renunciation
Written explanation on why US
citizenship not obtained at birth
U.S. Citizen
U.S. Resident (Green Card)
U.S. TIN: ___________
U.S. ID : ___________
W9 (Submitted)
I authoriz
e the Bank to rely upon the same and, if I am a US Person or have US indicators that render my account reportable under FATCA, I consent to
the reporting and disclosure of the required information by the Bank to the Internal Revenue Services (IRS) and/or Bureau of Internal Revenue (BIR) in
compliance with FATCA. In consideration of the foregoing, I agree to hold the Bank, its directors, officers, employees, representatives and agents free and
harmless from any liability, action and suits, costs, and expenses, arising from or in connection with the Bank’s compliance with FATCA regulations and/or
as a result of disclosure made to the US IRS and/or BIR.
CERTIFICATION AND AUTHORIZATION
By signing this form, I hereby certify that the information I provided herein is true, accurate and complete, and I agree to
notify/update the Bank of any change
in any of the information supplied in this form.
I acknowledge to have read and understood, and I agree to be bound by, the terms and conditions of the deposits, products, services, facilities and/or
channels which I open/avail of, as the same may be amended from time to time. Such terms and conditions are provided and/or are made available to me
via www.bpi.com.ph/terms and/or other channels.
I likewise acknowledge to have read and understood the Bank’s Data Privacy Statement, posted on www.bpi.com.ph and in branch premises, and I agree
that the Bank and/or its agents may, as described in said Data Privacy Statement, process, obtain, collect, record, organize, store, update, modify, use,
access, share and/or disclose to the Bank’s subsidiaries, affiliates, and third parties, information relating to me and/or my account(s) of whatever nature.
The consent given herein is deemed to be the consent required under bank deposit confidentiality laws of the Philippines or other jurisdictions including but
not limited to RA 1405 (An Act Prohibiting Disclosure of or Inquiry into, Deposits with any Banking Institution and Providing Penalty Therefor), RA 6426 (The
Foreign Currency Deposit Act) and RA 8791 (The General Banking Law) and under data privacy laws of the Philippines or other jurisdictions, including but
not limited to RA 10173 (The Data Privacy Act).
If I am, become, or apply to become a client of any of the Bank’s subsidiaries or affiliates, I agree that the latter has the option but not the obligation to rely
on the above information for any and all of the concerned subsidiary’s or affiliate’s account opening, maintenance and transaction requirements.
NOTE: Should you wish to change your elected mailing address for any of your accounts, please visit any of our branches to su
(mm-dd-yyyy)
Processed and signature verified by:
Bank of the Philippine Islands is regulated by the Bangko Sentral ng Pilipinas with email address consumeraffairs@bsp.gov.ph Form No. BPI-CIS IND-07032020
