1. Are you an American Citizen?
Account Name Account Number
2. Do you have dual citizenship? If YES Please indicate citizenships
a. b.
3. Are you a permanent resident of the U.S. / green card holder?
4. Were you born in the U.S.?
5. Do you have a residence address in the U.S.?
6. Do you have a phone number in the U.S.?
7. Do you have any instructions to transfer funds to an account in the U.S.?
8. Have you bee
n to the U.S. in the last 3 years?
A. Name
B. US Address
No. Street Subdivision/District/Town
City Country
C. US Telephone Number
D. US TIN or US SS Number
E. US P.O Box
H. An “in-care-of” address or “hold mail” US address
Notes/Remarks (if any):
I. Length of stay in the US
Certified true and correct
G. Current Power of Attorney or signatory authority granted to a person with US address
F. Standing instructions to pay amount/transfer funds to an account maintained in the United States
If any of the answers to questions stated above is YES, kindly specify required applicable information below:
For Bank's Use Only
Yes No
Foreign Account Tax Compliance Act (FATCA) Due Diligence Form
Signature over printed name by Account’s signatory/ies Date (mm-dd-yyyy)
Customer Information File Number Bank representative’s printed name over signature
Please provide complete details and indicate NOT APPLICABLE to items/sections as deemed appropriate
Current Year No. of days Last Year No. of days Prior to Last Year No. of days Total Length of Stay