CUSTOMER INFORMATION SHEET
INDIVIDUAL/SOLE PROPRIETORSHIP
Malayan Savings Bank CIS Number
PERSONAL INFORMATION
*Name (Last Name, First Name, Middle Name,Suffix[if any])
Last Name First NameMiddle NameSuffix
*Present Address(House/Unit No., Floor &
Bldg./Street,L *PhilSys No.(If any)
District/Town
City/Province *TIN(If any)
Country Permanent Address is same as Present Address *SSS/GSIS No.(If any)
YesNo
·Permanent Address(House/Unit No., Floor & Bldg./Stree
District/Town City /Province Country
*Mailing Address
PresentBusiness
*Home Ownership *Resident Since(mm-dd-yyyy)
OwnedRented P/MonthLiving with Relatives
PermanentOthers: Used FreeMortgaged P/MonthOthers:
*Gender *Date of Birth(mm-dd-yyyy) *Birthplace *Nationality *Citizenship
MaleFemale
Mother's Maiden Name (Last Name,First Name, Middle Name) Father's Name (Last Name, First Name,Middle Name)
*Residence Phone (Country Code-Area Code-Phone No.) *Mobile Phone (Country Code -Area Code-Phone *Business Phone(Country Code-Area Code-Phone
No.) No.)
*Source of Fund (Check all that apply)
SalaryBusinessRegular RemittancesDonation/Contributins & the likeInterest on Savings/Placements/Investment
AllowanceCommissionPensionCampaign FundsOthers,Please specify
*Employment Status
Employed-PrivateOverseas Filipino Worker (OFW)Unemployed-RetireeUnemployed-HousehusbandOthers,please specify
Employed-GovernmentSelf-EmployedUnemployed-StudentUnemployed-Housewife
*Name of Employer/Business *Nature of Work/Business *Date Hired/Star of Business (mm-dd-yyyy) *Email Address
*Employment/Business Address(House/Unit No., Floor & Bldg./Street, Lot/Blk, Brgy/Village)
District/Town City/Province
Country
*Gross Monthly Income
50,000.00 and Below100,001.00 to 500,000.00O1,000,001.00 to 5,000,000.0010,000,001.00 to 20,000,000.00
50,001.00 to 100,000.00500,001.00 to 1,000,000.005,000,001.00 to 10,000,000.00Others,please specify
*Range Amount of Expected Transactions
50,000.00 and Below100,001.00 to 500,000.001,000,001.00 to 5,000,000.0010,000,001.00 to 20,000,000.00
50,001.00 to 100,000.00500,001.00 to 1,000,000.005,000,001.00 to 10,000,000.00Others,please specify
*Frequency of Transaction/s
1-5 times per Month6-10 times per Month11-15 times per Month16-20 times per MonthOthers. please specify
OTHER PERSONAL INFORMATION
Philippine ResidentMarriedSeparatedDivorced/AnnulledWidowed
Marital Status
YesNo If no,country of residenceUnmarried
E Others,please specify
T DoctorateCollege DegreeSenior High School GraduateHigh School Graduate
T
C Matr' DreeAssociate/Vocational GraduateElementary GraduateNo Formal Schooling
* f
Investm
ent
SavinasCheckingTime DepositPersonal LoanAuto LoanHousing Loan
Credit Card (No of Cards
SavingsCheckingTime DepositHousing LoanAuto LoanInvestmentNone
OwnedRented P/MonthUsed
FreeMortgaged P/Month
Are you an Officer,Director, Stockholder of a Company /Corporation?
No.of Cars OwnedNoYes
If yes,please indicate name of company/ies
SPOUSE'S INFORMATION(If Applicable)
Suffix
Last Name First NameMiddle Name
*TIN(if any) *SSS/GSIS No.(If any) *PhilSys No.(If any)
*Employment Status
Employed-PrivateOverseas
Employed-GovernmentSelf-Em Unemployed-RetireeUnemployed-HousehusbandOthers,please specify
Unemployed-StudentUnemployed-Housewife
*Name of Employer / Business *Nature of Work/Business *Date Hired /Start of Business (mm-dd-yyyy) *Email Address
*Gross Monthly Income1,000,001.00 to 5,000,000.0010,000,001.00 to 20,000,000.00
50,000.00 and Below100,001.00 to 500,000.00
000100 to 100,000.00500,001.00 to 1,000,000.005,000,001.00 to 10,000,000.00Others,please specify
1Gender
Children's Name (Last Name,First Name,Middle Name)Birth Date (MM/DD/YYYY)
BENEFICIAL OWNER INFORMATION
NoIf YES,please fill up all the information below
Is there any Beneficial Owner?Yes
*Last Name, First Name, Middle Name *Last Name,First Name,Middle Name
*Present Address House/Unit No., Floor & Bldg./Street, Lot/Blk,Brgy/Village *Present Address House/Unit No.,Floor&Bldg./Street,Lot/Blk,Brgy/Village
*Date of Birth*Birthplace *Date of Birth *Birthplace
*Nationality*Nature of Work
*Nationality Nature of Work
*Source of Fund(s) *Source of Fund(s)
*USE ANOTHER SHEET IF BENEFICIAL OWNERS ARE MORE THAN TWO (2)
*RELATIONS WITH MALAYAN SAVINGS BANK AND ITS EMPLOYEES (Including Malayan Savings Bank Subsidiaries)Director/Stockholder/Officer is a
relativeDirector/Stockholder/Officer is an acquaintanceApplicant is a Director/Stockholder/OfficerNot Applicable
Name and Unit of Director/Stockholder/OfficerRelationship
Foreign Account Tax Compliance Act (FATCA)
Note:The Information in this section is being collected as a part of Malayan Savings Bank's new
account on-boarding procedures to fully comply with the requirements of Foreign Account Tax
Compliance Act (FATCA)--------------------
1 Are you a citizen or resident of the United States?YesNo
2 If yes,provide the following information
aUS TINbUS Address
3 Please list all countries for which you hold citizenship
-------------
Please confirm your FATCA status by checking the relevant column and indicate the date IRS form is signed.
Date
Form of IRS Y
E N If YES,please provide the followig documents
(MM-DD-
YYYY) S O
1 US Citizen
1 IRS Form W-9:AND1 IRS Form W-9: AND
2 US Resident-Green Card 2 US identification document2 US or non-US identification document
(e.g.passport,etc.)(e.g.passport, driver's license etc.)
3 US Resident-Residing in the US for 183 days or
more
*If any of
please doyour answer 4,5,6,7,8.
not answer to number 1 to 3 is YES, *If any oftoyour
answer numb
4 US Place of Birth
Any of the folloing:
A.1 IRS Form W-8BEN:AND
2 Copy of Individual's Certificate of Loss of Nationality of the US; AND
3 Non-US identification document (e.g.passport, driver's
license, etc.)ORB. 1 Non-US identification document (e.g.
passport, driver's license, etc.) AND
2 Written explanation of your renunciation of US citizenship or the
reason you did
not obtain US citizenship at birth.
5 US Resident/Mailing Address
(Residence,Correspondence or
P.O.Box) 1 IRS Form W-8BEN:AND
2 Non-US Identification document (e.g.tax certificate or ID issued by the
government or anidentification document based on KYC as approved by the IRS in
6 US Telephone Number the QI system)
7 Standing instruction to transfer funds to an
account
maintained in the US
8 Power of Attorney or signatory authority Any of the following
granted to personwith US Address;or "in 1 IRS Form W-8BEN:OR
case of" or "hold mail" address 2 Non-US Identification document(e.g.tax certificate or ID issued by the
government or anidentification document based on KYC as approved by the IRS in
the QI system)
*IRS Form W-9-Request for Taxpayer Identification and Certification form W-9 is used by US person*IRS Form W-8BEN-
Certificate of Foreign Status and Beneficial Owner of US Tax Withholding,Form W-8BEN is used by non-US person
---------------------------
For Non-Resident Only
Have you stayed in the Philippines for an aggregate period of more than 180 days in any calendar year?OYesNo
Do you plan/intend to stay in the Philippines for an agrregate period of more than 180 days?YesNo
Are you opening the account for the benefit or on behalf of another person?OYesNo
If yes,please provide name and relationship
What is the reason for maintaining the account in your name?
Declaration and Authorization
I certify that all information provided herein are true,accurate and complete, and I agree to promptly inform the Bank of any changes thereto.I authorize the Bank to rely upon my
declaration herein and,if l ama US Poroon or have US indicatore that render my account reportable undor FATCA,I consent to the reporting and disclosure of the required information
by the Bank to the Internal Revenue Services(IRS)and/or Bureau of Internal Revenue(BIR)in compliance with FATCA.In consideration of the foregoing,I agree to hold the Bank,its
directors, officers, employees,representatives and agents free and harmlessfrom any liability,action and suits,costs,and expenses, arising from or in connection with the Bank's
compliance with FATCA regulations and/or as a result of disclosure made to the US IRS and/or BIR.Theconsent given herein is deemed to be the consent required under the bank deposit
confidentiality laws in the Philippines or in other jurisdictions including but not limited to RA 1405 (The Law on Secrecy of BankDeposits),RA 6426(The Foreign Currency Deposit Act)
and RA 8791 (The General Banking Law) and the consent required under the data privacy laws of the Philippines or of other jurisdictions, including,butnot limited to, RA 10173 (The
Data Privacy Act).
AGREEMENT/CERTIFICATION
I certify that all the information/s I have provided above are true and correct and consent to Malayan Savings Bank relying upon and updating any and all of my records with Malayan
Savings Bank usingsaid information/s.I likewise accept, consent to and agree to abide by the General Terms and Conditions Governing Malayan Savings Bank Accounts,a copy of which was
provided to me and/orwhich is available to me via www.malayanbank.com,together with any/all amendments made thereto from time to time.
Malayan Savings Bank Incorporated values all information under the Data Privacy Act of 2012 and pertinent laws of the Philippines.Our Data Privacy Policy explains how we
collect,record,use,share,store and dispose information when you avail any of our products and services and when you utilize our facilities such as website and email.To view our full
Data Privacy Policy, please visit our website atwww.malayanbank.com or visit any Malayan Savings Bank Branch near you.
Customer's signature over printed nameDate
1 Are you a citizen or resident of the United States?
a US Poroon or have USofindicatore that render
agreemy account
the reportable undor FATCA,I
officers,consent to the reporting and and
disclosure
agentsof theand
required information
from anybyliability,action
the Bank to theandInternal Revenueexpenses,
Services(IRS) and/or
fromBureau of Internalwith
Revenue(BIR)in compliance with
FATCA.In consideration the foregoing,I to hold Bank,its directors, employees,representatives free harmless suits,costs,and arising or in connection the Bank's compliance with
FATCA regulations and/or as a result of disclosure made to the US IRS and/or BIR.The consent given herein is deemed to be the consent required under the bank deposit confidentiality laws in the Philippines or in other jurisdictions including but not limited to RA
1405 (The Law on Secrecy of Bank Deposits),RA 6426(The Foreign Currency Deposit Act) and RA 8791 (The General Banking Law) and the consent required under the data privacy laws of the Philippines or of other jurisdictions, including,but not limited to, RA
10173 (The Data Privacy Act).
Update Source:
Branch H.O.Unit
Branch/Unit:
Customer Risk Rating:
Low High Negative List Screening Yes No
Conducted?
Related Party Transaction(RPT)
Yes No
Encoded by:
d by: Verifie
mployee name (Last, First, MI) & Signature E
Employee' name (Last,First, MI) & Signature
Date:
MM
ate: D
DD M MD D YYYY
YYYY
