® / ™ Trademark(s) of Royal Bank of Canada. Used under licence. 89438(07-2017)
RBC Life Insurance Company VPS 99108
Supplementary Application:
Source of Funds Declaration
This form must be completed whenever a payment for deposit is made where:
A. The form of payment is other than a cheque drawn on the Applicant/Owner’s account or Insured’s account
(for example: bank draft, money order, non-RBC wire transfer or third-party cheque if the amount exceeds $10,000);
B. A lump sum payment of $100,000 or more is made by an individual identied as a Politically Exposed Person (PEP),
including both foreign and domestic PEPs, Heads of International Organizations (HIOs) or their family member and
close associate pursuant to the Proceeds of Crime (Money Laundering) and Terrorist Financing Regulations.
Policy Number Amount of Payment Currency Type of Negotiable Instrument Date Purchased or Wired (dd/mm/yyyy)
Name of Financial Institution
Applicant/Owner Information
Name (rst or corporate name, middle initial, last name) Date of Birth (dd/mm/yyyy)
Street City Province Postal Code
Principal Business or Occupation
Yes No
(a) Is this payment being made on behalf of an individual or entity other than the Applicant/Owner or the Insured?
(b) Will payments be made to this policy by an individual or entity other than the Applicant/Owner or the Insured?
o o
o o
If yes to either (a) or (b), please provide details below.
Name of Third Party
Date of Birth (dd/mm/yyyy) Principal Business or Occupation
Address (must be a valid civic or street address)
Relationship to Applicant/Owner
Incorporation Number Date of Incorporation Place of Incorporation
Purpose of Payment
o Premium Payment o Additional Deposit o Loan Repayment o Prepayment of Future Premiums
o Other (specify)
Source of Where Funds Originated
o Personal Account o Corporate Account o Other (specify source)
Source of Wealth of the Individual/Entity Initiating the Payment (select all that apply)
o Inheritance o Investments o Employment Earnings o Other (specify source)
Complete only for lump-sum payments of $100,000 or more made by a PEP, HIO or their family member or close associate.
Annual Income
Primary Source of Income (please select one option below):
o Inheritance o Investments o Employment Earnings o Other (specify source)
Is Canada the primary country where wealth was derived? o Yes o No
If no, please list the country or countries where the wealth was derived
Dated at this day of
(place) (date) (month, year)
Signature of Applicant/Owner* Signature of 3rd Party (if applicable)
* If corporate Owner, include the title of the ofcer with the authority to bind the company, or corporate seal.
