Agent Banking Personal Questionnaire – Specimen Response

AGENT BANKING PERSONAL QUESTIONNAIRE

APPLICABLE FOR PROPOSED SUBSTANTIAL SHAREHOLDERS, DIRECTORS, OFFICERS, AND PRINCIPAL AGENT BANKING EMPLOYEES OF COMPANIES APPOINTED OR PROPOSED TO BE APPOINTED AS AGENTS UNDER SECTION 108 OF THE BANKING SERVICES ACT, 2014

Instructions: a) Please answer all questions in the spaces provided. b) Where the question is not applicable, please indicate N/A. c) In the event that there are unanswered questions, please note that the Personal Questionnaire will be returned for completion.

SECTION I

1(a)	Name of agent* or proposed agent in connection with which this questionnaire is being completed.	Maribec Limited
1(b)	Name of Deposit Taking Institution in connection with this questionnaire is being completed.	Trust Fund Bank Limited
		Position/Relationship	Start Date (MM/DD/YYYY)
1(c)	Position or relationship with the agent or proposed agent.	Managing Director	4-Jan-15

SECTION II - BIOGRAPHICAL INFORMATION

(Please provide a certified passport-sized colour photograph and attach to the Personal Questionnaire)

		First Name	Middle Name(s)	Last Name
2(a)	Given Name	Michelle	Andrea	Bourdain
2(b)	Other Names Used (Trade Names, Aliases)	Chelle		Bourdy
2(c)	Please state maiden name, if applicable			Black
2(d)	Gender	Female
2(e)	Marital Status	Married
2(f)	Home Address
	Address 1	270 Julius Caesar Avenue
	Address 2	N/A
	Address 3/City	Kingston 9
	Parish/State	St. Andrew
	Postal / Zip Code	N/A
	Country	Jamaica
2(g)	Address of Employment/Business
	Address 1	13 High Street
	Address 2	N/A
	Address 3/City	Kingston 5
	Parish/State	St. Andrew
	Postal / Zip Code	N/A
	Country	Jamaica
2(h)	Occupation	Human Resource Practitioner
2(i)	Taxpayer Registration Number (issued by Tax Administration Jamaica. If not applicable, please indicate N/A in the space provided and complete passport information in question 2(n))	111-102-000
2(j)	Place of Birth
	Parish or City & State	St. Andrew
	Country	Jamaica
2(k)	Date of Birth (MM/DD/YYYY)	12-Dec-70
2(l)	Nationality	Jamaica
2(m)	If Naturalized Citizen, indicate:
	Date of Naturalization (MM/DD/YYYY)	N/A
	Certificate No.	N/A
2(n)	If not Jamaican, complete the following:
	Work Permit Number	N/A
	Passport No. or other unique Identification Number (ID)	N/A
	Place of Issue of Passport or other ID mentioned above	N/A

• An agent is a company, other than a deposit taking institution (DTI), which has been appointed by a DTI under section 108(1) of the BSA to carry out one or more banking services specified in that section.

3	State all the places (local or international) where you have resided for six or more months after attaining the age of eighteen. Also include the period of residence
Street Name	City/Parish	Country	From	To
270 Julius Caesar Avenue	St Andrew	Jamaica	2015	present
15 Forrester Patch	St Ann	Jamaica	1998	2015
4975 Daubon Lane	Atlanta	USA	1993	1998
57 Wedgewood Crescent	Kingston	Jamaica	1987	1993

SECTION III - CONNECTED PARTY INFORMATION

4(a)	Information on Immediate Relatives:	Spouse	Father	Mother
	First Name	John	Webster	Maureen
	Middle Name	Washington	Alexander	Margaret
	Last Name	Bourdain	Black	Black
4(b)	Other Names Used (Trade Names, Aliases, Pseudonyms for professional reasons).	Johnny B	N/A	N/A
4(c)	Taxpayer Registration Number (issued by Tax Administration Jamaica. If not applicable, please indicate N/A in the space provided and complete passport information below)	100-111-100	120-787-100	118-454-100
	Passport or other unique Identification Number (ID)	N/A	N/A	N/A
	Place of Issue of Passport or other ID mentioned above	N/A	N/A	N/A
4(d)	Home Address	Spouse	Father	Mother
	Address 1	270 Julius Caesar Ave	475 Hamilton Ave	Jeffers Ville
	Address 2	N/A	N/A	N/A
	Address 3/City	Kingston 9	Morris Town	Jeffers Ville PA
	Parish/State	St Andrew	New Jersey	St Mary
	Postal / Zip Code	N/A	08045	N/A
	Country	Jamaica	USA	Jamaica
4(e)	Address of Employment/Business	Spouse	Father	Mother
	Address 1	45 Brownlow Ave	Retired	Retired
	Address 2	N/A	N/A	N/A
	Address 3/City	N/A	N/A	N/A
	Parish/State	Kingston 2	N/A	N/A
	Postal / Zip Code	N/A	N/A	N/A
	Country	Jamaica	N/A	N/A
4(f)	Nationality	French	Jamaican	Jamaican
4(g)	Address(es) while living overseas	Spouse	Father	Mother
	Address 1	357 Rue Pasteur	See Above	475 Hamilton Ave
	Address 2	N/A	N/A	N/A
	Address 3/City	Cabourg	N/A	Morris Town
	Parish/State	N/A	N/A	New Jersey
	Postal / Zip Code	14930	N/A	08045
	Country	France	N/A	USA

Name (Print): Michelle Bourdain
Revised June 2017
Date: 11 July 2017

4(h)	Particulars of children over the Age of 18 years (please include step-children)
	First Name	Middle Name(s)	Last Name	TRN (or equivalent ID number for overseas jurisdiction)
	Giselle	Genevieve	Bourdain	100-100-100

SECTION IV - EMPLOYMENT/ACADEMIC PROFILE

5(a)	Give details of your employment history up to the filing date of this questionnaire, including for each place of employment: details of the type of business; your job title and the duties attached to your position; the dates of employment, the name and address of your employer(s) and reason(s) for leaving. See sheet "Question 5(a)"

5(b)	Provide information for two references.	First Name	Last Name	Position/Occupation	Telephone No.	Email Address
		John	Doe	Lecturer	(876) 333-3331	joed@yahoo.com
		Jane	Brown	Lawyer	(876) 444-4141	janed@gmail.com

5(c)	Give details below of your educational and your professional qualifications and affiliations, if any, including relevant dates.	Qualification	Institution	Year Conferred
		PhD - Finance	Berk University	2010
		MSc - Economics	George State Uni.	1998
		BSc - Finance & Econ	George State Uni.	1993

SECTION V - Kindly indicate 'Y' for 'YES' or 'N' for 'NO' for all questions in this section. If the answer to any question in this section is 'YES', please give details in the Comments column.

	PROFESSIONAL CONDUCT	Yes/No (Enter Y for Yes and N for No)	COMMENTS
6
6(a)	Have you at any time been charged with or convicted of any offence or otherwise found liable by a Civil, Criminal or Military Court (excluding minor road traffic offences) whether in Jamaica or elsewhere? If charged, please give details of the charge, and the outcome of the matter (eg. whether the charges were dropped or court proceeding started and the outcome of those proceedings). If convicted, the date of conviction and full particulars of the offence (including any offences taken into consideration) and the penalty imposed. In relation to a civil proceeding, please state the complaint, the outcome of the matter (eg. whether the complaint was withdrawn, court proceedings started and the outcome of those proceedings) and if a finding of liability was imposed, the date of the judgment or ruling and full particulars of the circumstances resulting in the civil proceeding (including any other complaint) taken into consideration and the penalty, sanction or remedy imposed.	N
6(b)	Has a suit ever been brought against you in your personal capacity? Please state if pending, and if not state how the matter was resolved in the comments column.	N
6(c)	Have you ever been the subject of any investigation or of disciplinary procedures, censured, disciplined or publicly criticised by any professional body or trade association or other body which operates in a representative capacity, to which you belong or have belonged whether in Jamaica or elsewhere? If yes, give details in the 'comment' column.	N

Name (Print): Michelle Bourdain
Revised June 2017
Date: 11 July 2017

6(d)	In connection with the formation or management of any legal person or arrangement, have you been adjudged by a Court civilly or criminally liable for any fraud, misfeasance or other misconduct towards that legal person or arrangement, or any member or customer thereof whether in Jamaica or elsewhere? If yes, give details in the 'comment' column.	N
6(e)	Have you ever been disqualified by a Court or by virtue of any statutory enactment from being a director or from acting in the management or conduct of the affairs of any legal person or arrangement whether in Jamaica or elsewhere? If yes, give details in the 'comment' column.	N
6(f)	Has a bankruptcy petition ever been served on you, or any legal person or arrangement in which you were a shareholder or held the position of director or manager in any jurisdiction? If yes, give details in the 'comment' column.	N
6(g)	Have you ever, in any jurisdiction
	i) Been adjudged bankrupt by a Court? If yes, give details in the 'comment' column.	N
	ii) Had a receiving or administrative order made against you? If yes, give details in the 'comment' column.	N
	iii) Had your estate seized? If yes, give details in the 'comment' column.	N
	iv) Entered into any arrangement, or other composition with your creditors? If yes, give details in the 'comment' column.	N
6(h)	Whether in Jamaica or elsewhere, have you ever been a shareholder, director of, or directly concerned in the management of a legal person or arrangement:
	i) Which has been served with a petition to wind up? If yes, give details in the 'comment' column.	N
	ii) Which has been wound up by a Court? If yes, give details in the 'comment' column.	N
	iii) The licence of which has been revoked? If yes, give details in the 'comment' column.	N
	iv) Which has been placed in receivership? If yes, give details in the 'comment' column.	N
	v) Which has entered into any arrangement or other composition with its creditors? If yes, give details in the 'comment' column.	N
	vi) Which has had an administrative order made against it? If yes, give details in the 'comment' column.	N
	vii) Which has been sued? If yes, give details in the 'comment' column.	N
	viii) Which has been charged by law enforcement authorities regarding the commission of a criminal offence? If yes, give details in the 'comment' column.	N
	ix) Which has been sanctioned for any criminal offence?	N
	x) Whose business has been adjudged to have been conducted imprudently or fraudulently? If yes, give details in the 'comment' column.	N
	xi) Which has failed to meet the solvency requirements prescribed by law or by a licensing or supervisory authority? If yes, give details in the 'comment' column.	N
	xii) To which financial assistance has been given by a government agency to effect a restructuring? If yes, give details in the 'comment' column.	N
	xiii) Which has been placed under Temporary Management/Judicial Management; which has been the subject of administrative censure or penalty; or formal statutory censure action or which has been the subject of a Vesting Order or any other intervention process by the relevant regulatory authority? If yes, give details in the 'comment' column.	N
6(i)	Whether in Jamaica or elsewhere, have you ever been a shareholder, director, or been directly concerned in the management or conduct of affairs of a legal person or arrangement which has become insolvent and/or gone into liquidation, whilst you were associated with it? If yes, give details in the 'comment' column including name of company and name and address of liquidator.	N
6(j)	Are you in compliance with tax and other statutory obligations imposed on you? If no, give details in the 'comment' column. If yes, please provide a copy of your Tax Compliance Certificate.	Y
6(k)	Has any bank or other financial institution with which you or any legal person or arrangement owned, controlled or managed by you ever threatened or commenced legal action/court proceedings or declined doing any new business with you or your legal person or arrangement as a result of outstanding debts owed by you or the legal person or arrangement, or due to your not honouring other facilities afforded you (e.g. guarantee, etc.) by these institutions? If yes, give details in the 'comment' column.	N
6(l)	Do you have any immediate relative who holds a position as a substantial shareholder director, officer, or key employee in the Deposit Taking Institution with which this questionnaire is being completed? If yes, give details in the 'comment' column.	N
6(m)	Are you currently a beneficial owner or shareholder (holding at least 5% of issued share capital) of any limited liability companies or other corporations engaged in financial services as defined in the Banking Services Act, 2014? If yes, please provide response in Sheet "Question 6 (m)"	N

Legal Person - This refers to a company or other body corporate.
Legal Arrangement - This includes a trust, partnership, or benevolent society, etc

Name (Print): Michelle Bourdain
Revised June 2017
Date: 11 July 2017

Declaration

	First Name	Middle Name	Last Name
I,	Michelle	Andrea	Bourdain

declare that the answers to the above questions are true and that I am fully aware that proceeding to act, knowing that I am not fit and proper whether this occurs through my submitting false or misleading information or withholding information which if submitted would most likely render me unfit, will constitute a breach of Regulation 11(1) of the Banking Services (Deposit Taking Institutions) (Agent Banking) Regulation, 2016 and may result in my being debarred from acting in the position indicated in this statement in relation to the agent for which this questionnaire is being completed. I further UNDERTAKE, that as long as I continue to be a substantial shareholder, director, manager/executive officer or key employee of the agent for which this questionnaire is being completed, I will notify the appointing DTI and the agent with which this questionnaire is being completed of any material changes to or affecting the completeness and/or accuracy of the information herein supplied by me as soon as possible, but in no event later than ten (10) business days from the day that the changes come to my attention.

Date: 11-Jul-17
Signature of Applicant: [Signature]
In the presence of:

	First Name	Middle Name	Last Name
Justice of the Peace (JP)/Attorney-at-Law/Notary Public	Richard	Kareem	Green

Signature of JP/Attorney-at-Law/Notary Public: [Signature] Affix Seal of Office, if JP, or Stamp of Office, if Attorney-at-Law/Notary Public

Please note the following:

1. Applicants are required to submit the following items along with the Personal Questionnaire and Schedules:
   a). A certified passport-sized colour photograph taken within the last six (6) months. b). Tax Compliance Certificate
2. Access to credit report will be required.

Name (Print): Michelle Bourdain
Revised June 2017
Date: 11 July 2017

Question 5(a)

Give details of your employment history up to the date of this questionnaire, including for each place of employment: details of the type of business; your job title and the duties attached to your position EMPLOYMENT PROFILE (List Current Employment First)

	Name of Entity	Address 1	Address 2	City/Parish	Zip / Postal Code	Country	Nature of Business	Job Title	Duties Attached to Your Position	Start Date (MM/DD/YYYY)	End Date (MM/DD/YYYY)	Reason(s) for Leaving
Co. 1	Maribec Ltd	13 High Street		Kingston 5		Jamaica	Bill Payment	Managing Director	Management of day to day operations	4-Jan-15
Co. 2	Johnny B Enterprise	13 Main Street	St Ann's Bay	St Ann		Jamaica	Haberdashery	Chief Financial Officer	Managed all the company's finances	25-Jul-98	31-Dec-14	Company restructuring
Co. 3	Sunrise Financials	12 Golfe Links Park		Atlanta	33339	USA	Tax Preparation	Chief Operating Officer	General management and tax preparation	8-Sep-94	12-Jun-98	Return to Jamaica

Revised June 2017
Name (Print): Michelle Bourdain
Declaration Date: 11 July 2017

Question 6(m)

Have you ever been or are you currently a beneficial owner or shareholder (holding at least 5% of issued share capital) in any limited liability companies or other corporations engaged in financial services as defined in the Banking Services Act? If yes, state:

	Name of Companies/ Societies/ Corporations	Address 1	Address 2	City/Parish	Zip/Postal Code	Country	Nature of Business	Number of Shares	Class of Shares Held	Date of Termination of Shareholding	Method of Termination of Shareholding
Co. 1	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A

Revised June 2017
Name (Print): Michelle Bourdain
Declaration Date: 11 July 2017