Comprehensive Authority Delegation & Third-Party Access Intake for High-Net-Worth Client Accounts

Full Legal Name (as per government-issued identification)

Have you ever been known by any other legal names, including maiden names, previous married names, or legal name changes?

List all former legal names with corresponding effective dates:

Date of Birth

Gender Identification

Please specify your gender identification:

Country of Birth

Current Nationality

Do you hold any additional nationalities, citizenships, or have permanent residency status in any other jurisdictions?

List all additional nationalities and residency statuses with corresponding countries:

Primary Country of Tax Residency (CRS/FATCA jurisdiction)

Taxpayer Identification Number (TIN) for primary tax residency

Are you tax resident in any additional jurisdictions?

Additional Tax Residencies

Full Residential Address (must be verifiable with utility bill or bank statement)

Is your mailing address different from your residential address?

Alternative Mailing Address:

Primary Contact Telephone Number (including country code)

Secondary Contact Telephone Number

Primary Email Address for Official Communications

Type of Primary Government-Issued Identification Document

Identification Document Number

Identification Document Expiry Date

Can you provide a second form of government-issued identification?

Second ID Type and Number:

Account Number(s) and/or Relationship Number(s) for which authority is being granted (list all)

Current Marital Status

Are you currently or have you been within the last 5 years a Politically Exposed Person (PEP), Senior Public Official, or Head of International Organization?

Provide detailed position held, jurisdiction, dates in office, and current status:

Detailed Description of Source of Wealth (how you accumulated your overall wealth)

Detailed Description of Source of Funds for this specific account relationship

Estimated Total Net Worth (in USD equivalent)

Current Professional Status

Provide employer name, your position, and industry sector:

Provide employer name and professional designation:

Provide business name, type, ownership percentage, and operational jurisdiction:

Please specify your professional status:

Do you own or control any corporate entities, trusts, or legal arrangements that require disclosure under beneficial ownership regulations?

Beneficial Ownership Details

Agent's Full Legal Name (individual or authorized representative)

Has the agent ever used other legal names?

List agent's former legal names:

Agent's Date of Birth (if individual)

Agent's Country of Nationality/Registration

Agent's Primary Country of Tax Residency

Agent's Taxpayer Identification Number

What is the agent's relationship to you (the primary account holder)?

Professional Advisor Registration Details

Provide law firm name, bar association membership, and areas of legal specialization:

Specify immediate family relationship:

Specify extended family relationship (e.g., niece, nephew, cousin-in-law):

Provide trust company registration number, jurisdiction, and authorized signatories:

Describe the professional advisory relationship and nature of services provided:

Specify the agent's relationship and professional capacity:

Agent's Full Residential or Registered Business Address

Agent's Primary Contact Telephone

Agent's Primary Email Address

Agent's Government ID Type and Number

Agent's ID Expiry Date

Is the agent currently or has been within the last 5 years a Politically Exposed Person (PEP)?

Provide detailed PEP position, jurisdiction, dates, and current status:

Does the agent have any criminal record, regulatory sanctions, or adverse financial history?

Provide full details of incidents, jurisdictions, dates, and resolution status:

Agent's Relevant Professional Qualifications & Certifications

Do you have any existing business, personal, or financial relationships with the agent outside of this authority delegation?

Describe all existing relationships that may present a conflict of interest:

Will there be more than one designated agent acting jointly or severally?

Additional Agents & Authority Structure

Do you wish to designate a successor agent if the primary agent becomes incapacitated or resigns?

Provide successor agent's name, contact details, and succession trigger conditions:

Type of Authority Being Established

Specific Powers Granted to Agent (select all that apply)

Will fund withdrawals be limited to specific pre-approved beneficiary accounts?

Pre-Approved Beneficiary Accounts for Withdrawals

Will sub-agents require separate written approval?

Does this include authority to increase risk tolerance or leverage exposure?

Specify maximum leverage ratio, derivative exposure limits, and risk rating boundaries:

Financial Thresholds & Transaction Limits (all amounts in USD equivalent)

Maximum Total Account Value the agent can manage under this authority (USD equivalent)

Asset Classes Authorized for Trading/Investment (select all applicable)

Specify cryptocurrency exposure limits, approved exchanges, and wallet custody arrangements:

Does this include pre-IPO and restricted securities requiring qualified investor status?

Are there geographic or jurisdictional restrictions on where the agent can execute transactions?

Specify permitted and/or restricted jurisdictions:

Should this authority have a specific expiration date or be subject to automatic review?

Authority Expiration Date

Automatic Revocation Triggers (select all that apply)

Specific Restrictions or Prohibited Actions (negative covenants)

Do you require real-time notifications for all agent activities?

Select notification methods and triggers:

Should certain high-risk transactions require dual authorization (agent + account holder)?

Specify transaction types requiring dual approval and secondary approval method:

Sample Transaction Scenarios & Expected Outcomes (for operational clarity)

Primary Source of Wealth Documentation Provided (select all)

Upload Source of Wealth Documentation (consolidated PDF preferred)

Upload Source of Funds Documentation for initial account funding

Are you (account holder) a close associate or family member of a Politically Exposed Person (PEP)?

Provide PEP's name, relationship to you, position held, and jurisdiction:

Is the designated agent a close associate or family member of a PEP?

Provide PEP details and nature of relationship to agent:

Do you consent to ongoing adverse media and sanctions screening for both parties?

Have you or the agent ever been subject to regulatory enforcement, fines, or sanctions?

Regulatory History Disclosure

Transaction Monitoring & Reporting Frequency

Expected Transaction Patterns & Profile (for anomaly detection)

Is there any ultimate beneficial owner different from the account holder?

Provide UBO name, percentage ownership, relationship, and verification documents:

Will any third parties be making payments into or receiving payments from this account?

Third-Party Payment Instructions

Do you or the agent have any exposure to high-risk jurisdictions (as defined by FATF grey/black lists)?

Specify jurisdictions, nature of exposure, and enhanced due diligence measures in place:

Enhanced Due Diligence Measures to be Applied (select all applicable)

Required Documentation Checklist & Verification Status

Preferred Legal Jurisdiction for Governing Law

Do you require this authority to be effective immediately upon signing?

Specify effective start date and time:

I acknowledge that I have read, understood, and accept all terms and conditions of this authority delegation, including liability limitations and indemnification clauses.

I confirm that all information provided in this intake form is true, accurate, and complete to the best of my knowledge.

I understand that the financial institution reserves the right to reject any transaction that violates policy, exceeds limits, or raises compliance concerns, even if technically within granted authority.

I acknowledge the risks associated with granting third-party authority, including potential fraud, negligence, or misuse, and accept responsibility for monitoring the agent's activities.

I consent to the fees and charges associated with third-party authority setup, maintenance, and transaction processing as outlined in the fee schedule.

Do you consent to audio recording of all phone calls where the agent transacts on your behalf?

Do you consent to video verification calls for high-value transactions or periodic compliance reviews?

Preferred Communication Methods for Authority-Related Matters

Does this authority arrangement require notarization or legalization for your jurisdiction?

Specify notarization requirements, applicable apostille conventions, and responsible parties for arranging:

Required Signatures & Authority Execution

Do you require independent legal counsel to review this authority delegation before execution?

Provide legal counsel details, firm name, and required turnaround time for opinion:

Frequency of Periodic Authority Review and Re-confirmation

Emergency Contact Person (if authority issues arise)

Emergency Contact Telephone

I consent to the processing of my personal data and special category data (if any) as defined by applicable data protection regulations for the purposes of establishing and maintaining this authority delegation.

I understand my rights regarding data access, rectification, erasure, and portability, and know how to exercise them with the institution's Data Protection Officer.

Additional Comments, Special Instructions, or Qualifying Statements

Account Holder Digital or Physical Signature

Designated Agent Acknowledgment & Acceptance Signature

Final Execution Date