eee pensar sen tame Us} cae = | Customer CIF No. | | Please Note: The information requested is in compllance ofthe rules and regulations sot out by the Financial Intelligence Unit (FIU) of Contra! Bank of Sri Lanka and wil be trated with utmost confdentiaty | Cargills Bank Limited | Branch oa Dear Si! Madam, | the undersigned do hereby agree to comply with and be bound by all the prevailing Rules and Regulations relating tothe account to which | ‘am a party to, and further be bound by any variation, amendment and change made to the same as may be prescribed by the Bank from time tote in future. | agree that this agreement shall be governed and construed in accordance with the laws of Si Lanka. 1. Name in ful : Rew Mr Mrs. Miss. = Date of bith = 00107 3, Place of bith 4. "National Identity Card No.(PIDy" Date of issue Nationality? saturn Othe Dualit Nanette county ves Tee Couey snc Det ay I 5. Permanent address Tol(Fixed) (Mobile) Fax E-mail 6. Correspondence address (it dies from above): (7. Maiden name {8 Occupation / Position: 8. Name and address of employer (if applicable): Tek - 410. Source(s) of income 11. Expected annual income Expected Monthly Income: * LKR | tess nan 5,009 ‘000-1000 | waonanin | 22001 300,000 s0.0040,009 m0-100000 [| Above 000000 |] Netaptete Wealth generated from * [| polesonersnpoment [| Gunese Omang || itatance | | vestments | | Savge |_| Oe spect) |dentcaton of Poltically Exposed Person : Are you of any member of your family a Politically Exposed Person (PEP)"? Primary Applicant: [| ves [| wo In anyway relate to any ofthe persons refered to above: Yee | |no _Ifyes please stato the relationship |am a subject of the USA Taxes as por tho Foreign Account Tax Compliant Act (FATCA) and fal within the categories mention herein yes | |No 5 1) UsActtzens 2) USA.Citizens resident in another country 3) Individuals bon in the USA and resident in another country 4) Lawful residents ofthe USA, including a Green Card Holder '5) Persons residing in the USA, 6) US Corporations, estates and trusts 7) Nor-UISA Entities! persons with substantial interest 8) ‘Non-USA Enites with at east one USA person tony USA entity ‘asa substantial beneficial owner 9) Joint accounts where atleast one party falls within any of the above categories “PID. Personal Identification No. — NIC, Passport, Driving License OPS-Form-15-E-V5your response is "Yes", 1. Please submit the Foreign Account Tax Compliant Act (FATCA) compliance form! obtained trom the Bank, along with your account ‘opening application, 2, | authorize Cargils Bank to furnish my information tothe US Inland Revenue services. iF Enty: ‘Account Entry: CF Auth: ‘Account Auth: