Self-Declaration Form (Regarding Income, Profession & Source of Fund)
Date: ______/______/___________
The Manager
BRAC Bank PLC
Branch/Unit/Sub-Branch/AB Outlet/Booth
Account Number
Account Name
Occupation Type : (Please put √ mark multiple if applicable)
□ Service (Government/Private) □ Business □ Student □ Landlord/Landlady □ Teacher □ Farmer □ Professional (Doctor/Lawyer/
Accountant/Engineer/Architect) □ Freelancer Consultant (other than IT) □ Freelancer-IT □ Retired Service Holder □ Mariner
□ Law/Audit Farm, Legal & Tax Adviser □ Athlete/Trainer/Coach □ Cattle-Farm □ Poultry Farm □ Poultry Feed Manufacturer
□ Share/Stock Trader □ Internet Service Provider □ Youtuber/Vlogger/ Digital Content Creator □ Research/Journal/Publication
□ Artist: Actor/Actress/Painter/Musician/Dancer/Sculptor □ Film/Drama Producer □ C&F/Commission Agent □ Brick Field Owner
□ Training Institute/ Coaching Center □ Gym Instructor □ Others (specify) ……………………………………………………………..……………………………
Occupation Details : (Please fill up multiple fields if applicable)
For Service Holder Designation: ……………………………………………………………………………… Department: ……………………………………………………..
Name of the Organization: ……………………………………………………………………………………………………………………………..………………………………….…
Organization Type: □ Govt □ Semi-Govt □ Autonomous □ Private
For Businessmen Name of the Business Entity:
Designation: □ Proprietor □ Partner □ Managing Director □ Director □ Shareholder/Investor □ Others ………………………………………………
Nature of Business Details of Products/Services Nature of Business Details of Products/Services
□ Manufacturing □ Service Provider/Cable Operator
□ Trading/ Wholesaler □ Distributor/ Supplier
□ Export-Import □ Retailer
□ IT Firm (please specify) □ Cottage/Small Industry
□ Agri-Based Industry □ e-Commerce/Online Seller
□ Consultancy/Training □ MFS Agent/ Business
□ C&F Agent □ Others (Please specify)
For Professionals (Doctor/ Lawyer/ Accountant/ Engineer/ Architect etc.)
Profession Title/ Details: …………………………………………………………………………………………..………………..………………………………………………….…...
Name of the Entity/Firm: …………………………………………………………………………………………………………..…………………………….………………….………
Nature of the Business/Industry: ………………………………………………………………………………………………………..……………………………………………….
Monthly Income : (in BDT equivalent) (Please put √ mark)
□ Less than 15,000 □ 15,001 - 50,000 □ 50,001 - 150,000 □ 150,001 - 250,000 □ 250,001 - 350,000 □ 350,001 – 500,000
□ More Than 500,000 (you should obtain income supporting documents)
Primary Income (amount in BDT): Additional Income (amount in BDT):
Additional Source of Fund/Income: (Please put √ mark multiple if applicable/if any):
□ Bonus & Allowance/Incentives (other than salary) □ Fisheries/Livestock □ Freelancing □ Pvt. Tuition □ Rental Income
□ Govt. Bonds/SP/WEDB/Treasury Bond □ Savings/Pension Scheme/Retirement Benefits □ Profit Sharing from Family Business
□ Providing other Professional Services □ Online Sales/e-Commerce □ Ride Sharing □ Affiliate Marketing □ Streaming Video Games
□ Seasonal Crops selling (Agricultural income) □ Share/Stock Investment □ Photography □ Family Contribution/Gift/ Inheritance
□ YouTuber/Vlogging/ Digital Content Making □ Remittance (mention country of origin & sender’s details, relation with a/c holder)
………………………………………………………………………………………………………………………………………………………………………………………………………..……
□ Other Remarks:
For Housewife, Student, Farmer & Unemployed obtain Beneficial Owner (BO) details (if they have no own income source):
Relationship with the fund provider/ earning member/ BO: ………………………………………………………….………………………..……….…….………...…
Occupation Details of BO: Profession ……………………………………………… Nature of Service/Business (others)……………………..……………..……
Designation: …………………………………………………………….……… Source of fund(s)……………………………………………………………………………………….
Monthly income of BO (in BDT) ………………………..………………………………………………… Proof of Employment of BO should be obtained
Additional Source of Income (if any): □ Rent □ Return from Savings/Fixed Deposit □ Return on Investment □ Return from Govt.
Savings Bond(s) □ Family Contribution □ Gift/Inheritance □ Trust Fund □ Others (specify) ……………………………………….…………………………
□ Remittance (mention origin country, sender’s details, relation with a/c holder) ……………………….………………………………………………………
Specific Income Source of STUDENT Specific Income Source of FARMER Specific Income Source of Self-Employed
Tutoring (Private Tutoring/ Coaching Crop Farmer Occasional/ Undefined Freelancing
Center) Poultry, Dairy Farmer Driver/ House help/ Maid/ Security Guard
Part-Time Jobs/ Photography Fish Farmer (Fisheries) Street Vendor (tea stall, bakery, food,
Freelancing: Offer services like Flower Cultivating clothes, shoes, plastic items, accessories)
writing, graphic design, or tutoring Apiarist/ Beekeeper Labor based Small Businessman, like:
Rent Your Car/ Bike/ Bicycle Animal Breeder (applies genetics Carpenter/ Small furniture repairing
Ride Sharing improve livestock and poultry quality) shop, small car/bike repairing
Stream Video Games Online Organic Farmer: farming naturally workshop, welding workshop, tailor/
Affiliate Marketing: If you have a without synthetic substances sewing and alteration shop, gardener/
platform and a following, promote Hay Farmer: Grows processed grass nursery/ plan sell outlet, barber shop,
products and earn sales commissions & legumes for feeding livestock ironsmith, pottery, plumber/ repairing
Artist- Painter/ Musician/ Sewing/ Cooperative Farmer: Works within a Beautician/Beauty Parlor/ Make-up artist
Sculpture group where resources and profits Food caterer/ Daycare owner
Media Personality/ Influencer/ Social are shared among members Mover & Packers/ Cleaner
media content creator/ Vlogger/ Commercial Farmer: Production on a Private Tuition income/ Coaching Center
Writer/ Blogger/ Copywriter large scale, often for export-oriented Artist: Painter/ Musician/ Sewing/
Subsistence Farmer: Produces food Sculpture/Actor/Actress
Non-Professional Source: primarily for family consumption Media Personality/ Social Influencer/
Profit from seasonal businesses/ Agricultural Sales Representative Media Content Creator/ Vlogger
selling foreign products occasionally Agronomist: Specializes in plant & soil Writer/ Blogger/ Copy writer
Gift money received from family/ science to improve crop production Profit from Seasonal Businesses/ selling
relatives such as parents, siblings Seasonal Farming Foreign Products occasionally
Earned from financial investment
Non-Professional Source: Non-Professional Source:
such as (Savings Certificate, FD/DPS)
Profit from seasonal businesses/ Profit from seasonal businesses/ selling
Trust Fund
selling foreign products occasionally) foreign products occasionally
Remittance
Gift money received from family/ Gift money received from family/
Others ……………………………..……….………
relatives (parents, siblings etc). relatives such as parents, siblings etc.
Earned from Financial Investment Earned from financial investment such
such as (Savings Certificate, FD/DPS) as (Savings Certificate, FD/DPS etc.)
Remittance Remittance
Others………………………………...………….… Others …………………………….…………………..…
I/we, hereby also confirm that the account will be utilized for personal transaction purposes only and will not be operated/utilized
to serve any 3rd party (non-account holder) interest in any capacity.
Account Holder’s/ Walk-in-Customer’s Signature Signature
FOR BANK USE ONLY
Received By (Sourcing Staff): Supported By (BM/BOM/BDM/SM/SRM/CM):