A.

Foreign Account Tax Compliance Act (FATCA) Due Diligence Form

Individual

Please provide complete details and indicate NOT APPLICABLE to items/sections as deemed appropriate

ISIDRO MARTIN F. REYES JR. RUBY ELIZABETH P. REYES

Questions Borrower’s Name Spouse’s Name Co-Borrower’s Name
Yes No Yes No Yes No

1. Are you an American citizen? □ □ □ □ □ □

2. Are you a dual citizen? If so, indicate
countries of citizenship.
3. Are you a permanent resident of the U.S. /
green card holder? □ □ □ □ □ □
4. Were you born in the U.S.? □ □ □ □ □ □
5. Do you have a residence address in the
U.S.? □ □ □ □ □ □
6. Do you have a phone number in the U.S.? □ □ □ □ □ □
7. Do you have any instructions to transfer
funds to an account in the U.S.? □ □ □ □ □ □
8. Have you been to the U.S. in the last 3
years? □ □ □ □ □ □
If any of the answers to questions stated above is YES, kindly specify the required applicable information below. If more than
two (2) answered YES, please fill out a separate form.

□ Borrower □ Spouse □ Co-Borrower

A. Name:
B. U.S. Address:
No. Street: Subdivision/District/Town:
City: Country:
C. U.S. Telephone Number:
D. U.S. TIN:
E. U.S. P.O Box:
F. Standing instructions to pay amount/transfer funds to an account maintained in the United States:

G. Current power of attorney or signatory authority granted to a person with U.S. address:

H. An “in-care-of” address or “hold mail” address:

I. Length of stay in U.S.
Current Year No. of days Last Year No. of Days Prior to Last Year No. of Days Total Length of Stay

Please see guidelines on how to compute for the length of stay in U.S. by following the computation of substantial presence
test below:
Qualification/Eligibility for substantial presence test must involve being physically present in the United States on at least:
a. 31 days during the current year and;
b. 183 days during the 3-year period that includes the current year and the 2 years immediately before that, counting:
i. All the days you were present in the current year and;
ii. 1/3 of the days you were present in the first year before the current year, and;
iii. 1/6 of the days you were present in the second year before the current year

Client Conforme:

ISIDRO MARTIN F. REYES JR. RUBY ELIZABETH P. REYES

Borrower Signature Spouse Signature Co-Borrower Signature

over Printed Name / Date over Printed Name / Date over Printed Name / Date

For Bank’s Use Only

Customer Information File Number Bank Representative Signature over Printed Name
Notes/Remarks (if any):