TRINIDAD CEMENT LIMITED
APPENDIX 3: SOURCE OF FUNDS DECLARATION
BROKER:
DATE
:
CUSTOMER INFORMATION
PERSON CONDUCTING THIS TRANSACTION IF DIFFERENT THAN ABOVE
ACCOUNT INFORMATION
Equity Settlement a/c #:
Currency:
Fixed Income Paper a/c #:
Currency:
DESCRIPTION OF TRANSACTION
Cash
Amount:
Currency:
Non-cash
Amount:
Currency:
DECLARATION
I declare that the source of funds for this transaction is:
By reason of the requirements of the Proceeds of Crime Act 2000, West Indies Stockbrokers’ Limited policy requires it to be satisfied as to the
source of funds before accepting funds for investments or transfer or for the purchase of any other currency or instrument. Consent is hereby
given to West Indies Stockbrokers Limited to disclose information provided herein to law enforcement authorities.
Customer’s Signature or person conducting transaction
NOTE: This section is to be signed if the depositor is acting on behalf of a Third Party in a fiduciary capacity
(e.g. Attorney-at-law, Notary Public, Trustee, Accountant etc.)
FOR COMPANY USE ONLY
Transaction taken by:
Authorizing Officer:
Name:
Name:
Transaction Accepted
Transaction declined
Customer refused to sign form
Remarks (continue on a separate sheet, if necessary)
Date: Reviewed by Compliance Officer
Print Name
Name (First Name, Middle Name, Surname) Date of Birth
National Identification No./DP No./Passport No.
Address
Country of Birth
Business/Residence Phone No.
Occupation/ Nature of Business
Local Resident
Other
Name ( First Name, Middle Name, Surname)
Date of Birth
National Identification No./DP No./Passport No.
Address
Country of Birth
Business/Residence Phone No.
I/We have made inquiry and to the best of my/our knowledge and belief the funds were not derived from or are being employed in any illegal
transaction by the person/company for whom/which I am acting.
Investor’s Name, Address and ID No. Investor’s Signature
