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DDD 12

The document is a Declaration of Source of Funds Form required by the Bank of Saint Lucia Limited under the Money Laundering (Prevention) Act 2010. It collects personal and business information from the account holder and requires a declaration of the source of funds being deposited. Financial institutions must verify this information and report any false declarations as an offense.

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Okey Ugwu
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7 views1 page

DDD 12

The document is a Declaration of Source of Funds Form required by the Bank of Saint Lucia Limited under the Money Laundering (Prevention) Act 2010. It collects personal and business information from the account holder and requires a declaration of the source of funds being deposited. Financial institutions must verify this information and report any false declarations as an offense.

Uploaded by

Okey Ugwu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Bank of Saint Lucia Limited Date of Transaction: (dd/mm/yy)

Financial Centre Building


1 Bridge Street
Account Number:
P.O. Box 1860

DECLARATION OF SOURCE OF FUNDS FORM


Section 21 of the Money Laundering (Prevention) Act 2010
Information on Business or Depositor (if different to account holder)

NAME

Current Address:
Resident e Status : Resident Non-resident

Date of Birth Place of Birth Nationality Occupation

Telephone Numbers Home: Work: Mobile:

Information on account holder


Name:

Date of Birth Place of Birth Nationality Occupation

Telephone Numbers Home: Work: Mobile:

Resident Status: Resident Non-Resident

Identification: (Valid Picture ID required)


National ID [ Passport [ Driver’s Licence [ Other [ Identification details:
Description / Nature of Business Transaction:

Deposit Wire Transfer Loa Currency exchange [ Monetary Instrument Other [ (specify)
[

Amount and Currency


FINANCIAL INSTITUTIONS ARE REQUIRED BY LAW TO VERIFY THE SOURCE OF FUNDS BEING DEPOSITED BEFORE ACCEPTING
DEPOSITS AND TO DISCLOSE SUCH INFORMATION TO LAW ENFORCEMENT AUTHORITIESIF REQUIRED. THE MAKING OF A FALSE
DECLARATION AS TO THE SOURCE OF FUNDS CONSTITUTES AN OFFENCE UNDER SECTION 21 (2) OF THE MONEY LAUNDERING
(PREVENTION) ACT 2010. I DECLARE THAT THE SOURCE OF FUNDS IS: (Show supporting evidence, eg. Receipt, invoice, title deeds etc)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Transaction Approved: Yes No (If no state reason)


[ [

Depositor’s Signature: Transaction taken by: (signature and title) Witness

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