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DECLARATION OF SOURCE OF FUNDS FORM

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Section 20 of the money laundering and financing of terrorism (prevention and control) act 2011-23

Declaration of Source of Funds Form

Account Holder Information
Name
MM slash DD slash YYYY
Contact Information
Depositor Information (if different to Account Holder)
Name
MM slash DD slash YYYY
Contact Information
Identification (Valid Photo ID required)
Identification
MM slash DD slash YYYY
MM slash DD slash YYYY
Further reinforced by the aml/cft guidelines issued by the central bank of barbados in conjunction with the anti-money laundering authority October 2013 section 8.1 (I)
Description / Nature of Business Transaction
Description / Nature of Business Transaction
Capita financial services inc. Is required by law to verify the source of the funds before accepting deposits to any account and to disclose such information to law enforcement authorities where required. Failing to complete this form may result in the transaction not being accepted.
Give details and attach supporting evidence, e.g. receipt, invoice, bank receipt, etc.
Clear Signature
MM slash DD slash YYYY
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