Clico Credit Union

Source of Funds Declaration Form

Member Information

Depositor Information

If different from Member

Transaction Details

Declaration of Source of Funds

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)