Loyal Bank Transfer Form

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Loyal Bank Transfer Form Powered By Docstoc
					Created by                                                    Declaration of Source of Funds (DSF)
                                                                    for incoming transaction




Please fully complete and sign this form and immediately fax it to Loyal Bank Ltd on
+ (1-784) 451-2757 or send a scanned copy by e-mail to loyalbank@loyalbank.com

               DETAILS OF YOUR ACCOUNT AT LOYAL BANK LTD.
NAME OF THE ACCOUNT AT LOYAL BANK
NUMBER OF THE ACCOUNT AT LOYAL BANK
ADDRESS OF ACCOUNT HOLDER
PHONE NUMBER
E-MAIL ADDRESS
OCCUPATION/BUSINESS
            DETAILS OF YOUR INCOMING PAYMENT or TRANSACTION
TYPE OF TRANSACTION (PLEASE TICK ONE)   Wire OR SWIFT transfer sent to Loyal
                                         Bank
                                        Cheque or Bank draft deposited with
                                         Loyal Bank

CURRENCY (Tick the box) USD □ EUR □ AMOUNT
GBP □ YEN □ CHF □
        LOYAL BANK ACCOUNT AUTHORISED PERSON’S PERSONAL DETAILS
 YOUR NAME (IF DIFFERENT FROM THE
ABOVE)
 YOUR PASSPORT/ID NUMBER


I / We declare that the source of funds for this transaction is:




I /We have attached supporting documentation (e.g. invoice copy, a bill or remittance advice) for this transaction.

I/We understand that under the requirements of the Proceeds of Crime and Money Laundering (Prevention) Act 2001
of St. Vincent and the Grenadines and the Anti- Money laundering Regulations of Loyal Bank as currently in force,
your policy requires Loyal Bank to be satisfied as to the source of funds before accepting any inbound wire transfer,
cheque or draft for credit to any account in Loyal Bank.


……………………………………………………………………………………
Account Holder’s Signature / Corporate Stamp
Date……………………

LOYAL BANK ONLY
Transaction accepted or declined

Reasons for decline ………………………………………………………………………………………………………………………..
Bank Officer’s signature…………………………………………………………………….. Date……………………………………

				
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posted:4/22/2011
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Description: Loyal Bank Transfer Form document sample