Account Opening Kit for Individuals

Account Application and Customer Account Agreement
Account Registration

IndividualJoint AccountIndistinct
Primary Signature:
First Name:*
Second Name:
Last Father's Name:*
Last Mother's Name:
Date of Birth:*

MonthDayYear
Physical Address, (not a P.O. Box):*
City:*
State:*
Country:*
Zip Code:*
Type of Residence*

OwnRentNot applicable
Residential Telephone:*
Mobile:*
Email:*
example@example.com
Spouse's Name, if applicable:
Mailing Address, (if different from above):
City:
State
Country:
Zip Code:
Gender:*

FM
Marital Status*

SingleMarriedDivorcedWidowed
Number of Dependents:*
Country of Citizenship:*
Nationality:*
Country of residence where you pay taxes, if it is different from the country of citizenship:
Tax ID number:
Employment Status*

Employed/Not OwnerBusiness OwnerRetiredStudentHomemakerNot employed
Occupation:*
Profession:*
Employer or Business Name:
Nature of Business/Type of Industry:
Department:
Years of service:
Annual salary(in local currency):
Mailing Address of employer or Business:
City:
State:
Country:
Zip Code:
Employer web page:
Telephone:
Other annual income (in local currency), if apply:
Details of other income:
Identification Method
Copy of passport is mandatory in addition to a second ID.*

Passport
Passport Number:*
City / Country of Issuance:*
Issue Date: (month/day/year)*

MonthDayYear
Expiration Date: (month/day/year)*

MonthDayYear
Identification 2
Type of identification:*
Identification number:*
City / Country of Issuance:*
Issue Date: (month/day/year)*

MonthDayYear
Date
Expiration Date: (month/day/year)*

MonthDayYear
Date
Account details (Select more than one, if necessary)
Type of Account:*

Checking with Debit CardChecking without Debit CardCODSavings
Terms of COD:
Amount USD:
Purpose of the account:*

Personal PaymentsSavingsOtherPersonal Investments
Specify:
Bank Reference
Bank Name:*
City:*
State:*
Account Number:*
Telephone Number:*
Information related to USA Patriot Act
Estimated amount of the initial deposit in dollars:*
Origin of the initial deposit funds:*
Source of wealth of the initial deposit: (If the initial deposit is greater than 100,000 USD)
Estimated number of monthly operations to be performed in the Bank
Origin of funds of future deposits. Select all the options that correspond:*

Income from professional activitiesInvestment incomeSale of assets / propertiesHeritage, gift or donationIncome from insurancePension or savingsSale of participation in businessSalary for employmentOther
Specify:
Check Movements
Expected amount in USD for check deposits:*

1 - 10,000.0010,000.01 - 15,000.0015,000.01 - or more
Number of checks expected to be deposited monthly:*

1 - 1011 - 2021 - or more
Expected monthly amount in USD for issuance in checks:*

1 - 10,000.0010,000.01 - 15,000.0015,000.01 - or more
Number of checks expected to be issued monthly:*

1 - 1011 - 2021 - or more
Electronic Bank Transfers
Amount expected to receive monthly in USD through transfers:*

1 - 25,000.0025,000.01 - 75,000.0075,000.01 - or more
Number of transfers you expected to receive monthly:*

1 - 1011 - 2021 - or more
Expected amount of monthly shipments in USD through transfers*

1 - 25,000.0025,000.01 - 75,000.0075,000.01 - or more
Number of transfers you expect to send monthly:*

1 - 1011 - 2021 - or more
Indicate from where you expect to RECEIVE deposit transfers
Countries:*
Purpose:*
Person:
Company:
Indicate where you expect to be sending wire transfers
Countries:*
Purpose:*
Person:
Company:
Access only by Internet
Signers expressly authorize Intercam Banco Internacional Inc., to use the Internet as the only communications channel. Account statements sentby other means will incur in a $10.00 surcharge per statement. The Client needs to request a PIN to access Intercam Banco Internacional Inc.,Online services. The signers understand and agree that if Intercam needs to notify or request additional documentation or information related tothe account, we authorize electronic contact through one of the following methods:
Email:*
example@example.com
Telephone: *
Mobil: *
Fax:
To regain access to your account without your PIN, please answer the following security questions.
Name of your middle school:
What is your favorite color:
Your first employer
Name of your maternal grandmother:
Name of your favorite pet:
What is your favorite sport:
Tax Certification for U.S. Persons, including U.S. Citizens and U.S. Resident Aliens

Tax Certification: By signing this Account Application, each Account Owner certifies under penalties of perjury as follows:
Primary Account Owner (A), Secondary Account Owner (B), and all additional owners (C & D) must check the corresponding box
A*

1. I am a U.S. citizen (including a U.S. resident alien). The Tax ID I have provided on this Account Application is my correct taxpayer identification number2. I am not a U.S. person (including a U.S. resident alien), I am submitting the applicable Form W-8BEN with this application to certify my foreign status.
* Select only one option.
B

1. I am a U.S. citizen (including a U.S. resident alien). The Tax ID I have provided on this Account Application is my correct taxpayer identification number2. I am not a U.S. person (including a U.S. resident alien), I am submitting the applicable Form W-8BEN with this application to certify my foreign status.
* Select only one option.
C

1. I am a U.S. citizen (including a U.S. resident alien). The Tax ID I have provided on this Account Application is my correct taxpayer identification number2. I am not a U.S. person (including a U.S. resident alien), I am submitting the applicable Form W-8BEN with this application to certify my foreign status.
* Select only one option.
D

1. I am a U.S. citizen (including a U.S. resident alien). The Tax ID I have provided on this Account Application is my correct taxpayer identification number2. I am not a U.S. person (including a U.S. resident alien), I am submitting the applicable Form W-8BEN with this application to certify my foreign status.
* Select only one option.

	Yes	No
• Are you or any of the account owners an employee of Intercam Banco Internacional, Inc. or any of its affiliate companies?

	Yes	No
• Are you or any of the account owners related to an employee of Intercam Banco Internacional, Inc. or any of its affiliate companies?

If yes, please provide name of the employee and relationship to you.
Public Figure Questionnaire

	Yes	No
Are you, or other account owner, or beneficiary or anyone with any interest in this account a public figure? – “Public Figure” is defined for these purposes as a current or former senior official in the executive, legislative, administrative, military, or judicial branches of a foreign government, whether or not they are or were elected officials; a senior official of a major foreign political party; and a senior executive of a foreign government-owned commercial enterprise. This definition also includes a corporation, business, or other entity formed by or for the benefit of such an individual. Senior executives are individuals with substantial authority over policy, operations, or the use of government-owned resources.

If yes, please provide details, including all positions and titles held, and dates held:

	Yes	No
Is any immediate family member or close associate of yours a public figure, as defined above?

If yes, please provide details, including all positions and titles held, and dates held:
__________________________________________________________________________________________

Federal law requires financial institutions to obtain, verify, and maintain records of information that identifies each person who establishes an account with the institution. This is intended to help the Government of the United States of America and its territories to combat the financing of terrorism and money-laundering activities. When you apply for an account you will be asked for name,
residential or physical address, date of birth and other information, as well as the documents that allow us to identify it.
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AGREEMENT:
OF THE FIRST PART, the depositor (or depositors) that subscribes to the fit, (hereinafter referred to as '' The Depositor ''

IN THE SECOND PART, Intercam Banco Internacional Inc, a banking entity organized and doing business under the laws of the Commonwealth of Puerto Rico, and represented in this act by the officer indicated below, who is duly authorized to campaign in this act in representation of Bank Whose faculties will credit as many times as necessary, (hereinafter referred to as "the bank"

All of represented parties acknowledge to be within their civil rights and to possess all necessary faculties required to perform this agreement. THEREFORE, the Depositor authorizes the Bank to begin investigations into the Depositor's credit, banking habits, personal or commercial references necessary for the opening of this account.

THEREFORE, according to the dispositions set forth by the "Unlawful Internet Gambling Enforcement Act" of 2006 and the GG Regulation, the Depositor certifies that he/she does not take part in the gambling business or illegal games of chance, or that accepts payments related with a person's participation in illegal games of chance or gambling over the Internet. Furthermore, the Depositor certifies that it will not process or will process any type of transactions (debit or credit, including and not limited to, ACH transactions or wire transfers) related to games of chance or gambling over the Internet through the accounts or products acquired with the Bank. The Depositor will not use services offered by the Bank in relation to those types of gambling and games of chance. The Depositor understands and accepts that the Bank will close all accounts and it will end all commercial relationships if at any moment the Depositor uses any products or services offered by the Bank for the payment, deposit or any other transaction related to gambling and games of chance over the Internet.

THEREFORE, the Depositor, with the sole purpose to induce the Bank to offer the services, based on the information supplied to the Bank in the aplication documents related to such services, signs and adheres to the terms and conditions in this Application and in the Deposit Accounts Agreement.

THEREFORE, the Depositor certifies to have received the Deposit Accounts and Other Banking Services Agreements, the disclosure of Information and Characteristics of Deposit Accounts and the Interest Rates Disclosure, when dealing with Savings and Checking Accounts. The Bank’s Privacy Policy, Terms and Conditions of the products contracted and the Electronic Account Statement Agreement.

THEREFORE, considering the services of deposit accounts and considering the credit lines covered by such services and other services that the Bank will lend and the mutual lending and counter-lending of value, the Depositor will submit to the norms and procedures of the Bank, to the dispositions of this request and to the dispositions of the Deposit Account and Other Banking Services Agreement.

THEREFORE, The depositor recognizes and agrees that the deposits available through the Bank are not insured by the Federal Deposit Insurance Corpo ration (FDIC), and are not deposits or other obligations of any other financial institution, and are not warranted by any other financial institution, and involve risk of investment, including the possible loss of capital.
THIS APPLICATION AND CONTRACT WILL BE ENFORCED ONCE THEY ARE APPROVED AND SUBSCRIBED BY AN INTERCAM BANCO INTERNACIONAL INC., AUTHORIZED OFFICER AND ALL THE ACCOUNT OPENING DOCUMENTS (CORPORATE RESOLUTION, ARTICLES OF INCORPORATION TWO FORMS OF IDENTIFICATION AND FINANCIAL STATEMENT) ARE RECEIVED IN TESTIMONY TO WHICH WE SUBSCRIBE THIS APPLICATION,
Date*
Month*
Year*
* Incorrect Date
Principal Client Signature*

Clear
Date (month/day/year)*

MonthDayYear
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SECURITY PROCEDURE

The client understands and agrees that the authenticity of all transfer requests made will be verified according to the following parameters:

- The Bank, at the time of authenticating your request, will ask you to provide some personal information, which will be compared to the previously provided with the account application.

- The Bank will confirm the payments according to the limitations established for each one of the authorized signers.

CONDITIONS FOR THE CONFIRMATION OF TRANSFERS
Please select one of the following options:*

We agree with the standard confirmations made by the Bank. We wish to confirm all transaction requests considering the following parameters (See table below):I want the bank to confirm ALL our transfer requests regardless of the amount.I DO NOT want to receive confirmation calls for ANY of our transfer requests.
To secure your funds, the bank will make a confirmation call via telephone to the client, to verify the transfer request's authenticity. The bank will only be considering the data provided by the client in the account opening request.

ADDITIONAL SUPPORTS

The client understands that due to bank procedures, supporting documents may be required to support the payment he is making.

The client understands that these documents can be requested at any time by the Bank, even after they have been processed.

The request for additional supporting documents will be sent to the email designated by the client.
Name:*
Account Number:
Signature*

Clear
Date:*

MonthDayYear
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FACTS	WHAT DOES INTERCAM BANCO INTERNACIONAL INC., DO WITH YOUR PERSONAL INFORMATION?
Why?	Financial companies choose how they share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do.
What?	The types of personal information we collect and share depend on the product or service you have with us. This information can include: • social security number and income • account balance and payment history • credit history and credit scores
How?	All financial companies need to share customers’ personal information to run their everyday business. In the section below, we list the reasons financial companies can share their customers’ personal information; the reasons Intercam Banco Internacional Inc., chooses to share; and whether you can limit this sharing.

Reasons we can share your personal information	Does Intercam Banco Internacional Inc., share?	Can you limit this sharing?
For our everyday business purposes - such as to process your transactions, maintain youraccount(s), respond to court orders and legal investigations, or report to credit bureaus	Yes	No
For our marketing purposes to offer our products and services to you	Yes	No
For joint marketing with other financial companies	Yes	No
For our affiliates’ everyday business purposes information about your transactions and experiences	Yes	No
For our affiliates’ everyday business purposes information about your creditworthiness	Yes	Yes
For our affiliates to market to you	Yes	Yes
For nonaffiliates to market to you	No	No

To limit
our sharing

• Call 800-099-0259 - our menu will prompt you through your choice(s)
• Visit us online: www.intercam.com.pr
• Send us the exclusion request that is included below

Please note:
If you are a new customer, we can begin sharing your information 30 days from the date we
sent this notice. When you are no longer our customer, we continue to share your information
as described in this notice.

However, you can contact us at any time to limit our sharing.

Questions? Call 800-099-0259 or go to www.intercam.com.pr
NO NEED TO COMPLETE if previous option was not to share your information.
Mark any/all you want to limit:

Do not share information about my creditworthiness with your affiliates for their everyday business purposes.Do not allow your affiliates to use my personal information to market to me.Do not share my personal information with nonaffiliates to market their products and services to me.
Leave Blank or [If you have a joint account, your choice(s) will apply to everyone on your account unless you mark below.

Apply my choices only to me]
Name
Address
City,State
Zip Code
Account Number
Send to:
Intercam Banco
Internacional Inc.
info@intercam.com.pr
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Page 2

Who we are
Who is providing this notice?	Intercam Banco Internacional Inc.,. and its affiliates (see definition below).
What we do
How does Intercam Banco Internacional Inc. protect my personal information?	To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured files and buildings. In addition, we limit access only to employees to provide products, services or to comply with local and federal regulations.
How does Intercam Banco Internacional Inc., collect my personal information?	We collect your personal information, for example, when you • open an account or deposit money • pay your bills or apply for a loan • use your credit or debit card We also collect your personal information from others, such as credit bureaus,affiliates, or other companies.
Why can’t I limit all sharing?	Federal law gives you the right to limit only • sharing for affiliates’ everyday business purposes information about your creditworthiness • affiliates from using your information to market to you • sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. See below for more on your rights under state law.
What happens when I limit sharing for an account I hold jointly with someone else?	Your choices will apply to everyone on your account unless you tell us otherwise.

Definitions
Affiliates	Companies related by common ownership or control. They can be financial and nonfinancial companies. • Our affiliates include companies with a Intercam name.
Nonaffiliates	Companies not related by common ownership or control. They can be financial and nonfinancial companies. • Intercam Banco Internacional Inc., does not share with nonaffiliates so they can market to you.
Joint marketing	A formal agreement between nonaffiliated financial companies that together market financial products or services to you. • Intercam Banco Internacional Inc., Our joint marketing partners.

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Dear Customer:

Since July 1st, 2014, Foreign Account Tax Compliance Act (FATCA) under the Internal Revenue Services of the United States (IRS) has been in effect. Some of the FATCA requirements includes due diligence when opening of a deposit account (Checking, Savings, CDs and IRAs), or when the customer changes its residential address. The customer must comply with the requirements of due diligence, which consists of a declaration or statement certifying his/her place of residency by using one of the forms listed below. The form to be use depends on the type of customer and must be delivered to Intercam as evidence of the proper due diligence.

Requirements for the Customer at the Opening of the Account or when Changing Personal Circumstances on Deposit Accounts (Checking, Savings, CDs & IRAs):

• Complete and submit to Intercam the corresponding IRS form during the account opening day. The Regulation grants thirty (30) calendar days from the day of the opening of the account.

• Submit to Intercam within 90 calendar days from the date of changes in residency address or customer data in the account, known as: Change in Circumstances. Applicable changes are: Name, postal and residence address, especially if it is in the United States; and changes in percentages of shareholders’ participation (for legal entities).

• Customer will receive an annual disclosure of interest paid to the IRS (form 1099/1042 form, as applicable).

All IRS forms may be downloaded from their web page: www.irs.gov.

Intercam Responsibility in Case Customer Does Not Bring Required IRS Forms:

• Must withhold 28% to 30% of the income paid for monthly interest or as provided for the accounts maturity of deposit accounts (checking , savings, CDs and IRAs).

• The withholding will be effective according to the following time-table:

• Day 31st from the date of the opening of the account.
• Day 91st from the change in circumstances.
• No withholding of the income paid is performed once the required IRS forms in received.

• The customer’s withheld amounts under FATCA will be sent to the IRS as tax withheld to the customer's account.

• Intercam does not benefit of the withholding, it is an obligation imposed by the IRS and FATCA.

For any claim about withholdings made to your account you should visit: http://www.irs.gov/uac/Contact-My-Local-Office-in-Puerto-Rico.

By signing this release, you confirm that you were properly oriented on the responsibility of completing the FATCA form/certification applicable at the opening of an account or when change of address; and the withholding of 28% to 30% of the income paid if the corresponding form pursuant the above mentioned table is not deliver to Intercam under FATCA Regulation.
Customer Name*
Signature*

Clear
Effective Date (mm/dd/yyyy)*

MonthDayYear
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Accept terms and conditions
Full Name*
Signature*

Clear
Date

MonthDayYear
DateHourMinutesAM/PM Option
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Please include the following documents in this section:
- Copy of valid passport in color
- Copy of a secondary identification in color
- Proof of address (no more than 90 days after its issuance) eg: electricity, water, gas, Cable TV
- Bank Reference (no more than 90 days after its issuance)
- Proof of income
If you need more information you can contact us by email customer_services@intercam.com.pr or toll-free 800-099-0259
Attach these files to the Account Application

Browse

Cancelof
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Should be Empty:

Account Application and Customer Account Agreement

Primary Signature:

Identification Method

Bank Reference

Access only by Internet

AGREEMENT: