Introductory BSA/AML Examiner School, Atlanta, CA

BANK SECRECY ACT Data Form for Individuals

_________________________ ________________________ ___________________ _________ Customer Name Social Security Number Account Number CIF# SECTION A (This section must always be completed) 1. Are you a senior foreign 1 or domestic 2 political figure ? Yes or No If yes, what is the position held? _________________ and in what city, state or country do you hold this position? _______________ If no, are you a close associate or family member of a senior foreign or domestic political figure? Yes or No If yes, what is your relationship to the associated senior foreign or domestic political figure? ____________________________ What is the name of the associated senior foreign or domestic political figure? _________________________________ 2. Country of Citizenship _________________ Country of Residence ________________________ SECTION B (This section must always be completed for any new (less than 90 days) transaction accounts) 3. What is the source of the initial deposit into this account? (Please circle one of the choices below) Transit Check Cash Wire Transfer from another NSB account Loan Proceeds Direct Deposit 4. What is purpose of this account? Household/Living Expenses Checking-specific purpose Combined - household/home business Savings - general Savings - specific purpose Other _______________________________________ 5. Please indicate the type, dollar amount(s) and volume of transactions you plan to conduct on this new account?

If yes, please indicate the expected average monthly value of this type of transaction

If yes, please indicate the expected # of transactions per month

Will you conduct this type of transaction? (Y or N)

Type of Transaction

$40,001 or greater Please provide

$5,001 - $10,000

Less than $5,000

$10,001 - $20,000

$20,001 - $30,000

$30,001 - $40,000

explanation below

Cash Deposits Cash Withdrawals

Incoming ACH Transfers Outgoing ACH Transfers

Incoming Domestic Wire Transfers Outgoing Domestic Wire Transfers Incoming Foreign Wire Transfers* Outgoing Foreign Wire Transfers* Check Deposits Check Withdrawals Purchase NSB Official Checks or Money Orders ATM Deposits ATM Withdrawals *If you intend to send or receive foreign wires, please indicate the countries involved: ________________________________________

Additional notes pertaining to anything stated above:

1 A senior foreign political figure is a senior official in the executive, legislative, administrative, military or judicial branches of a foreign government. 2 A senior domestic political figure is an individual who is or has been entrusted domestically with prominent public functions, for example Heads of State or of government, senior politicians, senior government, judicial or military officials, senior executives of state owned corporations, important political party officials. The definition of PEPs is not intended to cover middle ranking or more junior individuals in the foregoing categories.

Revised July 22, 2014