BT Customer Identification and Verification Form
Individuals & Sole Traders
SECTION 1: APPLICANT DETAILS (MANDATORY) 1.2 COMPLETE IF INDIVIDUAL IS A SOLE TRADER continued
Title Mr Mrs Ms Miss Dr Principal place of business (cannot be a PO Box)
Given name(s)
Family name State Postcode
Country, if not Australia
Are you known by any other name(s)? Industry
Yes (insert below) No
Date of Birth (DD/MM/YYYY) SECTION 2: FOREIGN TAX RESIDENCY (MANDATORY)
/ / Are you a resident of a country other than Australia for tax purposes?
Permanent residential address (cannot be a PO Box) Yes (complete section 2)
No (proceed to section 3)
Country/ies outside of Australia in which the individual is a resident for
tax purposes and country’s associated Tax Identification Number (TIN)*
State Postcode
* A TIN is an identifying number or equivalent used for tax purposes.
Country, if not Australia If a ‘TIN’ is not available, please specify the reason against the
appropriate country.
Occupation (only required if primary customer) – select from drop
down list only Note: If the individual has more than 3 countries in which they are
a tax resident, please provide the details on a separate paper.
Country 1
Employment Type: (only required if primary customer)
Full time Part time Foreign TIN 1
Self employed Casual
Temporary Retired Reason (if TIN not applicable)
Student Social security recipient Foreign TIN not issued by this country
Unemployed Other (home duties/
Foreign TIN pending issue by the country’s tax authority
Dependent contractor work compensation/etc.)
Independent contractor Country 2
Foreign TIN 2
1.1 CONTACT DETAILS
Mobile number Reason (if TIN not applicable)
Foreign TIN not issued by this country
Email address
Foreign TIN pending issue by the country’s tax authority
Country 3
1.2 COMPLETE IF INDIVIDUAL IS A SOLE TRADER
Foreign TIN 3
Full Business Name (if any)
Reason (if TIN not applicable)
ABN (if any) Foreign TIN not issued by this country
Foreign TIN pending issue by the country’s tax authority
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SECTION 3: ADDITIONAL INFORMATION (MANDATORY) SECTION 4: DOCUMENT VERIFICATION
PROCEDURE (MANDATORY)
3.1 SOURCE OF FUNDS
Individual completing this form to provide the relevant documentation
This refers to where your funds came from in regard to deposits into outlined in ONE of the below applicable parts.
the account. For example, if your superannuation contribution is made
by your employer you would select salary/wages. Please note you • Complete Part I OR Part II OR Part III (Age Care Resident customers)
may have multiple sources of funds. Please indicate all sources of OR Part IV (Indigenous customers)
funds below. • Contact your licensee if the individual is unable to provide the
required documents (applicable to advisers only).
Salary/wages Business income/earnings
Investment income/earnings Superannuation/pension PART I – Primary Photographic Identification Document
Bonus Commission
Sale of assets Liquidation of assets Tick Select ONE document from this section only
Business profits Rental income Australian driver’s licence/learner’s permit
Loan Compensation payment
Australian passport (a passport that has expired within the
Insurance payment Government benefits preceding 2 years is acceptable)
Tax refund Redundancy
Australian proof of age card issued by a State or Territory
Gift/donation Inheritance
Foreign passport or travel document issued by a foreign
Windfall
government, the United Nations or an agency of the United
Additional Sources (Please specify) Nations (must not be cancelled, defaced or mutilated) which
contains either a signature OR a unique identifier of the
person*
Foreign driver’s licence/permit that contains a photograph
of the person in whose name it issued and the individual’s
date of birth*
3. 2 SOURCE OF WEALTH
National identity card issued by a foreign government,
This refers to where or how you have built your net worth. For example, the United Nations or an agency of the United Nations which
if your assets have been gained through savings from your salary you contains either a signature OR a unique identifier of the
would select ‘employment income’. Please note that you may have person*
multiple sources of wealth. Please indicate all sources of wealth below.
Employment income/earnings Business income/earnings
Investment income/earnings Superannuation/pension
Sale of assets Liquidation of assets
Owns real estate/property Business profits
Rental income Redundancy
Insurance payment Compensation payment
Gift/donation Government benefits
Inheritance
Windfall
Additional Sources (Please specify)
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PART II – Primary Non-Photographic Identification Document PART III – AGE CARE RESIDENT ONLY
AND ONE Secondary Identification Document (complete if the
individual does not own a document from Part I) Tick BOTH of the following must be collected
Select ONE Primary Non-Photographic Document Notice/ invoice issued by an Australian Aged Care Facility
Tick
from this section within the last 3 months that includes the customer’s name
and date of birth; and the facility’s address;
Australian birth certificate (or extract)
Notice/letter from an Australian Government agency issued
Australian citizenship certificate within the last 3 months old which confirms the customer’s
address is the same as the Australian Aged Care Facility/
Pension card issued by Department of Human Services or that the Facility is receiving benefits on behalf of
the customer
Health card issued by Department of Human Services
Foreign birth certificate issued by a foreign government, PART IV – Indigenous Customer ONLY
the United Nations or an agency of the United Nations*
Tick Select ONE of the following documents
Citizenship certificate issued by a foreign government*
Indigenous Customer Identification Form that is:
AND ONE Secondary Identification Document from (i) Completed by one referee that is a recognised elder (or
Tick
this section another person that is regarded as a leader within the
community) to verify the information provided by the customer.
A notice issued by the Commonwealth or a State/Territory
within the last 12 months that includes the individual’s name (ii) Witnessed by an independent person.
and residential address and records the provision of financial Indigenous community identification card issued by an
benefits (e.g. Centrelink notice) Indigenous Council or Corporation that includes the
A notice issued by the Australian Taxation Office (ATO) within customer’s name, date of birth/approximate age, address/
the last 12 months that includes the individual’s name and location and photograph.
residential address and records a debt payable by or to the
* Documents that are written in a language that is not English must
individual (e.g. tax assessment)
be accompanied by an English translation prepared by National
Utilities notice issued by a local government or utilities Accreditation Authority for Translators and Interpreters (NAATI)
provider within the last 3 months and includes the customer’s translator.
name and residential address and records the provision of IMPORTANT NOTE:
a service to that address or name
• Attach a legible certified copy of the ID documentation used to
If the individual is under the age of 18 years, notice issued verify the individual (and any required translation)
by the principal of a school within the last 3 months ,that
includes the name of the individual, residential address and SECTION 5: APPLICANT DECLARATION (MANDATORY)
period of school attendance
I declare that to the best of my knowledge the information I have
Foreign driver licence which does not contain a photograph provided above is and correct as at the date of this document. I
understand that it is an offence to knowingly give false or misleading
Department of Veterans’ Affairs pension concession card information or knowingly produce a false or misleading document
(Australian) under the Anti-Money Laundering and Counter Terrorism Financing
Act 2006, and the Tax Laws Amendment (Implementation of the
A current tenancy/lease agreement (must not be cancelled
Common Reporting Standards) Act 2016.
or expired)
Signature of authorised person
Medicare card
Date (DD/MM/YYYY)
Australian Marriage certificate issued by State/Territory
Registry of Births, Deaths and Marriages / /
Signatory’s full name (please print)
Identification card issued to a student at an Australian higher
education institution (TAFE or University) which contains a
photograph and signature
Note: If you are not the Account Holder please indicate the capacity
A current card issued under a Commonwealth, State, or in which you are signing the form. If signing under a power of attorney
Territory law for the purpose of identification, for a government or guardianship please also attach a certified copy of the power of
service, or as a licence attorney or guardianship order and complete a separate individual
identification form.
Capacity
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SECTION 6: RECORD OF VERIFICATION PROCEDURE APPENDIX A:
(OFFICE USE ONLY)
A. HOW TO CERTIFY YOUR IDENTITY DOCUMENTS
ID DOCUMENTS DETAILS Document 1 The documents applicable to you can be certified by either:
Verified From Original Certified Copy • Your financial adviser – where they have introduced you to BT,
have an AFSL and 2 or more continuous years of service with one
Document Issuer or more licensees. Your financial adviser must complete the
Issue Date / / appropriate Identification Form and attach it to your Application
together with the original certified identification documents.
Expiry Date / / • Any other eligible certifier as listed in this Section. An original
certified copy is a document that has been certified as a true copy
Document Number of an original document.
Accredited English Translation N/A Sighted To certify an identity document:
• Take the original identity document and a photocopy to one of
ID DOCUMENTS DETAILS Document 2 (if required) the people listed below (eligible certifiers) and ask them to
certify that the photocopy is a true and correct copy of the
Verified From Original Certified Copy original document.
Document Issuer • That person will need to print their name, date and qualification/
occupation which makes them an eligible certifier on the photocopy.
Issue Date / / • The certifier must also include the following statement on the
photocopy ‘I certify that this is a true copy of the original document’.
Expiry Date / /
• Photocopies of certified documents will not be accepted.
Document Number • The original signature of the certifier must be visible.
Accredited English Translation N/A Sighted
By completing and signing this Record of Verification Procedure
I declare that:
• An identity verification procedure has been completed in accordance
with the AML/CTF Act/Rules, in the capacity of an AFSL holder or
their authorised representative and
• The Tax information provided is reasonable considering the
documentation provided.
AFS Licensee Name (if applicable)
AFSL Number (if applicable)
Representative/Employee Name and Staff ID
Phone number
Signature
Date Verification Completed (DD/MM/YYYY)
/ /
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LIST OF ELIGIBLE PERSONS WHO CAN CERTIFY YOUR
IDENTITY DOCUMENTS
The following people can certify your identification documents, for
a complete list of people who can certify your identification documents
please refer to our website www.bt.com.au/personal/help/how-to-
certify-id.html
Note:
• Customers can use certifiers in categories 1 to 17 where the
certifier is an officer who holds these positions within Australia;
or
• Where the certifier does not meet the above criteria, ONLY certifiers
in category 11, 12 or 13 may be used.
1. A person who is enrolled on the roll of the Supreme Court of
a State or Territory, or the High Court of Australia, as a legal
practitioner (however described)
2. A judge of a court
3. A magistrate
4. A chief executive officer of a Commonwealth court
5. A registrar or deputy registrar of a court
6. A Justice of the Peace
7. A notary public
8. A Police Officer
9. An agent of the Australian Postal Corporation who is in charge
of an office supplying postal services to the public
10. A permanent employee of the Australian Postal Corporation
with 2 or more years of continuous service who is employed
in an office supplying postal services to the public
11. An Australian consular officer or an Australian diplomatic
officer (within the meaning of the Consular Fees Act 1955)
12. A bank or building society officer with 2 or more years
continuous years of service (includes acceptable international
bank)
13. A finance company officer with 2 or more continuous years
of service (includes acceptable international bank)
14. An officer with, or authorised representative of, a holder of an
Australian financial services licence, having 2 or more
continuous years of service with one or more licensees
15. A member of the Institute of Chartered Accountants in Australia,
the Australian Society of Certified Practising Accountants or
the Institute of Public Accountants.
16. A Commissioner for Declarations
17. A Commissioner for Affidavits
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