b-packaged® verifying officer(s)
Use this form to add or remove verifying officer(s) to your
Community Sector Banking b-packaged® account.
Add new verifying officer(s) > go to section 2;
Remove a verifying officer > go to section 4
Return this form by email to [email protected],
by mail to Community Sector Banking, PO Box 585, Corrimal,
NSW, 2518, or by fax to 02 4255 8420.
If the signatory in section 2 is not already known to Community
Sector Banking, please ensure the original paperwork is sent to
us via mail.
1
Organisation Details
Existing Customer:
Yes
No
If yes, Account or Customer No.:
Full name of Organisation:
ACN / ABN / ARBN / Registration Number
Business Address:
City:
State:
Postcode:
State:
Postcode:
Mail Address (if different from Business Address):
City:
Phone Number:
Fax Number:
Email address:
Main Contact (ie. Name of preferred contact person):
2.
Add a new signatory
Verifying Officer #1 - Personal Details
Title:
Full Name:
Residential address (PO Box is not acceptable):
Suburb:
State:
Postcode:
State:
Postcode:
Postal Address:
Suburb:
Date of Birth:
Occupation:
/
/
Personal Contact Number:
Business Contact Number:
Email Address:
Signature:
Name:
Date:
/
/
Community Sector Banking Pty Ltd ABN 88 098 858 765 - Authorised Representative No. 265317 of Level 1, Wing C, Innovation Campus, Squires Way,
North Wollongong NSW 2500 is a wholly owned subsidiary of Community Sector Enterprises Pty Ltd ABN 95 098 858 354, a joint ve nture between
Bendigo and Adelaide Bank Liminted ABN 11 068 049 178 - AFSL 237879 and Community 21 Limited ABN 79 097 612 416. Community Sector Banking
Pty Ltd communitysectorbanking.com.au is a franchisee and authorised representative of Bendigo and Adelaide Bank Limited, The Bendigo Centre,
Bendigo Vic 3550.
OA002(i) (01/16)
Verifying Officer #2 - Personal Details
Title:
Full Name:
Residential address (PO Box is not acceptable):
Suburb:
State:
Postcode:
State:
Postcode:
Postal Address:
Suburb:
Date of Birth:
/
/
Occupation:
Personal Contact Number:
Business Contact Number:
Email Address:
Signature:
Name:
Date:
/
/
Verifying Officer #3 - Personal Details
Title:
Full Name:
Residential address (PO Box is not acceptable):
Suburb:
State:
Postcode:
State:
Postcode:
Postal Address:
Suburb:
Date of Birth:
/
/
Occupation:
Personal Contact Number:
Business Contact Number:
Email Address:
Signature:
Name:
Date:
/
/
Verifying Officer #4 - Personal Details
Title:
Full Name:
Residential address (PO Box is not acceptable):
Suburb:
State:
Postcode:
State:
Postcode:
Postal Address:
Suburb:
Date of Birth:
Occupation:
/
/
Personal Contact Number:
Business Contact Number:
Email Address:
Signature:
Name:
Date:
/
/
Community Sector Banking Pty Ltd ABN 88 098 858 765 - Authorised Representative No. 265317 of Level 1, Wing C, Innovation Campus, Squires Way,
North Wollongong NSW 2500 is a wholly owned subsidiary of Community Sector Enterprises Pty Ltd ABN 95 098 858 354, a joint ve nture between
Bendigo and Adelaide Bank Liminted ABN 11 068 049 178 - AFSL 237879 and Community 21 Limited ABN 79 097 612 416. Community Sector Banking
Pty Ltd communitysectorbanking.com.au is a franchisee and authorised representative of Bendigo and Adelaide Bank Limited, The Bendigo Centre,
Bendigo Vic 3550.
OA002(i) (01/16)
3.
Foreign Accounts Tax Compliance Act (FATCA) – Completion of all sections is mandatory
Are any applicants Citizens or Residents of the US for Tax
purposes?
Yes – please complete the FATCA Details Form (OA651)
No
Is the Entity’s created in the US, established under the
laws of the US or a US taxpayer
Yes – please complete the FATCA Details Form (OA651)
No
Are any controlling persons of an Entity Citizens or
Residents of the US for Tax purposes?
Yes – please complete the FATCA Details Form (OA651)
No
Is the Entity/s created in the US?
Yes – please complete the FATCA Details Form (OA651)
No
Is the Entity a Financial Institution?
Yes – please complete the FATCA Details Form (OA651)
No
For companies, trusts and partnerships a controlling person is an individual who is a shareholder, trustee, beneficiary, settlor or partner
AND who owns 25% or more of the Entity, controls 25% or more of the voting rights including a power of veto, or holds the position of
senior managing official of the Entity. For associations and co-operatives a controlling person is also an individual who is entitled to 25%
or more of the assets of the Entity upon dissolution.
4.
Remove verifying officer(s)
Remove the following individuals from the selected account(s):
Name
5.
Account numbers (or customer / ledger)
Authorisation
The below authorisation is to be signed by any two current board or committee members (e.g., director, chairman, partner, secretary,
treasurer or equivalent responsible person).
I/We confirm that the nominated Verifying Officer(s) is/are authorised to act as a Verifying Officer(s) on behalf of the organisation.
I/We undertake to advise you as soon as practicable should the nomination be revoked or a Verifying Officer ceases to be employed by
the organisation.
I/We authorise Community Sector Banking to complete necessary information pertaining to this form as required.
Executive Officer 1
Executive Officer 2
Full name
Full name
Position
Position
Signature
Signature
Date
/
/
Date
/
/
Privacy Statement: Community Sector Banking is collecting your personal information in order to assist in the identification of the
Verifying Officer(s) named in Part B.
Please note, the individuals providing authorisation will need to be either known to Community Sector Banking or Bendigo and
Adelaide Bank; or should provide a copy of identification with this form (eg, Drivers License or Passport) to verify their signatures.
\
Community Sector Banking Pty Ltd ABN 88 098 858 765 - Authorised Representative No. 265317 of Level 1, Wing C, Innovation Campus, Squires Way,
North Wollongong NSW 2500 is a wholly owned subsidiary of Community Sector Enterprises Pty Ltd ABN 95 098 858 354, a joint ve nture between
Bendigo and Adelaide Bank Liminted ABN 11 068 049 178 - AFSL 237879 and Community 21 Limited ABN 79 097 612 416. Community Sector Banking
Pty Ltd communitysectorbanking.com.au is a franchisee and authorised representative of Bendigo and Adelaide Bank Limited, The Bendigo Centre,
Bendigo Vic 3550.
OA002(i) (01/16)
6.
Identification Verification Documents for Individuals
Tick the identification verification document(s) used and attach an original certified copy of the original identification document(s) to this form:
NOTE: If you are unable to present one of the primary photographic documents you can present a primary non-photographic document PLUS
a secondary identification document to meet your identification requirements
Existing Customers*
If the applicant has previously been identified to meet Know Your Customer requirements please record the customer number that the
identification was recorded on.
Verifying Officer #1
Verifying Officer #2
Verifying Officer #3
Verifying Officer #4
New Customers*
One Primary Photographic document OR (Note: Must show a clear photograph)
1
2
3
4
Australian Driver’s Licence - (Current, Renewed, Interim, Provisional, Driver’s, Truck or Learner’s)
Australian or Foreign Passport (current or expired Australian Passport within preceding 2 years), with English
translation by an accredited translator (if not in English)
Proof of Age Card (issued by an Australian State or Territory)
Foreign National Identity Card (must be in English or English translation by an accredited translator)
ImmiCard: No account is to be opened unless the Centralised KYC team have performed the appropriate checks
Document for Travel to Australia: No account is to be opened unless the Centralised KYC team have performed the
appropriate checks
NSW Photo Card: Issued by the NSW State Government
Personal Information Card: Issued by the Tasmanian State Government
Minimum of one document is required for residents listed in Additional KYC Country List
One Primary Non-Photographic document AND
1
2
3
4
Birth Certificate (Australian) or Foreign Birth Certificate with English translation by an accredited translator (if not in
English)*
Birth Extract by an Australian State or Territory
Citizenship Certificate - Australian or Foreign with English translation by an accredited translator (if not in English)*
Pension or Government Health Card (reference number required) (issued by Centrelink or the Department of
Veterans’ Affairs)
Minimum of one document is required for residents listed in Additional KYC Country List
One Secondary Identification document
1
2
3
4
Notice issued by a Commonwealth, State or Territory Department which records provision of financial benefit less
than 12 months old (eg Centrelink statement).
Must contain the individual's name and residential address.
Notice issued by the Australian Tax Office of debt or assessment less than 12 months old that contains the name of
the individual and residential address.
Notice less than 3 months old issued by a local government body or utilities provider that notes the provision of
services to that address and/or that person (eg Council Rates, Water Rates, Electricity Bill, Gas Bill and Telephone
Landline Bill).
Must contain the name of the individual and residential address.
For a person under 18 years, a letter issued by a school principal (less than 3 months old) which includes a record
of the length of time the person attended the school. Must contain the name of the individual and residential
address.
Only in relation to a person aged 7 to 17 years, a Medicare/Pension/Heath Care Card Containing the name of the
individual.
Note: Only the name is required to be verified from the Medicare/Pension/Heath Care Card, not the date of birth or
residential address.
Special Cases
Aboriginal Person or Torres Strait Islander Resident
1
2
3
4
The full legal name of the signatory and either date of birth or residential address, may be verified by a statement
from two persons who are recognised as community leaders, including elected members of an Aboriginal Council of
the community to which the signatory belongs.
Community Sector Banking Pty Ltd ABN 88 098 858 765 - Authorised Representative No. 265317 of Level 1, Wing C, Innovation Campus, Squires Way,
North Wollongong NSW 2500 is a wholly owned subsidiary of Community Sector Enterprises Pty Ltd ABN 95 098 858 354, a joint ve nture between
Bendigo and Adelaide Bank Liminted ABN 11 068 049 178 - AFSL 237879 and Community 21 Limited ABN 79 097 612 416. Community Sector Banking
Pty Ltd communitysectorbanking.com.au is a franchisee and authorised representative of Bendigo and Adelaide Bank Limited, The Bendigo Centre,
Bendigo Vic 3550.
OA002(i) (01/16)
Know Your Customer Information Verified - Office Use Only
I confirm that the following Know Your Customer Information has been verified against the identification document(s) referred to above.
Full legal name {middle initial(s) acceptable for a drivers licence}
and
Either date of birth or residential address
and
Country of Citizenship (if applicant resides in an Additional KYC Country)
A manual search of the KYC Interface has been completed for all parties to an organisation who do not have signing authority
Yes
No
Does the applicant reside in an "Additional Know Your Customer Country?"
Yes
No
If 'yes', please ensure you capture the following information:
Foreign Applicants
If yes, complete the following fields:
Applicant Name:
Occupation:
Country of citizenship:
Reason for opening an account in Australia:
Salary range:
$0 - $30,000
$30,001 - $50,000
$50,001 - $100,000
$100,001 +
If there is more than one Foreign Applicant, please attach additional page(s).
Signed:
Staff number/ADM:
Date:
/
/
*Please note that all fields with an asterisk (*) are mandatory for the collection and verification of Know Your Customer identification.
Community Sector Banking Pty Ltd ABN 88 098 858 765 - Authorised Representative No. 265317 of Level 1, Wing C, Innovation Campus, Squires Way,
North Wollongong NSW 2500 is a wholly owned subsidiary of Community Sector Enterprises Pty Ltd ABN 95 098 858 354, a joint ve nture between
Bendigo and Adelaide Bank Liminted ABN 11 068 049 178 - AFSL 237879 and Community 21 Limited ABN 79 097 612 416. Community Sector Banking
Pty Ltd communitysectorbanking.com.au is a franchisee and authorised representative of Bendigo and Adelaide Bank Limited, The Bendigo Centre,
Bendigo Vic 3550.
OA002(i) (01/16)