Additional Forms for PEPs

PEP Status

Member Account Number

Member's Name

Member's Address

Address Line 1

Address Line 2

City

Country

Has the applicant or the registered owners, directors or signing officers, or one of their family members or close associates, ever held a senior position in a government, political party, military, tribunal, government-owned corporation, or been the head of an international organization, a leader or president of an organization funded by multiple nations or states?

Yes

No

Name of person who is/was politically exposed

Country where position is/was held

What category of position is/was held by the person who is/was politically exposed domestically or in a foreign country?

Head of State

Head of Government

Senior Politicians

Senior Government Official

Senior Judicial Official

Senior Military Officials

Senior Executive of State-Owned Corporations

Important Political Party Official

Persons who are or have been entrusted with prominent functions by an international organisation which refers to members of senior management

What is the relationship of the person named above?

Self

Family Member

Close Associate

A family member is considered to be:
(a) Their spouse or common-law partner; (b) Their child; (c) Their mother or father;
(d) The mother or father of their spouse or common-law partner e.a child of their mother or father (sibling)

A close associate is considered to be:
(a) Business partners with, or who beneficially owns or controls a business with, a PEP
(b) In a romantic relationship with a PEP, such as a boyfriend, girlfriend or mistress
(c) Involved in financial transactions with a PEP;(d) A prominent member of the same political party or union as a PEP (e) Serving as a member of the same board as a PEP; or (f) Closely carrying out charitable works with a PEP

Financial Information

Total/Overall Personal Asset Value (TT$)

0 - 250,000.00

250,001 - 1,000,000

1,000,001 - 2,000,000

2,000,001 and up

Company Signing Authority Level (TT$)

Less than or qual to 500,000.00

500,001 - 1,000,000

1,000,001 - 5,000,000

5,000,001 and up

Any other income source (specify)

Average Annual Earnings (TT$)

Earning Frequency

Weekly

Fortnightly

Monthly

Other

Other Professional Information - Board/Committee Memberships

Name of Body

Duration

Position Held

Status

Active

Resigned

Name of Body

Duration

Position Held

Status

Active

Resigned

Source of Funds

The source of funds that have been, will be, or are expected to be deposited into this account is as follows

	Check all that apply
Pension/Gratuity/Severance
Personal Savings
Salary/Wages
Sale of Vehicle
Proceeds from Investment
Employment Bonus
Sale of Property/Real Estate
Sale of Shares/Dividend
Insurance Setllement
Proceeds from Self-owned Business
Gift/Inheritance
Other (state below)

Details of other income sources

Dependents

Spouse Information

Full Name

Maiden Name (if applicable)

Gender

Yes

No

Date of Birth

Country of Birth

Residential Status

Resident

Non-resident

Nationality

Children Information

Child 1

Name

Nationality

Date of Birth

Country of Birth

Child 2

Name

Nationality

Date of Birth

Country of Birth

Child 3

Name

Nationality

Date of Birth

Country of Birth

PEP Status

Financial Information

Other Professional Information - Board/Committee Memberships

Source of Funds

Dependents

Spouse Information

Children Information

Child 1

Child 2

Child 3

Membership

Address

Telephone

Fax

Email

Tools & Support

Membership

Additional Forms for PEPs

PEP Status

Financial Information

Other Professional Information - Board/Committee Memberships

Source of Funds

Dependents

Spouse Information

Children Information

Child 1

Child 2

Child 3

Membership

Address

Telephone

Fax

Email

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