Clearshift application form for non-residents and their representatives

New Customer Intake Form

End of Part I

Part II

Standing Instruction (recommended but not required)

Identifying Information about you, the Ultimate Customer

Employment Status - current or most recent employment

Provide details of your current or former employment

Identity of your spouse(or legally recognized partner) (optional, but required if the spouse(or legally recognized partner) is to be added to the account or is the primary source of funds)

Information about Politically Exposed Persons (PEP)

Other Background Information

Identification Verification for the you (the Ultimate Customer):

Information about the anticipated money flows in your account

Source bank account details

Destination bank account details

Anticipated initial and ongoing levels of transfers

Source of funds/wealth (Note: The following information is required for compliance with anti-money laundering regulations)

Purpose of transfer(s)

Tax Residency Self-Certification Form for FATCA and CRS Purposes

Declaration of Beneficiaries

Appointment of Representative

Identifying Information about you, the representative

Ultimate Customer Identity

Information about Politically Exposed Persons (PEPs)

Other Background Information

Identification Verification for the Person Submitting This form:

Power of Attorney:

Certification

Declaration of Beneficiaries

*Please note. If at any time you need to stop and you want to save your progress, you will need to scroll down to the bottom and press the "Save" button. By doing so you will be provided a link (or an email with the link) to continue the form at a later time.

Israeli National?

Name (in Hebrew)

First Name (in Hebrew)Middle Name (in Hebrew)Last Name (in Hebrew)

Teudat Zehut number

Full legal name in English(as it appears in official documents):

Name

First NameMiddle NameLast Name

Passport #:

Passport country 2-letter ISO code:

Gender:

Nickname, other names, alias, maiden name etc.:

Date of birth

MonthDayYear

Country of birth 2-letter ISO code

Address of main residence:

Street #

Street Name

City

State/Province

Postal/Zip Code

Country

Email:

Mobile #:

Country CodeArea CodePhone Number

Is your spouse(or legally recognized partner) the primary wage earner? If you answered yes, please provide the employment info for your spouse(or legally recognized partner) in this form (as opposed to for yourself).

Full English Name of Spouse(or legally recognized partner):

Employment Status of the primary wage earner

If you indicated retired, how many years have you been retired?

If you indicated above “no relevant employment history”, please indicate your status:

Please explain:

Name of your current or former employer or, if self employed, the name of your business:

Professional occupation or the nature of your current or former job /work:

Official title at the current or former employer, trade or business:

Approximate # of years you were employed or self employed

Industry description that you are or were employed in:

Website/Facebook page of the current or former employer or business (if one does not exist please type N/A):

Your personal LinkedIn profile page URL/link (if you do not have one please type N/A):

For self-employed, indicate the legal form of the business:

Name:

Date of birth

MonthDayYear

Is your spouse(or legally recognized partner) an Israeli national?

Teudat Zehut #

Passport #:

ID Country 2-letter ISO code:

A Politically Exposed Person (PEP) is:

Someone bearing a senior public position, whether in Israel or any other country, such as an elected government official (including head of state, president, mayor, member of parliament/government) or senior appointee, high-ranking military or police officer, judge or the like, even if their title is not identical
“Close Family Member - spouse, sibling, parent, grandparent, child/stepchild, grandchild of a PEP, or the spouse of one of the aforementioned, who bears such a position
“Close Associate” - someone who has a close personal connection with a PEP, including someone in a position to carry out significant financial transactions (local or international) on behalf/or in cooperation with a PEP.

Are you or the ultimate customer, or any close family member or close associate of yours or theirs a PEP?

PEP's Name

PEP's Public Position

PEP's 2-letter ISO code:

Please provide details regarding the PEP relationship to the representative/ultimate customer:

Have you ever been refused banking services for reasons connected to money laundering/ funding of terror/ financial sanctions?

Please explain

Are you acting on someone else’s behalf, holding someone else’s funds in the account, or receiving, or transferring funds on their behalf?

please specify:

Main ID document: Israeli driver’s license, Teudat Zehut or passport; for non-Israelis: only your foreign passport is acceptable

2nd ID document: a government-issued photo ID with your ID number (can be another one from the Main ID document list). Inquire about other acceptable 2nd ID documents, if you are having difficulty.

Receiving funds directly from bank accounts not in your name will be allowed in limited circumstances; is subject to review and approval of additional documentation to be requested; and requires a satisfactory explanation of the need to receive directly from the third party and not from your own bank account.

Source Bank account details

Is your source bank account in Israel?

Israeli bank account details

Bank code:

Branch code:

Account #:

Is your spouse or another person listed on the account

Spouse or other person's name

Relationship

IBAN of my Israeli bank acccount

IBAN#:

Is your spouse or another person listed on the account

Spouse or other person's name

Relationship:

Foreign bank account details

Name on foreign source bank account

IBAN/Account #

Bank account country

Name of US bank

Routing # of US bank

Currency of foreign bank account

What year did you last reside in the foreign country

Attach an image of a check, statement or חשבון ניהול אישור.

Note that, depending on the owners of the bank account(s) which you intend to send/receive from/to, and the types of ID documents submitted, we may need to either (1) arrange a video session to remotely verify your identity or (2) schedule a face-to-face meeting with a Clearshift representative or messenger, who will collect the originals of some of the forms and verify your identity in person. Documentary verification of the residential address provided is not required.

Attach a valid ID for your spouse or other person listed on the bank account

Do you have a destination bank account where you want to send your funds?

Is your destination bank account in Israel?

Israeli bank account details

Bank code:

Branch code:

Account #

Is your spouse or another person listed on the account

Spouse or other person's name

Relationship

IBAN of my Israeli bank acccount

IBAN#:

Is your spouse or another person listed on the account

Spouse or other person's name

Relationship:

Foreign bank account details

Name on foreign destination bank account

Bank account country

Name of US bank

Routing # of US bank

IBAN/Account #

Currency of foreign bank account

What year did you last reside in the foreign country

For the above bank account, attach an image of a check, statement or חשבון ניהול אישור.

For the above bank account attach a valid ID for your spouse or other person listed on the bank account unless provided previously

*Please approximate amounts in $USD

I anticipate transferring:

Amount of one time transfer ($USD)

Approximate $USD to be transferred annually:

Approximate Number of transfers on a monthly basis:

Total estimated amount in $USD to be transferred in connection with the purchase of a home

The transfer amounts will range in size from ($USD):

My first transfer amount will be:

It needs to be completed:

please specify:

Are you married?

If married, please indicate if you or your spouse(or legally recognized partner) is the primary source of wealth

Regarding your source of wealth, check all that are applicable and provide relevant details in the text box below

If you are an Osek Murshe and plan to use Clearshift to send or receive payments to or from 3rd parties, please check this box and we will send you a separate form to filll out about these transactions

Please provide a fuller description of your source of wealth here

(Attach supporting documentation if available):

Sending funds directly to bank accounts not in your name will be allowed in limited circumstances; is subject to review and approval of additional documentation to be requested; and requires a satisfactory explanation of the need to send directly to the third party and not to your own bank account

Please check all that are applicable

Full Description Here

(Attach supporting documentation if available):

If purchasing a home, please check all that are applicable

I would like Clearshift to directly make payments to the following parties in connnection with my home purchase

Please describe in detail any additional money flows not already described above

Certification:

I, {nameEng}{nameinHeb}, certify that (1) I have examined the information on this form and that (2) to the best of my knowledge, all of the information provided in this form and other attached forms is true, accurate and complete. I agree to notify Clearshift Israel Ltd promptly of any change in the information that I have provided. I am aware that providing false information, including failure to provide updates of a reportable information item, to prevent the filing of a report, or in order to cause an incorrect report filing pursuant to Section 7 of the Israel Prohibition on Money Laundering Law, constitutes a criminal offense.

To be signed electronically after form is approved.

Tax Information (to be provided pursuant to section 135c of the Israel Tax Ordinance)

The following information is being requested from you, as required by law, for the purpose of determining whether the Account Beneficial Owner is a foreign tax resident. You acknowledge and consent that information on the Account Beneficial Owner will be shared with the relevant authorities in Israel or abroad and with other companies in the Clearshift group.

Tax Residency Declaration - Under penalties of perjury, I certify that:

US Tax ID Number

Additional tax residencies (excluding US and Israel)?

II. I am a tax resident of the following countries and no others (not including Israel or US):

Rows	Country	Tax ID Number	if no local tax Id number, state reason
1
2
3

3: Declaration:
I, {nameEng}{nameinHeb}, certify that I am the beneficial owner of all the account(s) to which this form relates. Under penalties of the law, I declare that: (i) I have examined the information on this form; (ii) that, to the best of my knowledge, all of the information provided in this form is true, accurate and complete; (iii) that I am NOT a tax resident of any country other than the countries disclosed above. The account will not be used to avoid any Israeli or foreign reporting or tax obligations that may apply to me pursuant domestic and international laws. In any event of a change in the information provided in this form, I undertake to submit a new form within 30 days.

To be signed electronically when the form is accepted.

Name (set)

Passport # (set)

ID Number (Teudat Zehut) (set)

Country code of Passport (set)

I, the Ultimate Customer, hereby declare that I am requesting, via my representative, the regulated financial services:

*If no ID number is provided in the table above, provide the individual’s address, birth date and gender below

I, {nameEng}{nameinHeb}, hereby legally obligate myself to inform the regulated financial services provider, in writing and at the earliest possible opportunity, regarding any change in the information provided above; I am aware that providing false information, including failure to provide updates of a reportable information item, to prevent the filing of a report, or in order to cause an incorrect report filing pursuant to Section 7 of the Israel Prohibition on Money Laundering Law, constitutes a criminal offense.

To be signed electronically after the application is completed.

**A Beneficiary is a person who, on his/her behalf of or for his/her benefit, property is being held or transacted in or who has the ability to direct a transaction in such property, whether directly or indirectly.

Name of Representative

First NameMiddle NameLast Name

Nature of the Relationship with the Representative (lawyer, family member, etc..)

Authorization from the ultimate customer:

I, {nameEng}{nameinHeb}, authorize the representative listed directly above to open up an account in my name and in trust for my benefit with Clearshift (Israel) Ltd and to exercise authority and perform any act on my behalf in connection with my Clearshift account, including transfers to his/her own account. All orders and transactions will be governed by the Clearshift Account Terms and Conditions, a copy of which was made available to me and to the representative.

To be signed electronically once the form is accepted.

Email address of your Representative

example@example.com

You have reached the end of your section. Please enter the email address of your representative above and click submit. The form will be forwarded to your representative for completion. Please contact your representative after submitting the form to confirm that he receives an email with the link. Please contact us if you need any assistance in this regard.

Sincerely.

The Clearshift Team

First Name

Country code

Beneficiary Type