Application Form for Special Foreign Exchange License for One-Time Transfer to Own Foreign Account

APPLICATION FORM FOR A SPECIAL FOREIGN EXCHANGE LICENSE FOR A ONE-TIME TRANSFER TO OWN FOREIGN ACCOUNT (Based on the provisions, regulations, and conditions of the State Ordinance Foreign Exchange Transactions, AB 1990 No. GT 6)

1. Undersigned:
2. Applies on behalf of resident:
3. Address/Telephone/E-mail: _____/________________/
4. Nature of the transaction: _____________________________________________________________________
   For a special foreign exchange license for a transfer to own foreign account (outgoing transfer) for an amount of USD/Afl./EUR/other, viz.: …………….., (circle as appropriate or state different currency) _________________________ (state the amount). B.1 In case of natural persons, the name of the foreign bank and the bank account number have to be stated. Name foreign bank: Bank account number:
   B.2 In case of non-natural persons with (a) notified foreign bank account(s) and intercompany account(s) not included in the “Quarterly list of compliant holders of FBAs and FIAs”, the reporters code (X________) has to be stated. Name foreign bank: Bank account number:
   Name affiliated company:
   B.3 In case of non-natural persons with a non-notified foreign account, the name of the foreign bank or the name of the affiliated company (intercompany account(s)) and the bank account number have to be stated. Name foreign bank: Bank account number:
   Name affiliated company:
   Truthfully filled out and signed without withholding any facts known by applicant and of importance to the application. /_____ Applicant’s Signature / Date (day/month/year) _____________________________________________________________________________________________ SPECIAL FOREIGN EXCHANGE LICENSE ISSUED for the transfer stated under (in accordance with application):
   CBA/reference number: Date:
   Foreign exchange license no.: Transaction code:
   Centrale Bank van Aruba