KYC Corporate 2019

“Know Your Customer”
Customer Information Form

Business Entities
Company Name: Company Registration #
Company Registered Address:
Proof of address: Utility bill Bank/C. Card Statement Other
Date of Incorporation: DD/MM/YYYY VAT Registration#
Business Type: (Please indicate using a Tick)
Professional Service Provider Private Company

Internet Gambling or Casino Operations Listed Company
Jewelers – Including Pawn Shop Partnership
Real Estate Branch/Subsidiary of Foreign Company
Money Lending Other
Lottery Services
Are any of the Direct/Indirect owners of the Company involved in any of the business types listed above?
Yes No
Please provide the following documents (where applicable) Submitted

1) Certificate of Incorporation (Required)
2) Articles of Incorporation or Continuance
3) Articles & Memorandum of Association
4) Annual Return (Required)
5) Recent utility bill as evidence of permanent address of the company (required)
6) One copy of government identification for all beneficial shareholders (>10%) (required)
7) Annual Report (Only applicable for customers that maintain accounts such as Leasing)
8) Audited Accounts/Management Accounts (required for cash purchases/vehicle not financed)
9) By Laws (Only applicable where customer is a Trust or Association)
10) Power of Attorney or other Authorities (Only applicable where third party is acting on behalf of customer)
11) Reference from Foreign Customer’s bank where applicable
12) Copy of the last three transactions where the amount in total exceed TT$90k
List of Key Shareholders with >10% Holdings

List of Directors, Key Management Personnel of the Company
Annual Turnover Annual Profit
Less than 100k per annum Less than 50k per annum
More than 100k per annum More than 50k per annum
Are any Directors of the Company:
a) A Legislative, Administrative or judicial branch of a foreign or local government? Yes No

Details (If Yes)
b) A Senior official of a major political party? Yes No

Details (If Yes)
c) A Senior Executive of a Foreign or Local Government-Owned Commercial Enterprise? Yes No

Details (If Yes)
d) Are you a senior foreign or local military official? Yes No

Details (If Yes)
e) An immediate family member of a person mentioned in paragraphs (a) to (d) meaning the spouse, parents, siblings
or children of that person and the parents, siblings and additional children of the person’s spouse; and Yes No
Details (If Yes)
f) Publicly known or actually known to the relevant financial institution to be a close personal or professional
associate of the person mentioned in paragraphs (a) to (d) Yes No
Details (If Yes)
Transaction Information
Nature and Value of Transaction:
Value of Last 3 Transactions with Company (if any)
How is the Transaction being funded?
Purpose of Transaction: Other Business
Payment Currency: TTD USD Other
Method of Payment: Cash Linx Visa MasterCard

Other
Declaration:
By reason of the requirements of the Proceeds of Crime Act 2009 (as amended by the Proceeds of Crime (Amendment) Act
2009), Anti-Terrorism Act 2010 (as amended by the Anti-Terrorism (amendment) Act 2010 and the Anti-Terrorism
(amendment) Act 2011), Financial Obligations Regulations 2010, Financial Obligations (Financing of Terrorism)
Regulations 2011, The Financial Intelligence Unit of Trinidad and Tobago Act 2009 (as amended by the Financial
Intelligence Unit of Trinidad and Tobago (Amendment Act 2011), The Financial Intelligence Unit of Trinidad and Tobago
Regulations 2011 (as amended by the Financial Intelligence Unit of Trinidad and Tobago (Amendment) Regulations,
2014), Miscellaneous Provisions (Financial Intelligence Unit of Trinidad and Tobago) Act 2012 and Miscellaneous
Provisions (Proceeds of Crime, Anti-Terrorism and Financial Intelligence Unit of Trinidad and Tobago) Act No. 15 of
2014 (collectively referred to as the “AML Legislation”), Lifestyle Motors Limited (LSM) compliance programme
requires that it be satisfied as to the identity of customer and the source of funds before accepting deposits or
funds for purchase of new vehicles, used vehicles and/or leasing. Consent is hereby given to LSM to disclose this
application or any information contained therein or any other related confidential information of my/our
current, future and other transactions to law enforcement agencies, regulatory authorities, regulated persons
or as otherwise which in the opinion of LSM is required to be disclosed by Law.
I/We hereby declare and confirm that the information given by me/us
in this application is true and correct and I/We further declare that I/We am/are not engaged in money
laundering, terrorist financing, fraud or other illegal activities.
I/We release and forever discharge all such persons and entities from all liabilities connected with such
disclaimer whosoever and howsoever arising.
Customer Signature/Person conducting transaction
Date [dd/mm/yyyy]:
Note: This section is to be signed if the customer is acting on behalf of a third party in a fiduciary capacity. (E.g. Attorney at law, Notary Public,
Trustee, Accountant, etc.)
I/We have made inquiry to the best of my/our knowledge and believe the funds were not derived from or are
being employed in any illegal transaction by the Person/Company for whom/which I am acting.
Authorised Signatory
Date [dd/mm/yyyy]:
FOR OFFICIAL USE ONLY
Verified against the Financial Action Task Force list of high risk and Non-Cooperative Countries and
Territories, the ISIL and Al Qaida Sanctions list, UN 1718 on the Democratic People’s Republic of Korea
Sanctioned list, UN2231 on the Islamic Republic of Iran and Trinidad and Tobago list of Court Orders
Risk Rating: Low Medium High
Transaction accepted Transaction declined – Customer’s explanation refused

Customer refused to sign form or unreasonable
Transaction completed by _ Authorising Officer
Name: Name:
Reviewed by:
Date[dd/mm/yyyy]:

KYC Corporate 2019

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“Know Your Customer”

Customer Information Form

Company Name: Company Registration #

Company Registered Address:

Proof of address: Utility bill Bank/C. Card Statement Other

Date of Incorporation: DD/MM/YYYY VAT Registration#

Business Type: (Please indicate using a Tick)

Professional Service Provider Private Company

Please provide the following documents (where applicable) Submitted

List of Key Shareholders with >10% Holdings

Annual Turnover Annual Profit

Are any Directors of the Company:

a) A Legislative, Administrative or judicial branch of a foreign or local government? Yes No

b) A Senior official of a major political party? Yes No

c) A Senior Executive of a Foreign or Local Government-Owned Commercial Enterprise? Yes No

d) Are you a senior foreign or local military official? Yes No

Nature and Value of Transaction:

Value of Last 3 Transactions with Company (if any)

How is the Transaction being funded?

Purpose of Transaction: Other Business

Payment Currency: TTD USD Other

Method of Payment: Cash Linx Visa MasterCard

Customer Signature/Person conducting transaction

FOR OFFICIAL USE ONLY

Risk Rating: Low Medium High

Transaction accepted Transaction declined – Customer’s explanation refused

Transaction completed by _ Authorising Officer

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