GCI FINANCIAL LTD 197 Main Street, Road Town, Tortola, British Virgin Islands ● DataPro Park, 13.5 Mile Northern Highway, Ladyville, Belize Tel: +1 800 395 0684 Fax: +1 866 728 2399

WITHDRAWAL FORM To withdraw funds or close an account, fill out and sign the Withdrawal Form. Method of Withdrawal is by bank wire transfer and a bank fee will apply. GCI does not add any fees to the transfer fees charged by the remitting bank(s). The request will be processed within two business days of receipt of this form. For fastest processing, please fax to: +1 866 728 2399.

Date

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Customer Name

___________________________________________

Account # or User Name

___________________________________________

Withdrawal Amount in USD

___________________________________________

1

Beneficiary Name

___________________________________________

E-mail Address:

___________________________________________

Beneficiary Bank name

___________________________________________

ABA or SWIFT

___________________________________________

Sort Code (If Applicable)

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Account #

___________________________________________

Bank Address

___________________________________________ ___________________________________________

Correspondent Bank Information ___________________________________________ (if any) ___________________________________________ ___________________________________________ ___________________________________________

Currency in which you wish to receive your funds:2

___ USD

___ Euros

British ___ Pounds

___ Japanese Yen

Swiss ___ Francs

Australian ___ Dollars

Canadian ___ Dollars

New Zealand ___ Dollars

Will your account be closed?

___ Yes

___ No

Any comments on our service? ____________________________________________________

Customer Signature

1 2

X __________________________________________________

GCI account holder only. Third party payments are not permitted. For currencies other than US Dollar (“USD”), the USD amount withdrawn from your GCI account will be converted at prevailing exchange rates at approximately 0.75% from mid-market.