UMB Stockbrokers | Know Your Client Individual Form

Account Information

Form Code

Aplication Type

Client first contact established through

Account Type

Mandate:

Category Of Investment

CSD No:

Client Information

Account Holder

Title:

Name:

Residential Address:

Postal Address:

Nationality:

Telephone (Mobile)

Telephone (Residential):

E-mail:

Marital Status:

Digital Address (GhanaPost GPS)

Residential Status:

Country of Origin:

Country of Residence:

If country of origin is not Ghana, please provide the following: Resident Permit Number:

Place of issue:

Permit Issue Date:

Permit Expiry Date:

TIN:

Proof of Identity

ID Type:

ID Number:

Issue Date:

Place of Issue:

Expiry Date:

Joint Account Holder

Title:

Name:

Residential Address:

Postal Address:

Nationality:

Telephone (Mobile)

Telephone (Residential):

E-mail:

Marital Status:

Digital Address (GhanaPost GPS)

Residential Status:

Country of Origin:

Country of Residence:

If country of origin is not Ghana, please provide the following: Resident Permit Number:

Place of issue:

Permit Issue Date:

Permit Expiry Date:

TIN:

Proof of Identity

ID Type:

ID Number:

Issue Date:

Place of Issue:

Expiry Date:

Employment/Business Details

Account Holder

Status:

Years of Current Employment:

Employer / Business / School Name:

Employer / Business /School Address:

Nearest Landmark:

Digital Address (GhanaPost GPS):

City / Town:

*Nature of Business:

Business/School/Office Contact Number 1:

Business/School/Office Contact Number 2:

Business/School/ Office Email

Joint Account Holder

Status:

Years of Current Employment:

Employer / Business / School Name:

Employer / Business /School Address:

Nearest Landmark:

Digital Address (GhanaPost GPS):

City / Town:

*Nature of Business:

Business/School/Office Contact Number 1:

Business/School/Office Contact Number 2:

Business/School/ Office Email

Bank Account Details

Bank Name:

Account Name:

Account Number:

Bank Branch:

Financial Information

Gross Annual Income(s)

Source of funds for this Investment:

Expected Account Activity

*Anticipated Investment Activity: Top-ups:

If Other, please specify:

Withdrawals:

If Other, please specify

Regular Top-up Amount (Expected):

Regular Withdrawal Amount (Expected):

Family Information

Spouse Name:

Spouse Telephone Number:

Spouse Email Address:

Contact Number:

Contact Details (In case if emergency)

Relationship to client:

Confirmation

Statement Services

Mode of Statement Delivery:

Mode Frequency:

Specify any other additional statement frequency:

In Trust For

Name:

Relationship with Account Applicant:

Marital Status:

Gender:

Date of Birth

Place of Birth:

Country of Origin:

Country of Residence:

ID Type: Passport:

ID Number:

Issue Date:

Place of Issue:

Expiry Date

Beneficiary

Account Holder

Name:

Percentage (%):

Relationship with Account Applicant:

Marital Status:

Gender:

Date of Birth:

Place of Birth:

Country of Origin:

Country of Residence:

Tel No.

ID Type:

ID Number:

Issue Date:

Expiry Date

Place of Issue:

Joint Account Holder

Name:

Percentage (%):

Relationship with Account Applicant:

Marital Status:

Gender:

Date of Birth:

Place of Birth:

Country of Origin:

Country of Residence:

Tel No.

ID Type:

ID Number:

Issue Date:

Expiry Date

Place of Issue:

Client Investment Profile

Investment Objective:

Risk Tolerance:

Investment Horizon:

Investment Knowledge:

Other Investment:

Portfolio Preference

Others Specify

Dividend

Payment Policy (Wealth Builder Clients only)

I wish to make regular payments of GH¢

Direct Debit Instruction

I/We authorize my/our Bankers:

Bank Branch:

to transfer an amount of GH¢

From my account number

on of every month

Quarterly Basis

Other (Please Specify)

Until/we instruct otherwise:

To

UMB Wealth Builder Account Number:

Bank:

Branch:

Declaration

I declare that the information provided is true and accurate. I authorize UMB Stockbrokers Ltd to use my personal information to evaluate my financial need(s) and comply with the Securities Industry Law, as amended. This information may be provided to other members of the Universal Merchant Bank Group.

Account Mandate

Name of Signatory:

Signature Specimen:

Name of Signatory:

Signature Specimen:

Instruction

Client Additional Information (1)

NB: THE FOLLOWING QUESTIONS ARE DESIGNED TO ENABLE THE INSTITUTION DETERMINE WHETHER THE CLIENT IS A POLITICALLY EXPOSED PERSON (PEP)
Do you, your spouse, or any other immediate family member, including parents, in-laws, siblings and dependants fall under the following:

A head of state/government, politician, senior public official, senior military offical, senior public corporation officer, high rank political party official in Ghana

If yes to any above, please specify name (if not the applicant) and nature of the position:

A head of state/government, politician, senior public official, senior military offical, senior public corporation officer, high rank political party official outside Ghana

If yes to any above, please specify name (if not the applicant) and nature of the position:

Client Additional Information (2)

NB: THE FOLLOWING QUESTIONS ARE DESIGNED TO CAPTURE INFORMATION FOR COMMON REPORTING STANDARDS AS WELL AS FATCA (Foreign Account Tax Compliance Act)

Are you a citizen of any foreign country (besides Ghana)?

Do you hold passport of any foreign country (besides Ghana)?

Do you hold green card of any foreign country (besides Ghana)?

Are you resident in any foreign country?

Have you spent more than 183 days in any foreign country?

If the responses to any of the above questions is Yes, please provide the following information:

Full Name:

Foreign Residential Address:

Foreign Mailing Address:

Foreign Telephone Number:

Foreign Tax Identification Number (TIN)/Social Security Number (SSN)/National Identity Number:

I/We

Hereby confirm the information provided above is true, accurate and complete

Signature 1

Date

UNDERTAKING TO BE SIGNED ONLY BY THOSE WHO RESPONDED ‘YES’ TO THE FIRST SET OF QUESTIONS ABOVE Subject to the applicable local laws, I hereby give consent to the Institution to share my information with foreign tax authorities where necessary to establish my tax liability. Where required by domestic or foreign tax authorities, give my consent and agree that the Institution may withhold from my investments such amounts as may be required according to the applicable laws of relevant jurisdictions.

signature 2

Date

*Client Additional Information (3)

For Depository Participant Use Only

Tick where applicable

Verified by CSD Officer: (verbose_name=_(""), Name of Depository Participant Officer)

Signature

Date

Signature

Stamp

Client CSD Securities Account Number