Fillable Update- Client Information Form - Individual 022021

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Update- Client Information Form - Individual 022021

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1
Thank you for your interest in joining the JMMB Group. Certain information will need to be provided. Please see the Client Requirements Checklist for requirements for each territory.
Kindly select territory where application is being completed
☐ Jamaica (JA) ☐ Trinidad & Tobago (TT) ☐ Dominican Republic (DR)
Universal Client Number
PERSONAL INFORMATION
Title (Mr. Ms. Mrs. Other)
First Name
Middle Name(s)
Last Name
Alias (If applicable)
Mother’s Maiden Name:
Gender: ☐ Male ☐ Female
Marital Status ☐Single ☐ Married ☐ Separated ☐ Common Law ☐ Divorced ☐ Widowed
Date of Birth (dd/mm/yyyy)
Country of Citizenship
Country where tax is paid
Are you a National of any other Country?
☐ No ☐ Yes
If Yes state:
Are you a citizen/permanent resident of any
other country? ☐ No ☐ Yes
If Yes state:
Is Tax paid in any other country? ☐ Yes ☐ No
If Yes state:
POLITICALLY EXPOSED PERSONS (PEP)
Are you or any of your immediate family members (spouse*, child, step & adopted child, parents, siblings, child’s spouse*) or their close business
associates, a current or former Head of State, Head of Government, member of any House of Parliament, Minister of Government, member of the
judiciary, military official above the rank of Captain, member of police above the rank of Assistant Commissioner, Permanent Secretary or Chief
Technical Director in charge of a Government department/ministry/executive agency/ statutory body, official of any political party &/or director
or CEO of any company owned by your country of residence or a foreign government?
☐ No ☐Yes If Yes in what capacity?
* including common-law
Are you acting as a trustee for another in relation to the business relationship or one-off transaction concerned? ☐ No ☐Yes
CONTACT INFORMATION
Residential/Permanent Address (Proof of address required – no older than 3 months)
Parish/City:
State:
Zip Code/Sector:
Country:
How long have you been living at this address? If less than 10 years please indicate previous address below.
☐ More than 10 years ☐ Less than 10 years
Previous address:
Parish/City:
State:
Zip Code/Sector:
Country:
Mailing address if different from residential address:
Parish/City:
State:
Zip Code/Sector:
Country:
Telephone Numbers: Home: Work: Mobile (1): Mobile (2):
Email address (1)
Email address (2)
Preferred Method of Contact: Call: ☐ Home ☐ Work ☐ Mobile ☐ Email ☐ WhatsApp ☐ SMS
EMPLOYMENT INFORMATION
Primary Employment Status ☐Full Time ☐Part Time ☐Retired ☐Self Employed ☐Student ☐Unemployed ☐Minor
Industry/Sector:
Occupation/Profession:
Start Date:
Employer’s Name
(Business name if self-employed):
Employer’s Address:
Parish/City:
State:
Zip Code/Sector:
Country:
CONTACT PERSON INFORMATION
Name
Address
Relationship
Contact Numbers
Email address
CLIENT INFORMATION FORM
INDIVIDUAL
FORM #CIF-022021
2
INCOME DETAILS & PROJECTED LEVEL OF ACTIVITY
Income Range (e.g. between $100,000 - $200,000 gross per
annum)
What is the maximum projected level of activity within a year? (E.g. between $100,000 - $200,000)
Expected transaction amounts and frequency (e.g. $10,000
per month, etc.)
Main source(s) of Funds/Income
(How will you fund your account?)
☐ Salary ☐ Investment ☐ Gift/Inheritance
☐ Pension ☐ Other:
Source(s) of Wealth
(How have you accumulated your wealth?)
☐ Salary ☐ Investment ☐ Gift/Inheritance
☐ Pension ☐ Other:
Principal Bankers
Branch/Address of Principal Bankers
REFERENCE INFORMATION
*Please note acceptable references stated in appendix
Name of Referee
Contact Number
Reference Capacity
Years known to Referee
Are you known to the referee
personally?
1-5 Years
> 5 Years
Yes No
1-5 Years
> 5 Years
Yes No
ELECTRONIC INDEMNITY
TO: JMMB GROUP LIMITED and its subsidiaries and affiliated companies
Authority and Indemnity re Electronic Mail and Verbal Instructions
The term “JMMB Group” when used in this document means, collectively, JMMB Group Limited and all of its subsidiaries and affiliated companies (as such terms are defined in the
Companies Act), whether such subsidiaries and affiliated companies are now in existence or are subsequently formed or become affiliated with JMMB Group Limited.
I (your client) hereby authorize JMMB Group to act on non-signature bearing instructions which it receives by any of the methods approved by me below (hereinafter referred to as “the
Instructions”). In consideration of JMMB Group, any of its officers or agents or otherwise accepting the Instructions, including regarding any of my accounts with you, whether such
accounts are individual or joint, or they currently exist or are subsequently opened or operated in my name, I agree:
1. that JMMB Group may accept and act on the Instructions sent by me from time to time and I voluntarily and with full knowledge take and assume any and all risks associated
with the Instructions;
2. that whenever the Instructions are received by JMMB Group and purportedly sent by the authorized signer(s) on an account (subject to specific signing instructions on the
account, e.g. “any one to sign” or “all to sign”), JMMB Group shall have no obligation to check or verify the authenticity or accuracy of the Instructions or the identity of the sender
or confirmer of the Instructions and may act on the Instructions as if they had been duly provided in writing under my signature or given by me in person at one of your offices;
3. to irrevocably authorize JMMB Group to execute the Instructions immediately upon first receipt by any of the methods approved by me below or from time to time (e.g. email),
and to debit my/our account(s) with all sums of money whatsoever, interest on money, costs, charges and expenses which JMMB Group may incur or charge as a result of its
complying with the Instructions. Where the Instructions are later duplicated or contradicted by instructions bearing signatures, JMMB Group may act on those signature-bearing
instructions as well as the previous Instructions sent in accordance with this authorization. If this should occur I acknowledge that JMMB Group shall not bear any loss or damage
resulting from acting on both sets of instructions and I hereby agree to indemnify JMMB Group against all losses, liabilities, claims or damages which may arise. JMMB Group in
line with good customer service may endeavor to assist me to rectify, however JMMB Group is not obligated to do so. Transactions involving a third party are at the sole discretion
of that party to assist in rectifying;
4. that in acting on the Instructions, JMMB Group will at all times be deemed to have acted properly in executing the Instructions and to have completely performed all obligations
owed to me, notwithstanding that the Instructions received by JMMB Group purportedly from me may have been initiated or communicated in error or fraudulently, or without or
in excess of any required authority and notwithstanding any error or misunderstanding or lack of clarity in the terms of such Instructions. I agree that JMMB Group may execute
any Instructions by reference to the account number only, even if the name on the account is also provided (including where there may be a discrepancy between the two). I
shall at all times be bound by the Instructions received by JMMB Group and purportedly sent by me from time to time on which JMMB Group may act;
5. that JMMB Group reserves the right, in its absolute discretion, not to act on the Instructions received in whole or in part. Without limiting that absolute power, JMMB Group may
refuse to act on the Instructions if JMMB Group believes that the Instructions were fraudulently provided. In its sole and absolute discretion, JMMB Group may put the Instructions
on hold pending further enquiry or further confirmation (whether written or otherwise) by me. JMMB Group shall in no event or circumstances be held liable in any respect for any
costs or losses suffered from declining to accept or act on the Instructions or putting the Instructions on hold;
6. that notwithstanding the above, JMMB Group is not obligated to carry out such further enquiry or seek or obtain further confirmation, and it may proceed to act in accordance
with the Instructions and shall in no event or circumstances be held liable in any respect for any costs or losses suffered from so proceeding;
7. JMMB Group may from time to time change its policies in relation this authorization without notice to me. These policy changes include the types of instructions to which this
authorization may or may not apply. Unless otherwise changed by JMMB Group, the policy is that this authorization will not apply to:
(i) changing signing instructions on accounts;
(ii) adding persons to existing accounts;
(iii) applications for cards (including debit and credit cards); and
(iv) applications for loans, hypothecations and guarantees;
8. to indemnify JMMB Group, its officers, agents and assigns and to keep each of them free and harmless from and against all actions, proceedings, liabilities, claims, damages,
diminution in value of property, costs, losses and expenses of any nature whatsoever and howsoever arising out of or in connection with JMMB Group acting on the Instructions
in whole or in part sent or having exercised (or failed to exercise) the discretion conferred upon JMMB Group in paragraph 5 above. I irrevocably agree to pay such amounts to
JMMB Group that arise pursuant to this paragraph on demand. This paragraph shall survive the termination or invalidity of this authorization or any portion of it;
9. to be jointly and individually liable under this authority and indemnity in respect of any and all joint accounts;
10. that JMMB Group is providing me with an additional contractual service via this authorization, and will hold and enforce its terms on me and any account holder(s) that are
currently on or that may be added to my account for which this service will apply. I agree that notice of the terms of this authorization to one joint account holder is deemed to be
notice to any/all other joint account holder(s), and all joint account holders will be bound by the terms herein. I undertake to inform all joint account holder(s) of the execution of
this authorization and its terms;
11. that I acknowledge that providing the Instructions is for my convenience and in my interest only and at my sole discretion and is not a feature of my account(s) with JMMB Group;
12. that this authorization will operate to terminate and supersede all previous authorities that I gave to JMMB Group to accept non-signature bearing instructions;
13. that this authorization may be terminated by me or by JMMB Group upon ten (10) days’ prior written notice to the other, provided, however, that this authorization may be
terminated by JMMB Group immediately without notice in the event JMMB Group deems the security of the procedures hereby established to have been materially compromised
or breached; and provided further that termination by JMMB Group or me shall not affect JMMB Group’s rights or release me from my obligations, including without limitation, to
indemnify JMMB Group with respect to any Instructions received by JMMB Group prior to termination;
3
14. JMMB Group may from time to time in writing vary, add to or replace the terms and conditions in this indemnity and unless I terminate this authorization, I will be deemed to
consent and agree to each such variation, addition and replacement which shall be binding on me;
15. that this authorization in all respects shall be construed in accordance with and governed by the laws of country where the member company of the JMMB Group is located.
Please indicate the method(s) for the transmission of Instructions to JMMB Group which are approved or not approved by you by checking the appropriate box. For each method of
transmission you must indicate either Yes or No.
Method of Transmission of Instruction Yes No
1) Electronic mail (by the means of transmitting information electronically between computers via the worldwide web hereinafter
referred to as “E-mail”) at the e-mail addresses indicated below:
Email Address: _______________________________________________
Email Address: _______________________________________________
2) Verbally (oral communication by telephone or other means) It being acknowledged and understood by me that verbal
instructions may only be provided to the Call Centre Unit or unless otherwise permitted by JMMB Group.
DECLARATION & CONSENT
Your financial information is used to help us manage operations, risk and to better serve you. Your information may also be used to satisfy valid
information requests from regulators and other organizations or individuals who are legally entitled to such information. In addition the information
provided may also be shared with other companies within the JMMB Group.
It is hereby agreed and accepted that JMMB Group reserves the right to collect, process and share as data for marketing and research efforts any
information that is provided herein. JMMB will ensure that the necessary technical and organizational measures are in place to safeguard against any
security breach before transferring any personal data.
I confirm that by signing this form, I declare and acknowledge that the information given by me is correct and can be relied upon by the JMMB Group;
also that I am authorizing the JMMB Group to take such steps as it may deem necessary to verify any of the information provided by me. I have read
this form before signing and am aware of the obligations contained herein.
Client’s Signature
Date dd/mm/yyyy ________________________
If documents were signed outside of JMMB’s Office, this section is to be completed by any of the following,
Justice of the Peace, Notary Public, Bank Manager or Attorney-at-Law.
I hereby certify that the signature(s) appearing on this form was/were affixed in my presence by the said person who
presented satisfactory identification.
Name
Signature
Date dd/mm/yyyy
FATCA CERTIFICATION
Please indicate your status by signing at A or B below
A. FATCA certification for Non-US Persons
Under penalties of perjury, 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
further certify under penalties of perjury that:
I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates
or am using this form to document myself as an individual that is an owner or account holder at a foreign financial institution,
The person named under the section entitled ‘Personal Information’ on this form is not a U.S. person,
The income to which this form relates is:
a) not effectively connected with the conduct of a trade or business in the United States,
b) effectively connected but is not subject to tax under an applicable income tax treaty, or
c) the partner’s share of a partnership's effectively connected income,
The person named under the section entitled ‘Personal Information’ on this form is a resident of the treaty country where they indicated tax is paid (if any) within
the meaning of the income tax treaty between the United States and that country, and
For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any
withholding agent that can disburse or make payments of the income of which I am the beneficial owner.
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4
I agree that I will advise the JMMB Group immediately if any certification made on this form is no longer valid.
Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date DD/MM/YYYY
B. FATCA Certification for US Persons
Under penalties of perjury, I certify that:
1. The Taxpayer Identification Number (TIN) provided is correct (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS)
that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to
backup withholding, and
3. I am a U.S. citizen, or other U.S. person (Including Green Card Holders or Persons with Substantial Us Presence e.g. Students)
Certification instructions - You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you
have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or
abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and
dividends, you are not required to sign the certification, but you must provide your correct TIN.
Signature of US Person Social Security Number (SSN) Date DD/MM/YYYY
FOR INTERNAL USE ONLY
Subsidiary/Branch/Department: _______________________________________________________________________________________
Documents Received from Client (kindly attach to this form)
Driver’s Licence Passport National ID + Birth/Adoption Certificate Marriage Certificate
Resident/ Citizenship Card Birth/Adoption Certificate Court Order Voluntary Declaration
Proof of Residential Address Tax ID (or foreign equivalent) Notarized Picture + Birth Certificate (Minors only) Decree Absolute
Certificate of Loss of Nationality of the United States Missing Certificate of Loss of Nationality of the United States Form
FOR BRANCH
USE ONLY
Receiving Agent:
Signature:
Date (dd/mm/yy):
Input Agent:
Signature:
Date (dd/mm/yy):
Relationship Officer:
Risk Status:
Low Medium High
Connected Party:
Yes No
FOR BRANCH/
COMPLIANCE
If High Risk Approved by:
Signature:
Date (dd/mm/yy):
Compliance Notes:
FOR
CENTRALISED
BUSINESS
SUPPORT
SERVICES
Input Officer:
Signature:
Date (dd/mm/yy):
Approving Officer:
Signature:
Date (dd/mm/yy):
Scanning Officer:
Signature:
Date (dd/mm/yy):
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Update- Client Information Form - Individual 022021

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Completed 18 November 2021

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