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FORMULIR REKENING DANA NASABAH
$33/,&$7,21)250)25&86720(5)81'$&&2817
A. MOHON DITULIS DENGAN HURUF CETAK
$3/($6(:5,7(,1%/2&./(77(56

Nama Nasabah (sesuai tanda pengenal) : No. Rekening yang sudah ada :
1DPHRI&XVWRPHU DVLWDSSHDUVRQ,'&DUG ([LVWLQJ$FFRXQW1R

5POP)BSUPOP
«««««««««««««««««««««««««««««««««««« Nomor Rekening Baru :
1HZ$FFRXQW1R
Alias (apabila ada) :
$OLDV LIDQ\ Cabang :  «««««««
%UDQFK
««««««««««««««««««««««««««««««««««««
Nama Perusahaan Efek / Bank Kustodian : 
No. Single Investor ID : 1DPHRI6HFXULWLHV&RPSDQ\&XVWRGLDQ%DQN
6LQJOH,QYHVWRU,'1R
«««««««««««««««««««««««««««««««««««
No. Sub Rekening Efek :
6XE6HFXULWLHV$FFRXQW1R Kode Perusahaan Efek / Bank Kustodian : 
&RGHRI6HFXULWLHV&RPSDQ\&XVWRGLDQ%DQN

Nomor Customer : Corporate ID KBB : «


&XVWRPHU1XPEHU .%%&RUSRUDWH,'

Dalam hal ini bertindak sebagai :  3ULEDGL Tujuan Pembukaan Rekening : 3HQ\HOHVDLDQ7UDQVDNVL(IHN
,QWKLVPDWWHUDFWLQJ 2QKLVKHURZQEHKDOI 3XUSRVHRI2SHQLQJWKH$FFRXQW 7R6HWWOH6HFXULWLHV7UDQVDFWLRQV

 :DNLOGDULSLKDNODLQ : 3HQJDPSX /DLQQ\D


$VDUHSUHVHQWDWLYHRUSUR[\IRUDQRWKHUSDUW\ 7UXVWHH 2WKHU

B. PRODUK YANG DIINGINKAN


%'(6,5('352'8&7

Giro, Mata Uang %JLPTPOHLBO TAPRES BCA Dollar, Mata Uang


&XUUHQW$FFRXQW&XUUHQF\ 7$35(6 %&$'ROODU&XUUHQF\
C. DATA NASABAH PERORANGAN
&'$7$2),1',9,'8$/&86720(5
Alamat (sesuai tanda pengenal) : Jenis Kelamin : ȼ/ /DNLODNL 3 3HUHPSXDQ
$GGUHVV DVLWDSSHDUVRQ,'&DUG 6H[ 0DOH )HPDOH
««««««««««««««««««««««««««««««««««««
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: ««««««««««««««««««««««««
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Kota +BLBSUB
: ««««««««««««««««««««««««« Negara Tempat Lahir *OEPOFTJB
: ««««««««««««««««««««««««
&LW\ &RXQWU\RI%LUWK
Kode Pos :  *OEPOFTJB
Negara :  Tanggal Lahir : 
 
3RVWDO&RGH &RXQWU\ 'DWHRI%LUWK

Alamat Surat Menyurat : Status Perkawinan : ȼ /DMDQJ  -DQGD'XGD


&RUUHVSRQGHQFH$GGUHVV 0DULWDO6WDWXV 6LQJOH :LGRZ:LGRZHU'LYRUFHG
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+M3BZB#FTBS*/P $MVTUFS)BSNPOJ "MBN3BZB 0DUULHG
««««««««««««««««««««««««««««««««««««
Agama :  ,VODP  +LQGX
Kota :
+BLBSUB
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Kode Pos :  *OEPOFTJB
Negara :   .ULVWHQ  ««««««««««
3RVWDO&RGH &RXQWU\ &KULVWLDQLW\

No. Telepon : 


 Kewarganegaraan : ȼ :1,
7HOHSKRQH1R 1DWLRQDOLW\ ,QGRQHVLDQ
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No. HP :  $YDLODEOHQDPHO\1R
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9DOLGXQWLO
Alamat(PDLO : UPOPIBSUPOP!HNBJMDPN
««««««««««««««««««««««««« Foreign Account Tax Compliance Act (FATCA)
(PDLO$GGUHVV $ODPDWHPDLO LQLDNDQGLJXQDNDQXQWXNSHQJLULPDQH6WDWHPHQW 1. Nasabah berkewarganegaraan Amerika Serikat (AS) <D ȼ 7LGDN
7KLVHPDLODGGUHVVZLOOEHXVHGIRUWKHGHOLYHU\RIH6WDWHPHQW &XVWRPHULVD8QLWHG6WDWHV 86 FLWL]HQ <HV 1R

NPWP : , $GD ȼ 7LGDNDGD 2. Nasabah adalah pemegang kartu penduduk tetap AS - Green Card <D ȼ 7LGDN
7D[,'1R $YDLODEOH 1RW$YDLODEOH &XVWRPHULVD863HUPDQHQW5HVLGHQW&DUG *UHHQ&DUG KROGHU <HV 1R
1R«««««««««««««««««««««««
3. Nasabah memiliki kewajiban pelaporan pajak kepada Pemerintah AS
,'6&5$%%7

Tanda Pengenal : ȼ .73  3DVSRU &XVWRPHULVREOLJHGWRILOHLQFRPHWD[UHWXUQVZLWKWKH86*RYHUQPHQW <D ȼ 7LGDN


,GHQWLW\&DUG 5HVLGHQW¶V,'&DUG 3DVVSRUW <HV 1R

1R««««««««««««««««««««««« -LND1DVDEDKPHPLOLKµ<D¶SDGDVDODKVDWXSHUQ\DWDDQGLDWDVPRKRQVHUWDNDQForm W-9 Request for Taxpayer
Identification Number and Certification) GDQWXOLVNDQTaxpayer Identification Number (TIN)/Social Security Number
Berlaku s.d. : 
  (SSN)1DVDEDK
,I&XVWRPHUDQVZHUVµ<HV¶WRDQ\RIWKHIRUHJRLQJIDFWVSOHDVHFRPSOHWHDQGIXUQLVK%&$ZLWK )RUP: 5HTXHVWIRU
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C. DATA NASABAH PERORANGAN
&'$7$2),1',9,'8$/&86720(5

Pendidikan Terakhir :  6'  $NDGHPL Nama Referensi +VKV4VSBUJO


: 
/DVW(GXFDWLRQ (OHPHQWDU\6FKRRO 1RQGHJUHH 1DPHRI5HIHUHH
 6/73  8QLYHUVLWDV
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+VKV4VSBUJO
: 
ȼ 608
6HQLRU+LJK6FKRRO
0RWKHU¶V0DLGHQ1DPH

Sumber Penghasilan :  +DVLO8VDKD  +DVLO,QYHVWDVL ȼ 2UDQJ7XD


6RXUFHRI,QFRPH %XVLQHVV3URFHHGV ,QYHVWPHQW3URFHHGV 3DUHQWV

 *DML  «««««««
6DODU\

Nama Kantor / Perusahaan Tempat Bekerja : 6OJWFSTJUBT&LPOPNJ


««««««««««««««««««««««««««««««««««««««««««««««««««««««««
1DPHRI2IILFH&RPSDQ\

Jabatan / Pangkat .BIBTJTXB


: ««««««««««««««««««««««««««««««««««««««««««««««««««««««««
3RVLWLRQ7LWOH

Bidang Usaha 1FOEJEJLBO


: ««««««««««««««««««««««««««««««««««««««««««««««««««««««««
)LHOGRI%XVLQHVV

Alamat Kantor / Perusahaan Tempat Bekerja :


$GGUHVVRI2IILFH&RPSDQ\
+M1FOEJEJLBO/P,BXBTBO5FSQBEV
««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««
,VOJOHBO
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Kota
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: ««««««««««««««««««««««««««««««««««««««««««««««««««««««««

Kode Pos :  *OEPOFTJB


Negara : 
3RVWDO&RGH &RXQWU\

No. Telepon : 



7HOHSKRQH1R

No. Fax : 



)D[1R

Pekerjaan : ȼ 3HODMDU0DKDVLVZD  ,EX5XPDK7DQJJD  .DU\DZDQ6ZDVWD


2FFXSDWLRQ 3XSLO6WXGHQW +RXVHZLIH 3ULYDWH(PSOR\HH

 3HJDZDL1HJHUL  71,3ROUL  3ME1HJDUD'DHUDK


&LYLO6HUYDQW $UPHG)RUFHV3ROLFH 6WDWH5HJLRQDO2IILFLDO

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6HUYLFH3URYLGHU 'RFWRU /DZ\HU

 $NXQWDQ  :DUWDZDQ  6HQLPDQ


$FFRXQWDQW -RXUQDOLVW SUHVV $UWLVW

 1RWDULV  3URIHVLRQDOODLQQ\D  ««««««««««««««


1RWDU\ 2WKHU3URIHVVLRQDO

Penghasilan / Gaji Kotor per Tahun :  ”-XWD  !-XWD-XWD


*URVV,QFRPH6DODU\SHU<HDU ”0LOOLRQ !0LOOLRQ±0LOOLRQ

 !-XWD-XWD
ȼ  !-XWD
!0LOOLRQ±0LOOLRQ !0LOOLRQ

Penghasilan Lainnya per Tahun : ««««««««««««««««««««««««««««««««««««««««««««««««««««««««««


2WKHU,QFRPHSHU<HDU
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”0LOOLRQ !0LOOLRQ±0LOOLRQ

ȼ
 !-XWD-XWD  !-XWD
!0LOOLRQ±0LOOLRQ !0LOOLRQ

Total Penghasilan :  ”-XWD  !-XWD-XWD


7RWDO,QFRPH ”0LOOLRQ !0LOOLRQ±0LOOLRQ
,'6&5$%%7

 !-XWD-XWD
ȼ  !-XWD
!0LOOLRQ±0LOOLRQ !0LOOLRQ

Status Rumah :  0LOLN3ULEDGL  .RQWUDN


+RPH6WDWXV 6HOIRZQHG 5HQWHG

 6HZD.RV ȼ ,NXWRUDQJWXD
0RQWKO\UHQW 2ZQHGE\SDUHQWV

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''$7$2)&25325$7(&86720(5
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5HSUHVHQWDWLYHRI)RUHLJQ&RXQWU\ &RRSHUDWLYH 2WKHU

Negara asal (bagi badan usaha asing) : ««««««««««««««««« Bidang Usaha : «««««««««««««««««««««««««
&RXQWU\RIRULJLQ RQO\IRUIRUHLJQHQWLW\ )LHOGRI%XVLQHVV
Izin Usaha : ««««««««««««««««««««««««««««« Berlaku  
%XVLQHVV/LFHQVH 9DOLG8QWLO
Nama Nasabah : ««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««
&XVWRPHU1DPH
Alamat Nasabah : ««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««
&XVWRPHU$GGUHVV
««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««

Kota ««««««««««« Kode Pos Negara : 


&LW\ 3RVWDO&RGH &RXQWU\
Alamat Surat Menyurat : ««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««
&RUUHVSRQGHQFH$GGUHVV
««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««««

Kota ««««««««««« Kode Pos Negara : 


&LW\ 3RVWDO&RGH &RXQWU\
Dalam hal ini bertindak :  8QWXNNHSHQWLQJDQ1DVDEDK  6HEDJDLZDNLOGDULSLKDNODLQ  :DOL$PDQDW /DLQQ\D
,QWKLVPDWWHUDFWLQJ ,Q&XVWRPHU¶VLQWHUHVW $VDUHSUHVHQWDWLYHRUSUR[\IRUDQRWKHUSDUW\ 7UXVWHH 2WKHU
No. Telepon :   No. Fax : 
7HOHSKRQH1R )D[1R
  Alamat(PDLO : «««««««««««««««««««««««««
(PDLO$GGUHVV $ODPDWHPDLO LQLDNDQGLJXQDNDQXQWXNSHQJLULPDQH6WDWHPHQW
7KLVHPDLODGGUHVVZLOOEHXVHGIRUWKHGHOLYHU\RIH6WDWHPHQW

Tanggal Berdiri :   Tempat Pendirian : «««««««««««««««««««««««««


'DWHRI(VWDEOLVKPHQW 3ODFHRI(VWDEOLVKPHQW
NPWP :
7D[,'1R
Pendapatan per Tahun :  ”0LOLDU  !0LOLDU0LOLDU  !0LOLDU0LOLDU  !0LOLDU
,QFRPHSHU<HDU ”%LOOLRQ !%LOOLRQ%LOOLRQ !%LOOLRQ%LOOLRQ !%LOOLRQ

Sumber Dana :  +DVLO8VDKD  +DVLO,QYHVWDVL  /DLQQ\D ««««««««««««««««««««««««««««


6RXUFHRI)XQGV %XVLQHVV3URFHHGV ,QYHVWPHQW3URFHHGV 2WKHU
Nama Referensi : «««««««««««««««««««««««««««
1DPHRI5HIHUHH
STRUKTUR KEPEMILIKAN BADAN USAHA
6758&785(2)&25325$7(2:1(56+,3
No. Tanda Pengenal Kewarganegaraan
Nama (KTP/Paspor) NPWP 1DWLRQDOLW\ Negara Tempat Lahir Jabatan
1DPH ,GHQWLW\&DUG1R 7D[,'1R WNA /WNI Negara &RXQWU\RI%LUWK 7LWOH
.733DVVSRUW WNA/WNI &RXQWU\



STRUKTUR KEPENGURUSAN BADAN USAHA
6758&785(2)&25325$7(0$1$*(0(17
No. Tanda Pengenal Kewarganegaraan
Nama (KTP/Paspor) NPWP 1DWLRQDOLW\ Negara Tempat Lahir Jabatan
1DPH ,GHQWLW\&DUG1R 7D[,'1R WNA /WNI Negara &RXQWU\RI%LUWK 7LWOH
.733DVVSRUW WNA/WNI &RXQWU\



PROFIL PELANGGAN
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1. Badan Usaha/Badan Hukum ini merupakan Badan Usaha/Badan Hukum Amerika Serikat (AS) <D 7LGDN
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Paraf: ___________ 3/6


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