this Fica Declaration form

T 0860 10 20 43 F +27 21 941 0770
BSE Building, 89 Voortrekker Road, Bellville 7535 PO Box 12451, Die Boord, Stellenbosch 7613
capitecbank.co.za
Fica Declaration
Declaration of Residential Address
To be completed for clients who are unable to provide any of the approved documents.
Capitec Bank Branch Name
Declarant’s Details (Person making the declaration)
Name
Surname
ID Number/Passport Number
Applicant’s Details (Person opening the account)
Name
Surname
ID Number/Passport Number
Address Details
Residential Address
Postal Code
Formal Residential Address Confirmation
I, the declarant, confirm that the applicant is my
(State the nature of the relationship. E.g. son, mother, uncle, domestic worker, boarder.)
and that s/he resides with me at the above address.
To confirm proof of residence, I have attached the following documents:
• ID document
• Proof of residential address
I, the declarant, hereby certify that the above information is true and correct. I realise that should any of this information be false, I will be
liable for prosecution or penalties under the law.
Signed at
Place
on this
Day
of
20
Month
Year
Signature of declarant
A registered credit provider. NCR Reg. No.: NCRCP13 Capitec Bank Limited Reg. No.: 1980/003695/06
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Fica Declaration 03/03/2015