SUMMIT Rural Bank of Lipa City, Inc Account Number N/A Type of Account ® Regular Savings © Special Savings Regular Current Account Classification ® Individual © Joint "AND" © Joint "OR" © Parental/By Account. Date: N/A Last Name @ First Name @ Middle Name STA ANA MA VANESSA SERAFICO Spouse's Last Name Spouse's First Name Spouse's Middle Name NONE NONE NONE Present Address Zip Code TAYTAY, 1920 Permanent Address: Zip Code: TAYTAY, 1920 Primary Mobile Number @ Home Phone O 09178560373 3686200Birth Month 1976 Civil Status SINGLE Birth Year @ Birth Place Do City/Municipality/Province CALOOCAN DD Gender DQ FEMALE Father's Last Name @ Father's First Name STA ANA ALFREDO @ Father's MiddleName VALLE Mother's Last Name @ Mother's First Name Mother's Middle Name STA ANA NARCISA SERAFICO. Nature of Work: EMPLOYEE Name of Employer: UNIONBANK If Self-Employed, Name of Business: NONE If Self-Employed, Nature of Business: NONE If Self-Employed, Address of Business: NONE Source of Funds EMPLOYERTIN No. @ 58S ID/UMID No. @ GsIs No. 201-693-950-000 33-1234567-8 NONE Name of Beneficiary ALFREDO STA ANA Address of Beneficiary TAYTAY Relationship to the Beneficiary FATHER List of Documents Presented N/A List of Identification Cards Presented N/A Client Signature Date Signed N/A 09/17/2019 The information in this section is being collected as part of Summit's new account onboarding procedure to comply with FATCA NONE 1) Are you a citizen or resident of the United States? Yes ®No 2.) If you are a US Citizen or US Resident, provide US TIN NONE3.) If you are a US Citizen or US Resident, provide US Address NONE 4) Please list all countries for which you hold citizenship NONE Please confirm your FATCA status by answering questions below. NONE 1,) US Citizenship - Date of IRS Form (MM/DD/YYvY) NONE 2.) US Resident - Green Card: Date of IRS Form (MM/DD/YYYY) NONE 3.) US Resident - Residing in the US for 183 days or more: Date of IRS Form (MM/DD/YYYY) NONE 4, US Place of Birth: Date of IRS Form (MM/DD/YYYY) NONE 5.) US Resident/Mailing Address: Date of IRS Form (MM/DD/YYYY) NONE 6.) US Telephone Number: Date of IRS Form (MM/DD/YYYY) NONE 7, Standing instruction to transfer funds to an account maintained in the US: Date of IRS Form (MM/DD/YYYY) NONE US Citizenship Yes ®No Us Resident - Green Card Yes ®No US Resident - Residing in the US for 183 days or more Yes ®No Us Place of Birth Yes ®No US Resident/Mailing Address Yes ®No US Telephone Number Yes ®No Standing instruction to transfer funds to an account maintained in the US Yes ®No8) Power of Attorney or signatory authority Power of Attorney or signatory authority granted to person w/US Address or "in care granted to person w/US Address or “in care of" or "hold mail” address: Date of IRS of” or "hold mail” address NONE Yes ®No DECLARATION AND ACKNOWLEDGEMENT. @ | declare that the above information and the information in the submitted documents to be true, corrected and updated Customer Signature over Printed Name Date Signed: N/A 09/17/2019