DECLARATION OF SOURCE OF WEALTH AND FUNDS

I, the below undersigned

residing at

and holder of passport / ID card number

Hereby declare and confirm that my wealth has been generated via:*

Current and past professional activity
Current and past ownership and/or investment
Inheritance or/and Gift
Other

Current and past professional activity

Current and past ownership and/or investment

Inheritance or/and Gift

Other

I also declare that:

• I undertake to produce any and all documentation to support the above, should the Service Provider request so.
• all my wealth has not been derived from any illegal or criminal activity of any nature.
• no funds transferred to the Service Provider and any entity related in any way to the services provided the Service Provider are derived from illegal activities of any nature and that I am legally entitled to transfer such funds.
• all the information declared above is to the best of my knowledge true and correct.

Full name*

Signature

Date*

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