Registered Deposit Brokers Association Clear Form

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Client Identity Verification Form
RDBA Member Number Broker Client #
Client Information
Title First Name Middle Name(s)
Dr.
Ms.
Mrs.
Mr.
Last Name Date of Birth Day Month Year
The Proceeds of Crime (Money Laundering) and Terrorist Financing Act11 1234567890(PCMLTFA) requires
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12 1234567890 that you verify
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client using original, valid and current documents or information from independent and reliable sources: (i) by viewing your client’s
government issued photo ID while in the presence of your client (photo ID method); or (ii) by referring to two separate documents or
information sources that each contain the client’s name and that contain two of the following: date of birth; address; confirmation of
the existence of an account with a financial entity (dual process method); or (iii) by referring to a Canadian credit file that has been in
existence for at least three years (credit file method).
Client ID verification method: Photo ID Dual process Credit file
Date the clients identity was verified for Photo ID method, Dual
Process method or Credit File inquiry date, as applicable Day Month Year
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Photo ID
Type of photo ID Reference #
Place of issue Province/State Country
Expiry date Day Month Year
ID #2 Type of ID 11
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Place of issue Province/State Country
Expiry Date Day Month Year
Dual Process 11
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verified using dual process method (Information must come from two different sources):
Name & address + name & DOB Name & address + name & Name & DOB + name & confirmation
confirmation of financial account of financial account
Reliable source of information #1 (example: most recent T4 statement)
Type of information Issuing company or gov’t jurisdiction
Document date Day Month Year Account / reference #
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Reliable source of information #2 (example: notice of assessment)
Type of information Issuing company or gov’t jurisdiction
Document date Day Month Year Account / reference #
Credit File 1234567890
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Name of credit bureau queried Credit file inquiry ref #
Date the client’s credit file was firstEquifax
TransUnion
created Day Month Year
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Consent To The Collection Use And Disclosure Of 11
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Information
By signing this Client Identity Verification Form below, I consent to the deposit broker collecting my personal information contained
in this form and from time to time providing this information to one or more financial institutions for the sole purpose of transacting
deposit business on my behalf. I also consent to the use, retention and disclosure of my personal information by such financial
institutions, as is reasonably required by them in connection with the establishment and maintenance of an account in my name, to
meet legal and regulatory requirements and for statistical, audit and security purposes in the manner set out in the financial institutions’
published privacy policy. I give consent to my deposit broker and / or the issuing financial institution to use my personal information
to obtain a consumer report from a credit bureau / consumer reporting agency in order to verify my identity for the sole purpose of
transacting deposit business on my behalf and I understand that this inquiry will not affect my credit rating.
I have read the above paragraphs and hereby give my consent to the collection use and disclosure of the personal information
contained herein.
Client / POA Signature Date
Deposit Broker Declaration
I, as an authorized representative of the deposit broker, certify that in accordance with the PCMLTFA and FINTRAC’s Methods to
ascertain the identity of individual clients Guidelines, available at http://www.fintrac-canafe.gc.ca/guidance-directives/client-clientele/
Guide11/11-eng.asp, I have used either (a) the photo ID method; or (b) the dual process method; or (c) the credit file method to verify
the identities of the person above.

Deposit Broker Company Name Representative Name Deposit Broker Signature Date
Form content and certification valid only when completed by an RDBA member in good standing.
For Financial Institution Use Only:
Client / Customer Number
Pg 1 of 1 Client ID Verification Form 2017-5 compact © 2017 Registered Deposit Brokers Association. All Rights Reserved.