Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697641308524.pdf (Antigua and Barbuda)
Number Question Response Yes No Depository Institution Custodial Institutions Investment Entity Specified Insurance Company Other Yes No Yes No 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 Section 1-Financial Institution Profile Data FI Name FI Number Reporting Period* Is the FI registered with the Inland Revenue Department Date of registration Tax Payer Identification Number (TIN) Please confirm the nature of the FIs business activities Please provide details of business activities if you selected Other in 1.7 Section 2 – Financial Account Data Please confirm currency used for CRS reporting purposes is USD* Please confirm the number of Financial Accounts for the reporting period* Please confirm the value of the FIs Financial Accounts for the reporting period* Please confirm the number Reportable Accounts* Please confirm the value of the Reportable Account.
* Does the FI have any Non-Reportable accounts for the reporting period* Please confirm the reason the accounts(s) are considered to be Non-Reportable Please provide clarification details of the Financial Account (s) where the Account Holder is not a Reportable Person but is a Reportable Jurisdiction person Total number of Non-Reportable Accounts Total Value of Non-Reportable Accounts Total Number or USD Value of Non-Reportable Account that is Unknown Please provide classification details of the Financial Account(s) where the Account holder and all Controlling Persons are not Reportable Jurisdictions Persons US Person – Total Number of Non - Reportable Accounts US persons – Total Value of Non - Reportable Accounts US person – Total number or USD Value of Non – Reportable Accounts that is Unknown 2.12 Does the FI have any Excluded Accounts?
* Yes No Uncertain 2.13 2.14 2.15 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 4.1 4.2 4.3 4.4 4.5 4.6 Is the existence, number or value of Excluded Account unknown?

Total number of Excluded Account.

Total value of the FIs Excluded Accounts.

Section 3 – AML/KYC and Accounting Does the FI have audited Financial Statements* Yes No Yes No Which Entity carries out the AML/KYC obligations?
* FI itself Other Name of Entity/service provider Location of Entity/service provider Are the AML/CFT obligations performed in accordance with Antigua and Barbuda laws* Was the entity audited by the ONDCP for AML/KYC purposes for the last reporting period* Does AML/KYC procedures to its officers?

* Frequency of training the Fi provide ongoing training of internal Yes No Yes No Yes No Monthly Semi-Annually Other Quarterly Annually Who facilitates the training?
FI itself Other Date of last training Section 4 – CRS Process Which Entity reviews Account Holder information and drafts the Reportable Accounts list for review by the management of the FI* Name of entity/service provider FI itself Other Location of Entity/service provider Please confirm the FI has established and maintained written policies and procedures which comply with the FIs the Antigua and Barbuda CRS obligations under legislation* Please confirm the FI has implemented and complied with its said written policies and procedures Yes No Yes No N/A Please confirm if the FI has complied with the CRS legislation in relation to self-certification* Yes No 4.7 Has the FI complied with the CRS legislation in relation to Yes No 4.8 4.9 4.10 4.11 4.12 4.13 5.1 5.2 the requirement to obtain TINS* Has the FI complied with the CRS legislation in relation to the requirement to obtain date of birth information?
* Has the FI complied with the CRS legislation in relation to maintain records for a minimum six years?

* Does the FI provide on-going training of CRS procedures to its officers?

* Frequency of training Who facilitates training?

Date of last training?

Section 5 – Reporting History For which reporting period has the FI submitted CRS filing(s)?

For which reporting period has the FI submitted Nil CRS filing(s)?
Yes No Yes No Yes No Monthly Semi-Annually Other Quarterly Annually FI itself Other 2017 2018 2019 2020 None 2017 2018 2019 2020 None I hereby declare that the information given on this form is to best of my knowledge and belief, true and correct and that I have authority to disclose the information provided.
I understand that a Financial Institution that refuses to or fails to provide any information requested by the Competent Authority, without lawful or reasonable excuse, is liable to a penalty for the following breaches; a Financial Institution that fails to file information as an when require; a Financial institution that makes a false statement or omits to include a statement in information required; a Financial institution which fails to file in a manner required;.
such penalty being Ten Thousand United Sated Dollars for each instance of non-compliance with the Automatic Exchange of Financial Account Information Act No.

11 of 2016 and the Automatic Exchange of Financial Account Information Regulations Act No.

18 of 2017.

SIGNATORY FULL NAME SIGNATURE DAY/MONTH/YEAR