Large Transaction Declaration Form

LARGE TRANSACTION DECLARATION FORM

(Tobefilledfortransactionsequivalenttoorexceedingine.1millionorUSD10,000oritsequivalent.)

Transacting Branch Date / /

SECTIONA:PARTICULARSOFTHECUSTOMERACCOUNT
NameofAccount:.................................................................................AccNo:.................................................................................DomicileBranch.................................................................................

SECTIONB:PARTICULARSOFTRANSACTION
Pleasetickasappropriate:TypesofTransactions:
(Deposits) (Withdrawals)

Currency: INR USD Others-Pleasespecify AmountinFigures:

Amountinwords:

ProvidethereasonofchoosingcashratherthanRTGS .................................................................................

(a)Sourceoffunds:Pleasetickasappropriate b)Purposeoftransaction:Pleasetickasappropriate
Saleofproperty Paymenttosuppliersandworkers
Cashsales/businessproceeds Purchasingbusinessstock
Mobilemoneyfloat Constructionmaterial
Rentalincome Businessuse/pettycash
Saleofagriculturalproducts/livestock Propertypurchases
Others-pleasespecify: Others-pleasespecify:

SupportingdocumentationprovidedforCashDeposit/CashWithdrawaltransaction

Invoice ................................................................................. SaleAgreement................................................................................. Contractref................................................................................. Others

1fnot,indicatethereasons..................................................................................

DataProtectionPrivacyNotice
TheinformationthatyouinputhereshallberetainedbyusstrictlyforourownuseinlinewiththeDataProtectionActNo. 24 of 2019,
our Privacy Policy and the Privacy Notice and you consent to the application of the Data Protection Act No. 24 of 2019 and
the Bank’s Privacy Policy and the Privacy Notice to all information provided to the Bank. This Privacy Notice may be
updated from time to time and the most recent version can be found on our website or with our customer care
representative. If you would like any further informationcontact our Data Protection Offcer or kindly contact us at ABC
Bank House, Woodvale Grove, Westlands, P. O. Box 38610 – 00800, Nairobi addressed ‘for the attention of the DPO’.

SECTIONC(1):DECLARATION(3RDPARTY/AGENT)
Tobe completed if personisa3rd party/agent (not theaccountholderAttacha copyof ID)

Name.................................................................................ID/PPNo.................................................................................Nationality.................................................................................D.O.B.................................................................................
Occupation.................................................................................Relationshiptoaccount(e.g.agent/supplier)................................................................................. Signature.................................................................................

SECTIONC(2):DECLARATION(ACCOUNTSIGNATORY)

Tobe completed if personconductingthetransactionis anaccountsignatory)

I/wethe undersigneddeclarethattothebest ofmy knowledge and belief, theinformationcontained hereinis complete andaccurate. Ialsocertifythat the funds
in this transaction are not from proceeds of crime and will not be used for unlawful purposes.

Name.................................................................................ID/PPNo.................................................................................Signatory(1)................................................................................. Date.................................................................................

Name.................................................................................ID/PPNo.................................................................................Signatory(2) ................................................................................. Date.................................................................................

FOROFFICIALUSEONLY
Receivingofficer’sname .................................................................................Signature:.................................................................................Date.................................................................................

Approvingofficer’sname .................................................................................Signature:.................................................................................Date.................................................................................

ABCBO074-1222