D. Bank form-FATCA

...................................................................Branch Foreign Account Tax Compliance Act (“FATCA”) Account Number Name Country of Residence/Registration Country of Birth/Incorporation Please check’’ ” ‘Yes’ or ‘No’ for each of the following questions 1. Are you a U.S. Resident? 2. Are you a U.S. Citizen? 3. Do you hold a U.S. Permanent Resident Card (Green Card)? 4. Is your entity a foreign entity where there is substantial “US ownership” ? i.e.10% or more (for company/non-individuals) Yes / No Applicant’s Signature Applicant’s Name Date .......................................................................... .......................................................................... .......................................................................... Account Opening Form Supplement (use additional copies, if required) This form must be completed by any individual/non-individual/entity who wishes to open a Bank Account/have been maintaining one. I hereby confirm the information provided above is true, accurate & complete. Subject to applicable local laws, I hereby consent for Prime Bank Limited, Bangladesh or any of its affiliates (including branches) (Collectively “the Bank”) to share my information with domestic/U.S. regulators or tax authorities where necessary to establish my tax liabilities in any jurisdiction. Where required by domestic or U.S. regulators or tax authorities, I consent and agree that the Bank may withhold from my account(s), such amounts as may be required according to applicable laws, regulations and directives. I undertake to notify the Bank within 30 (thirty) calendar days if there is a change in any information which I have provided to the Bank. A/C Opening Officer (With Name Seal, Signature & Date) BM/OM (With Name Seal, Signature & Date) ✓