BankTaiwan Securities: Entity or Group Statement(For AML/CFT)
法人、團體聲明書(防制洗錢及打擊資恐專用)
立聲明書人＿＿＿＿＿＿＿＿＿＿於貴公司開立帳戶或進行交易，為配合貴公司遵循「洗錢防制法」、「資恐防制法」、「金融機構防制洗錢辦法」、「證券商業防制洗錢及打擊資恐注意事項範本」等相關規定，茲聲明下列事項：
一、 基本資料：
註冊地之國家□中華民國□其他
主要營業處所與登記地是否相同□是 □否(請註明營業處所地址)
開戶/交易之目的：□投資/資金運用 □其他
法人、團體身分：
□本公司客戶；信託之 □受託人 □委託人 □受益人 □監察人 □其他可有效控制信託帳戶之人
二、法人、團體類別：請完成(ㄧ)及(二)：
(一)請勾選以下適用之類別、填寫相關資料並提供相關文件證明： | |||
□ | 1. 我國政府機關。 | □ | 6. 受我國監理之金融機構及其管理之投資工具。 |
□ | 2. 我國公營事業機構。 | □ | 7. 設立於我國境外，且所受監理規範與防制洗錢金融行動工作組織（FATF）所定防制洗錢及打擊資恐標準一致之金融機構，及該金融機構管理之投資工具。 |
□ | 3. 外國政府機關。 | ||
□ | 4. 我國公開發行公司或其子公司。 公司簡稱/母公司名稱： 股票代號/母公司股票代號： | ||
□ | 5. 於國外掛牌並依掛牌所在地規定，應揭露其主要股東之股票上市、上櫃公司，或其子公司 。 公司簡稱/母公司名稱： 掛牌國別/母公司掛牌國別： 股票代號/母公司股票代號： | □ | 8. 我國政府機關管理之基金。 |
□ | 9. 員工持股信託、員工福利儲蓄信託。 | ||
□ | 10. 非屬編號1.至9.之法人類別。 備註: | ||
(二) 本法人或本法人之法人股東為股份有限公司時，請勾選以下項目： | |||
□ | 1. 已發行無記名股票者，請於下列(1)或(2)擇一勾選並提供資訊。 | ||
□ (1) 本法人之實質受益人不包括本法人或法人股東之無記名股票股東。 | |||
□ (2) 本法人之實質受益人包括本法人或法人股東之無記名股票股東，其名單如下: ※持有無記名股票之實質受益人姓名: (a) ；(b) ；(c) | |||
□ | 2. 未發行無記名股票；另倘章程明定得發行無記名股票但尚未發行，承諾將於發行無記名股票時通知 貴公司，並提供實質受益人資訊。 | ||
本法人或法人股東之「持有無記名股票之自然人股東」轉讓無記名股票予他人時，倘該無記名股票受 讓人經確認為本法人之實質受益人時，承諾於知悉時將該受讓人之身分資料即刻通知貴公司。 | |||
三、 實質受益人及高階管理人員：
(ㄧ)實質受益人 | ||||||
姓名 | 出生日期 (YYYY/MM/DD) | 國籍 | 身分證明文件號碼 | 備註 | ||
1 | ||||||
2 | ||||||
3 | ||||||
實質受益人: 指對客戶具最終所有權或控制權之自然人，或由他人代理交易之自然人本人，包括對法人或法律協議具最終有效控制權之自然人。所稱具控制權係指直接、間接持有該法人股份或資本超過百分之二十五者；如無前述自然人，則為透過其他方式對客戶行使控制權之自然人；如未發現前述具控制權之最終自然人，則應揭露擔任客戶「高階管理人員」之自然人身分。 倘具有非自然人股東(指直接或間接持有客戶已發行股份之股東)時，請提供非自然人股東之股東名冊或出資證明等證明文件 或填寫附件「實質受益人股權結構圖」，以辨識具控制權之最終自然人。 | ||||||
(二)高階管理人員 | ||||||
姓名 | 出生日期 (YYYY/MM/DD) | 國籍 | 身分證明文件號碼 | 職稱 | 備註 | |
1 | 董事長 | |||||
2 | 總經理 | |||||
3 | ||||||
4 | ||||||
5 | ||||||
至少取得高階管理人資料:董事長、總經理(或相當於前述職位之人士，如理事長等)。 若有未能提供者，請述明原因。□董事長兼任總經理 □僅有董事長職位 □僅有總經理職位 □其他 | ||||||
請完成(ㄧ)及(二)，倘屬「二、法人、團體類別」第(ㄧ)部分編號1.至9.之法人或團體，且該法人或團體及其法人股東「非」為已發行無記名股票之股份有限公司，僅需完成下表(二)高階管理人員：
四、 聲明及簽署：
本法人或團體茲聲明、瞭解並同意下列事項：
上述資料及相關文件(包括附件)均為屬實、正確，且同意依貴公司業務需求，提供資料予以佐證，嗣後若有任何異動，同意將於異動日起30日內主動通知並提供相關證明文件向貴公司申請變更，且將配合貴公司要求辦理相關措施(包括但不限於辦理銷戶)；若有聲明不實或違反本聲明書之聲明保證事項，貴公司得要求立即辦理關戶，屆時將無條件遵照辦理。
已向高階管理人及實質受益人說明並取得其同意後始提供個人資料予貴公司，且上開人等均已了解本聲明書符合個人資料保護法及相關法令規定，本聲明書及附件並具有上開人等同意貴公司蒐集、處理及利用其個人資料之效力。
因本聲明書或附件所生之爭議，悉依與貴公司間之業務契約及交易所約定之條款辦理。
此致 臺銀綜合證券股份有限公司立聲明書人
原留印鑑： 或代表人/代理人親簽：
【註:本公司客戶得僅蓋印原留印鑑，立聲明書人為信託受託人以外之信託關係人則必須親簽。】
中 華 民 國 年 月 日
經辦： 主管：
BankTaiwan Securities: Entity or Group Statement(For AML/CFT)
※Please complete each section of the statement.
I. Identification of the Entity:
The entity or group is □Customer of BTS; □Trustee □Settlor □Beneficiary □Supervisor of the trust or □any other person exercising ultimate effective control over the trust □Occasional Transaction Person |
Full Name: ; Registered Number: |
Registered address: |
Country(Place) of effective management: |
II. Entity or Group Type:
Please complete Part A and Part B.
A. Please select the applicable type of entity and provide related information and supporting documentary evidence. | |||
□ | 1. a R.O.C government entity | □ | 6. a financial institution supervised by the R.O.C. government, and an investment vehicles managed by such institution |
□ | 2. an enterprise owned by the R.O.C government | □ | 7. a financial institution incorporated or established outside R.O.C. that is subject to and supervised for compliance with AML/CFT requirements consistent with standards set by the Financial Action Task Force on Money Laundering (FATF), and an investment vehicle managed by such institution |
□ | 3. a foreign government entity | ||
□ | 4. a public company and its subsidiaries • Company name abbreviation/Name of parent company: • Ticker Symbol of the company/parent company: | ||
□ | 5. an entity listed on a stock exchange outside of R.O.C. that is subject to regulatory disclosure requirements of its principal shareholders, and the subsidiaries of such entity • Company name abbreviation/Name of parent company: • Listed country of the company/parent company: • Ticker Symbol of the company/parent company: | □ | 8. Public Service Pension Fund of R.O.C. |
□ | 9. Employee Stock Ownership Trust, Employee Savings Trust. | ||
□ | 10. None of the above. Note: | ||
B. I/We or my/our entity stockholders are limited corporations. Please read the following statement and tick the box if applicable. | |||
□ | We have issued bearer shares. Please select one of the two following options and provide information. | ||
□ 1. The beneficial owners do not include any bearer stockholders. | |||
□ 2. The beneficial owners include bearer stockholder(s), and the list is provided as follows. ※Full name of the beneficial owners who hold bearer shares: (1) ；(2) ；(3) | |||
□ | We have not yet issued bearer shares. I/We hereby undertake to notify your Comapny and provide the information of the beneficial owners upon issuing bearer shares. | ||
■ Upon transferring bearer shares, I/We hereby undertake to notify your Company the information of the transferee immediately if the transferee is identified as our beneficial owner. | |||
III. Beneficial Owners and Senior Managing Officials
Please complete Part A and Part B.
A. Beneficial Owner | ||||||
Full Name | Date of Birth (YYYY/MM/DD) | Nationality | Identification Number | Note | ||
1 | ||||||
2 | ||||||
3 | ||||||
■ Beneficiary Owner: The natural persons who ultimately have a controlling ownership interest in the customer, or the natural persons who authorized others to execute transactions, including the natural persons who have ultimate and effective control over a legal entity or legal agreement. Controlling ownership interest refers to owning directly or indirectly more than 25 percent of a company’s shares or capital. When no natural person is identified as above, the identity of the natural persons (if any) exercising control of the customer through other means. Where no natural person is identified as above, the identity of the relevant natural person who holds the position of senior managing official. ■ If the Entity has any legal entity or Group that directly or indirectly holds the Entity’s issued shares, please provide the legal entity’s Register of Shareholders or the Group’s Capital Contribution Certificate or complete Annex “Structure of Beneficial Owners” to identify the natural persons who ultimately have a controlling ownership interest in the Entity. | ||||||
B. Senior Managing Officials | ||||||
Full Name | Date of Birth (YYYY/MM/DD) | Nationality | Identification Number | Title | Note | |
1 | Chairman | |||||
2 | General manager | |||||
3 | ||||||
4 | ||||||
5 | ||||||
￭ Obtain at least high-level management information: chairman, general manager (or equivalent of the aforementioned positions, such as the chairman of the board, etc.). ￭ If anyone fails to provide, please state the reason. □The chairman concurrently serves as the general manager □Only the chairman position □Only the general manager position □Others | ||||||
If you are any of the No. 1~9 entity listed in “II. Entity or Group Type”, and you and your entity shareholders are not limited corporations that have already issued bearer shares, please complete Part B only.
IV. Declaration and Signature
I/We hereby declare and warrant the following things:
■ The information given in this statement and annex submitted to you are complete, true and accurate and that I/we have not willfully withheld any material fact/information. I/We shall give your Company written notice of any change in my/our particulars within 30 days.
■ I/We also declare that I/we am/are hereby consent the Representative and your Company to contact me/us to
obtain further information immediately from me/us for the purpose of Representative’s and your Company’s compliance with domestic and international regulations. If any information is found false or misleading, or if the need to obtain further information is not met, your Company may reject any of my/our application and/or instructions including but not limited to, any transactional-related activities or closing the accounts.
■ I/We certify that I/we are authorized to provide the personal information in respect of the above individuals
to which the statement relates. The above individuals are aware that this statement complies with the Personal Information Protection Act and the relevant regulations. I/We consent to your Company collecting, using and disclosing the information provided in this statement and annex.
■ Any dispute arising out of this statement and annex shall be governed by the terms of service agreement
between both parties.
Original Seal:
Representative/Authorized Person:
(Note: Customer of BTS can choose to stamp original seal field only，but occasional transaction or trust-related person shall sign in the Representative/Authorized Person field)
Date (YYYY/MM/DD): /_ /
Facilitator: Supervisor:
附錄:客戶辨識實質受益人股權結構圖
Appendix: Beneficial Owner Structure of Customer
• 範例 Example
• 客戶辨識實質受益人股權結構圖 Beneficial Owner Structure of Customer (請填寫於背面， Please complete the structure on the reverse side)
• 聲明及簽章 Declaration and Signature
謹聲明客戶填寫之股權結構圖內容均屬實、正確
The information given in this structure submitted to you is complete, true and accurate
原留印鑑 Original Seal： 或 or
代表人/代理人親簽 Representative/Authorized Person：
註:本公司客戶得僅蓋印原留印鑑，臨時性交易者或立聲明書人為信託受託人以外之信託關係人則必須親簽。
(Note: Customer of BTS can choose to stamp original seal field only，but occasional transaction or trust-related person shall sign in the Representative/Authorized Person field)
中 華 民 國 年 月 日
經辦： 主管：
• 客戶辨識實質受益人股權結構圖 Beneficial Owner Structure of Customer
辨識結果 Result:
□實質受益人為: Beneficial owners are:
□未發現實質受益人。 No beneficial owners identified.
【註:本結構圖之欄位若不敷使用，請自行增列。 Note: Please add more columns if
necessary.】