CORPORATE ACCOUNT APPLICATION FORM
SECTION 1 - GENERAL INFORMATION
Name of entity/organisation:
Type of entity/organisation:
Company
General partnership
Limited partnership
Limited liability partnership
Non-profit corporation / organisation
Other (please describe below:)
Correspondence address:
Registered office address:
Telephone number:
Fax number:
Date of incorporation / formation:
Company registration number (if applicable):
Country of incorporation / formation:
If entity was incorporated in the US or formed under the laws of the US, this information must be supported by a completed IRS form
W-9 (accessible from www.IRS.gov).
Country of business:
Tax identification number:
Country of issue:
If the entity/organisation is a resident for tax purposes in any country other than the one listed above, please list each country below
and the corresponding tax identification number held:
Country:
Country:
Country:
Tax identification number:
Tax identification number:
Tax identification number:
Global intermediary identification number:
(if registered with the IRS for FATCA reporting purposes)
Is the entity organisation sponsored for FATCA reporting purposes?
If “Yes”, name of sponsoring entity:
CORP 009-14 Ver 11-14
Global intermediary identification number of sponsoring entity:
Information Classification: Confidential
The Bank of N.T. Butterfield & Son Limited
Yes
No
CORPORATE ACCOUNT APPLICATION FORM
SECTION 2 – BENEFICIAL OWNERSHIP INFORMATION
(i) Is the entity/organisation’s stock publicly traded or is it an affiliate of a publicly traded company?
Yes
No
If Yes, what is the name of the publicly traded company and on what stock exchange(s) are securities traded:
(ii) Are there any intermediary entities involved in the ownership structure of the entity/organisation? Yes
No
If “Yes” please provide details of these entities below (attach additional sheets if necessary):
Name of entity/organisation
Country of incorporation/formation
Is the share capital of any of the entities issued in the form of bearer shares?
Yes
Ownership %
No
(iii) List every person that is an ultimate beneficial owner(s) of organisation/entity with an equity interest in excess of 10%
(Please note that each of these individuals must also complete a Declaration of Tax Status Form in support of this request)
Country of citizenship
Country of residence
Date of birth
(dd/mm/yy)
Shareholding (%)
CORP 009-14 Ver 11-14
Full name
Information Classification: Confidential
The Bank of N.T. Butterfield & Son Limited
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CORPORATE ACCOUNT APPLICATION FORM
SECTION 3 – BUSINESS ACTIVITY
Please describe the principal activities/business lines of the entity/organisation:
(i) Is the entity/organisation considered to be an “Exempt Beneficial Owner” under FATCA (such as a
governmental or international organisation) as described in the US Treasury Regulations sections
1.1471-6(b) through (g)?
Yes
No
If “Yes,” you must confirm this to Butterfield by submitting a completed IRS Form
W-8BEN-E or W-8EXP (as appropriate) with your application. These may be accessed at
www.IRS.gov).
(ii) If “No”, does the entity/organisation:
a) provide banking or similar deposit-taking services?
b) hold financial assets for the account of others as a substantial portion of its business?
c) act as a portfolio manager, fund administrator or fund manager, or engage in the business of
investing, reinvesting or trading securities, partnership interests, commodities or any interest
in such assets (including derivatives such as forwards, futures, or options)?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
d) operate as an insurance company (or holding company of an insurance company) that issues
policies with cash surrender values or annuities?
e) operate as a captive insurance or reinsurance company (or is affiliated with a captive
insurance or reinsurance company) that:


sells life insurance policies, annuities, or any other form of other insurance which has a
cash value greater than $50,000 or;
holds policies that constitute assumption reinsurance?
CORP 009-14 Ver 11-14
(iii) If “No,” is the entity/organisation an “Investment Holding Company”, (i.e. one that derives more
than 50% of its gross earnings from passive income such as interest, dividends, rental income,
royalties, annuities or gains from the sale of such investments and which has deployed more than
50% of its assets (as a weighted average percentage) for the production of passive income?)
Information Classification: Confidential
The Bank of N.T. Butterfield & Son Limited
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CORPORATE ACCOUNT APPLICATION FORM
SECTION 4 – BUSINESS HISTORY
Total assets of entity/organisation:
Annual turnover (last 3 years, in $mil)
Issued share capital
(if applicable):
Year:
$
$
Year:
$
Year:
Have all shares in issue
been registered?
Yes
$
No
Is the entity/organisation:
Establishing a banking relationship for the first time:
Diversifying its existing banking arrangements:
Exiting an existing banking relationship:
Name and location of bank that is being exited (if applicable):
What attracted you to Butterfield?
List any other bank with which the entity/organisation maintains relationships:
Name of financial institution
Will any intermediary be involved in the management of this account?
Country
Primary service provided
Yes
No
If “Yes,” please complete the table below:
Relationship with account
CORP 009-14 Ver 11-14
Name of intermediary
Information Classification: Confidential
The Bank of N.T. Butterfield & Son Limited
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CORPORATE ACCOUNT APPLICATION FORM
SECTION 5 – ACCOUNT REQUIREMENTS
Purpose of account (select all that apply)
Type of account (select all that apply)
Brokerage
Chequing/Current account
Custody account
Subscription to Butterfield mutual fund(s)
Treasury Fixed, Call or Notice Deposit
Operating account
Savings/Cash management
Management of third party client monies
Management of personal/family wealth
Administration of security holdings
Fund administration/management
Details of initial deposit (if applicable):
(Butterfield reserves the right to close the account if not funded within 30 days of opening.)
Deposit amount
$
Method of delivery:
($2,500 minimum)
Wire
Source of funds:
Bank draft
Internal transfer
Personal cheque
Cash
Name:
City :
Country:
How were the funds
obtained?
Expected value of future deposits per month: $
Principal source of future deposits:
Expected number of future deposits per month:
Retail sales
Professional fees/commissions
Investment income
Insurance/Reinsurance premiums
Client monies
Rental income
Principal counterparties from which deposits/securities will be received:
Name of counterparty
Place of business (if in another country)
What are the most common channels through which future credits to the account will be received?
International wire transfer
%
Domestic transfers
%
Cash
Overseas cheques
%
%
Domestic cheques
Bank drafts
%
%
CORP 009-14 Ver 11-14
Expected value of debit transactions per month: $
Internal transfers
(inter-account)
Direct deposit
Other
%
%
%
Average number of debit transactions per month:
Principal currencies in which these transactions will be made (if not account currency):
Principal counterparties to which payments will be made:
Name of counterparty
Information Classification: Confidential
The Bank of N.T. Butterfield & Son Limited
Place of business (if in another country)
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CORPORATE ACCOUNT APPLICATION FORM
Anticipated breakdown of channels through which payments will be processed:
International wire transfer
Domestic transfers/direct
deposit
% Domestic cheques
%
Cash
%
%
Internal transfers
(inter-account)
Bank drafts
%
%
Anticipated methods of initiating banking transactions
%
Fax /email
%
Banking Centres
%
Mail
%
CORP 009-14 Ver 11-14
Online Banking
Information Classification: Confidential
The Bank of N.T. Butterfield & Son Limited
Page 6 of 7
CORPORATE ACCOUNT APPLICATION FORM
SECTION 6 – DECLARATION
1. I/we have been properly authorised to sign this Declaration on behalf of
pursuant to a Meeting of its directors / trustees / partners (delete as appropriate) dated
(the entity)
20
(insert date)
2. I/We apply to open an account and agree that this and any future accounts provided by the Bank of N.T. Butterfield & Son
Limited or any of its subsidiaries or affiliates (“Butterfield”) shall be operated in accordance with Butterfield’s General Terms &
Conditions, a copy of which may be obtained from Butterfield’s website and which may be amended at Butterfield’s sole
discretion from time to time.
3. This account(s) is not being acquired in violation of any applicable law.
4. I/we will confirm that the entity will comply with all present and future tax and exchange control laws, regulations and reporting
requirements relating to its account(s) maintained at Butterfield.
5. The information provided in this form is complete and accurate to the best of my/our knowledge and belief.
6. I/we shall notify Butterfield immediately of any change in this information, including (but not limited to): (i) any change in the
tax status of the entity or; (ii) any change in either the individuals that are beneficial owners of the entity or in their respective
beneficial ownership interests. I/we shall cause the entity to supply Butterfield with an updated form together with any
additional documentation that Butterfield, in its sole discretion, may reasonably request within 30 days of such changes
occurring, and further understand and agree that any failure to do so shall entitle Butterfield to suspend the services it provides
to the entity, up to and including the termination of any account provided.
I/We authorise Butterfield, at its sole discretion, to provide a copy of this form and information regarding any account with
Butterfield to: (i) any tax authority or party authorised on behalf of such authority; (ii) any person that has control, receipt, or custody
of income of which the entity is the owner; or (iii) any party that can disburse or make payments of income of which the entity is the
owner.
Signature
Name of authorised signatory
Signature
Position with respect to entity/organisation
Date
Position with respect to entity/organisation
CORP 009-14 Ver 11-14
Name of authorised signatory
Date
Information Classification: Confidential
The Bank of N.T. Butterfield & Son Limited
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