Ongoing due diligence: Confirmation of Information
Date:
Unique Customer Number (For Office Use):
FirstRand Group Ltd (FSR) (FirstRand Bank Limited), is required to maintain and reconfirm customer
information and documentation as per the Financial Intelligence Centre Act, Act 38 of 2001 (“FICA”).
This document records your information; ensure that the information is correct before submitting it.
Your Personal information
Full Names:
Surname:
ID/Passport Number:
Country of ID/Passport Issue:
Country of birth:
Date of Birth:
Nationality:
Work Tel Number:
Mobile Number:
Email Address:
Home Tel Number:
Occupation:
Employer:
Residential Address
Unit / Street Number:
Street/complex name:
City:
Post/zip code:
Country:
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Source of Funds
Please select any one of the following as your main source of income/revenue: Up to five
options are allowed
Pension
Royalty income
Investment Income / Capital
Social Grants
Rewards Earn
Commissions earned
Maintenance
Informal Income
Sponsorship / Donations
Court order
Salary
Insurance Payouts
Student Grants
Asset Disposal
Allowance
Prize Winnings
Rental Income
Proceeds from Own Business
Gifts
Interest
Inheritance
Dividends
Related Party and Mandated Persons Information
This section records your relationship with “KYC related parties/mandated persons” and their
personal information. This section must be completed for each related party/mandated person.
1. Personal Details of Related Party or Mandated Person
Full Names:
Surname:
ID/Passport Number:
Country of ID/Passport Issue:
Country of Birth:
Date of Birth:
Mobile Number:
Work Tel Number:
Home Tel Number:
Email Address:
Nationality:
Mandate/permissions: Options available:
Residential Address
Unit / Street Number:
Street/complex name:
City:
Post/zip code:
Country of residence:
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2. Personal Details of Related Party or Mandated Person
Full Names:
Surname:
ID/Passport Number:
Country of ID/Passport Issue:
Country of Birth:
Date of Birth:
Mobile Number:
Work Tel Number
Home Tel Number:
Email Address:
Nationality:
Mandate/permissions: Options available:
Residential Address
Unit / Street Number:
Street/complex name:
City:
Post/zip code:
Country of residence:
3. Personal Details of Related Party or Mandated Person
Full Names:
Surname:
ID/Passport Number:
Country of ID/Passport Issue:
Country of Birth:
Date of Birth:
Mobile Number:
Work Tel Number
Home Tel Number:
Email Address:
Nationality:
Mandate/permissions: Executor
Residential Address
Unit / Street Number:
Street/complex name:
City:
Post/zip code:
Country of residence:
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Dear Mr M Mabizela
Please note that the account has been closed due to the failure to submit required FICA documents and
suspicion of fraud.
Account will be reinstated in 7 working days after submission of required forms has been received and
above details properly filled in.
Regards
Zayd Abrahams
Fraud & Risk Management
087 575 9444
Disclaimer: The information contained in this email is confidential and may contain proprietary information. It is meant solely for
the intended recipient. Access to this email by anyone else is unauthorised. If you are not the intended recipient, any disclosure,
copying, distribution or any action taken or omitted in reliance on this is prohibited and may be unlawful. No liability or
responsibility is accepted if information or data is, for whatever reason corrupted or does not reach its intended recipient. No
warranty is given that this email is free of viruses. The views expressed in this email are, unless otherwise stated, those of the
author and not those of First National Bank Limited or its management. First National Bank Limited reserves the right to monitor,
intercept and block emails addressed to its users or take any other action in accordance with its email use policy. Licensed divisions
of FirstRand Bank Limited are authorised financial service providers in terms of the Financial Advisory and Intermediary Services
Act 37 of 2002
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