Declaration of Source Of Funds and/or Wealth

A Declaration of Source Funds Form is required to be completed by all Cardholders making payments of Ten Thousand Dollars ($10, 000) and above to their Payce Digital Account.

DECLARATION OF SOURCE OF FUNDS and/or WEALTH

Customer Name or Business

Email Address

Current Address

Identification Number

Home No.

Mobile No.

Work No.

Amount of Transaction & Currency

Transaction Date

Description / Nature of Business Transaction

Personal Savings Loan Other (please provide details below)

Source of Funds / Wealth

CUSTOMER SIGNATURE NAME ^*