Ongoing due diligence: Confirmation of Information

Date: 27 November 2021

FirstRand Group Ltd (FSR) (FirstRand Bank Limited), is required to maintain and reconfirm customer
information and documentation as per the Financial Intelligence Centre Act, Act 38 of 2001 (“FICA”).
This document records your information; ensure that the information is correct before submitting it.

Your Personal information

Full Names: Mothusi Coolio

Surname: Rantise

ID/Passport Number: 8108175549081

Country of ID/Passport Issue: South Africa

Country of birth: South Africa Date of Birth: 17 August 1981

Nationality: South African Work Tel Number: N/A

Mobile Number: 079 498 4747 Email Address: Cooliorantz@yahoo.com

Home Tel Number: N/A Occupation: N/A

Employer: N/A

Residential Address

Unit / Street Number: Broadacres Drive Street/complex name: Dainfern Golf Estate

City: Dainfern

Post/zip code: 2191 Country: South Africa

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Source of Funds
Please select any one of the following as your main source of income/revenue: Up to five
options are allowed

Pension Royalty income Investment Income / Capital

Social Grants Rewards Earn Commissions earned

Maintenance ✔ Informal Income Sponsorship / Donations

Court order Salary Insurance Payouts

Student Grants Asset Disposal Allowance

Prize Winnings ✔ Rental Income Proceeds from Own Business

Gifts Interest

Inheritance Dividends

Related Party and Mandated Persons Information

This section records your relationship with “KYC related parties/mandated persons” and their
personal information. This section must be completed for each related party/mandated person.

1. Personal Details of Related Party or Mandated Person

Full Names: Mothusi Coolio

Surname: Rantise

ID/Passport Number: 8108175549081

Country of ID/Passport Issue: South Africa

Country of Birth: 17 August 1981 Date of Birth: 17 August 1981

Mobile Number: 079 498 4747 Work Tel Number: N/A

Home Tel Number: N/A Email Address: Cooliorantz@yahoo.com

Nationality: South African Mandate/permissions:

Full Authority ✔ Limited Authority

Residential Address

Unit / Street Number: Broadacres Drive Street/complex name: Dainfern Golf Estate

City: Dainfern

Post/zip code: 2191 Country of residence: South Africa

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2. Personal Details of Related Party or Mandated Person

Full Names:

Surname:

ID/Passport Number:

Country of ID/Passport Issue:

Country of Birth: Date of Birth:

Mobile Number: Work Tel Number

Home Tel Number: Email Address:

Full Authority Limited Authority
Nationality: Mandate/permissions:

Residential Address

Unit / Street Number: Street/complex name:

City:

Post/zip code: Country of residence:

3. Personal Details of Related Party or Mandated Person

Full Names:

Surname:

ID/Passport Number:

Country of ID/Passport Issue:

Country of Birth: Date of Birth:

Mobile Number: Work Tel Number

Home Tel Number: Email Address:

Full Authority Limited Authority
Nationality: Mandate/permissions:

Residential Address

Unit / Street Number: Street/complex name:

City:

Post/zip code: Country of residence:

Please save this document and return via the original email we sent you

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