An Post AVC - Source of Funds | Halligan Insurances

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Unique ID

Source of Funds / Wealth Form

Section A - Policy Owners Details

The information requested is necessary to comply with the provisions of the Criminal Justice (Money Laundering and Terrorist Financing) Act 2010

Name*

First Last

Occupation*

Staff Number:*

Address*

Section B - Source of Funds

This section must be completed if paying by Bank Draft / Postal Order or if payment is not a cheque or Direct Debit drawn on the account of the Policy Owner

Payment to be made by?*

Direct Debit

Personal Cheque

Bank Draft

Postal Order

EFT

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Bank Details

Account Holder's Name*

Name of Bank / Building Society*

IBAN*

BIC*

Country Account is Based*

Section D - Declaration by the Policy Owner

Policy Holder's Signature*

I declare that the statements provided in this form are true and complete:

Section E - Supported Documents

Photo of Identification*

Identification accepted - Driving Licence / Passport

Accepted file types: jpg, jpeg, png, bmp, Max. file size: 2 MB.

Proof of Address*

Photo of Bill with Account Holder's Name and Address visible

Accepted file types: jpg, jpeg, png, bmp, Max. file size: 2 MB.

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Completed Application Form

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Source of Funds / Wealth Form

Section A - Policy Owners Details

Section B - Source of Funds

Bank Details

Section D - Declaration by the Policy Owner

Section E - Supported Documents

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