Tax Exempt Special Savings Account

Branch Code Branch Name Type of Account TESSA Date Tax Identification No.

I. MANDATORY INFORMATION
1. Name

Last Name First Name Middle Name Suffix (Jr., III) Other Name/AKA
2.a. Date of Birth 2.b. Place of Birth 3. With Beneficial Owner/Agent?
Yes (Fill-out: II. Beneficial None
City/Municipality Country Owner/Agent Information)
4. Present Address

House/Unit No. Floor Building Name Street Subdivision City Province District Country Zip Code

5. Permanent Address (if not same as present address)

House/Unit No. Floor Building Name Street Subdivision City Province District Country Zip Code

6.a. Residence Phone Number 6.b. Mobile Number 6.c. Email Address
Enroll in Metrobank Direct-Online? Yes No
Enroll in Metrophone Banking? Yes No Enroll in Mobile Banking? Yes No Preferred Customer Name:
7. Nationality 8.a. Nature of Employment/Business 8. b . Name of Employer/Business a.
b.
c.
9. Source/sof Funds (Please check ALL that apply) 10 . TIN/SSS/GSIS/UMID No. (Social Security No.)
Salary/Employment Pension Sale of Asset
Business Remittances (Please specify country Others (Please specify)
Commissions of origin) Reason for no TIN

II. BENEFICIAL OWNER/AGENT INFORMATION (If any) (Use separate sheet, if needed)
1 Beneficial Owner (e.g., TITF, ITF) Agent (e.g., Attorney-in-Fact) RM/Customer Number
Last Name First Name Middle Name Suffix (Jr., III)

Date of Birth Place of Birth Nature of Employment/Business Nationality

City/Municipality Country
Present Address

House/Unit No. Floor Building Name Street Subdivision Barangay Municipality/City Province District Country Zip Code
Source/sof Funds (Please check ALL that apply)
Salary/Employment Commissions Remittances (Please specify country Sale of Asset
Business Pension of origin) Others (Please specify)

2 Beneficial Owner (e.g., TITF, ITF) Agent (e.g., Attorney-in-Fact) RM/Customer Number
Last Name First Name Middle Name Suffix (Jr., III)

Date of Birth Place of Birth Nature of Employment/Business Nationality

City/Municipality Country
Present Address

House/Unit No. Floor Building Name Street Subdivision Barangay Municipality/City Province District Country Zip Code
Source/s of Funds (Please check ALL that apply)
Salary/Employment Commissions Remittances (Please specify country Sale of Asset
Business Pension of origin) Others (Please specify)

III. CLIENT PROFILING

12. Civil Status 13. Spouse's Name 14. Mother's Maiden Name

15. Gender 16. Type of ID Presented 17. ID Number

18. Purpose of Account Opening 19. No. of Dependents 20. No. of Children
Savings Pension
Business Remittance (Please specify country) Others (Please specify) 21. Monthly Bank Statement for Pick-Up
Payroll Origin Destination Yes No

22. U.S. Address (if applicable) House/Floor No., Street, City, State, Postal Code 23. U.S. TIN

24. Employer/Business Address

House/Unit No. Floor Building Name Street Subdivision Barangay Municipality/City Province District Country Zip Code

25. Job Title/Position

Top/Senior Management Rank and File/Clerical Overseas Filipino Worker Self-employed Others (Please specify)
Manager/Middle Mgt Professional/Consultant Government Employee Student
26. Expected Frequency of Transaction per Month 27. Average Amount per Transaction 28. Preferred Mailing Address
(deposits, withdrawals, etc)

MB-I-M-217/ Feb.'18
 List of Banks where the individual has maintained or is Bank Name/s 口 No
maintaining an account

DECLARATION AND ACKNOWLEDGEMENT

I declare that the face-to-face conduct of KYC as Reviewed Account Opening Documents and Signature Approved by (for High Risk)
prescribed by BSP has been performed. Authenticated /Approved by

SIGNATURE OVER PRINTED NAME OF SIGNATURE OVER PRINTED NAME OF SIGNATURE OVER PRINTED NAME OF
BANK OFFICER BRANCH OFFICER BRANCH HEAD