International Wire Request Form

PAYMENT REQUEST & DESTINATION OF FUNDS DECLARATION

Please complete all sections below to process an International Wire Transfer Request from your Capital Security Bank (“CSB”) account Contact the banking team on transactions@capitalsecuritybank.com if you have any questions.

1 Account Holder Information CSB Account Number: CSB Account Name: Type of Payment: For a list of CSB’s payment types and the requirements for each please refer to ‘Funds Transfer – Minimum Document Requirements’ by clicking www.capitalsecuritybank.com/funds-transfers-minimum-documents-required 2 Beneficiary Bank Information Name of Bank: SWIFT code:

Sort Code:

ABA Number (Needed for all US Banks):

Address of Bank: Suburb: City: Province/State: Country:

Zip Code:

3 Intermediary Bank Information (If Applicable) Name of Bank: Account Number (if applicable): SWIFT code:

Sort Code:

ABA Number (Needed for all US Banks):

Address of Bank: Suburb: City: Province/State: Country:

Zip Code:

CAPITAL SECURITY BANK LIMITED 1

4 Beneficiary Account Information Name of Account Holder: Account Holder Nature of Business / Occupation: Final Beneficiary (if applicable): Final Beneficiary Nature of Business / Occupation (if applicable): Account Holder Address: Suburb: City: Province/State: Country:

Zip Code:

Account Number / IBAN (IBAN Needed for all GBP/EUR Payments): 5 Payment Information Payment Currency: Conversion Required:

Amount: Yes

No

Deduct Fees From (Tick one):

If yes, Currency to Debit: Remittance:

CSB Account:

Payment Reference for Beneficiary: Reason/Economic Purpose for Payment:

Expected annual volume of payment: 6 Payment Authorization

I/ We declare that the above information is true and correct in all respects and confirm that funds being declared have not been derived from any illegal activities.

Name: Position: Date Signed: Place Signed: Signature:

CAPITAL SECURITY BANK LIMITED 2