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