Bank Reference Request

Bank Reference Request
Please mail this with the Action Form to:
Citibank, N.A., International Personal Banking, Robinson Road P.O. Box 0361, Singapore 900711

TO BE COMPLETED BY NEW CUSTOMER

Name of Account Holder

Name/Address of Bank/Finacial Institution

Authorization I authorize the above financial institution to release information regarding my account relationship to Citibank, N.A.
Account Holder Signature

TO BE COMPLETED BY REFERENCE BANK

Please ask your Reference Bank to complete this Bank Reference Request. Then send it to Citibank with your Action Form
Date Account opened

Year/Month/Day

Type of Bank Account/s:

Deposit Accounts: Average balance over the past year:
(in US$ equivalent)
1.

2.

3.

Loan Accounts: Average balance over the past year:
(in US$ equivalent)
1.

2.

3.

How has/have the Account/s been maintained?

Exceptionally Satisfactorily Unsatisfactorily

Comments

Verification of Customer's Signature
Compares favorably to our records

Bank officer's signature

Bank officer's name and title

Bank officer's seal/stamp

Please ask your Reference Bank to complete this Bank Reference Request. Then send it to Citibank with your Action Form
Date Account opened	Year/Month/Day

Type of Bank Account/s:
Deposit Accounts:		Average balance over the past year: (in US$ equivalent)
1.
2.
3.
Loan Accounts:		Average balance over the past year: (in US$ equivalent)
1.
2.
3.

How has/have the Account/s been maintained?
Exceptionally	Satisfactorily	Unsatisfactorily
Comments

Bank officer's signature
Bank officer's name and title	Bank officer's seal/stamp