FICA Standard Broker Declaration

Herewith a Standard Broker Declaration from FICA

DECLARATION

I, ………………………………………………………. (Full Names, Surname and ID-number of Broker) of  ……………………………………………………………………………(Name of Brokerage if it is a Legal Entity), confirm that I have identified the client mentioned below, as well as the person acting on behalf of the client (if applicable) and have verified their identities according to the requirements as set out in the Financial Intelligence Centre Act, 38 of 2001, and any legislation, regulations or guidelines related thereto.  I further confirm that I will keep record of the verification documents as required in terms of the said Act and will make available copies of these documents and details of the verification procedures followed on request to any party entitled thereto in terms of the Act.

DETAILS OF CLIENT:

Full Names and Surname:……………………………………………………………………….…………………………….……………
Identity number:………………………………………………………………………………………..……….……………………………….
If other entity (e.g. Company, Close Corporation or Trust), registered name of entity:..……………………………………………………………………………………………........……………………………………………………….
Contact phone number(s):…………………………………………………………………………………………………………………Residential address………………………………………………………………………………………………………………………………..
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DETAILS OF PERSON ACTING ON BEHALF OF THE CLIENT
(e.g. legal guardian/liquidator/trustee/curator)

Capacity*:…………………………………………………………………………………………………………………………………………………..
Full Names and Surname:……………………………………………………………………………………………
Identity number:……………………………………………………………………….……………………………………….……………………….
Contact phone number(s):……………………………………………………………………………………………………..
Residential address:………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………...………………………………………………………………………………………………………………………………..

Proof of authority to act is required (e.g. Letter of Authority as issued by the Master of the High Court of South Africa)

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Signature of Broker                Broker Code                          Date signed

Residential address of broker:

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