Due-Diligence Onboarding Entity

GENERAL INFORMATION

Company name

Phone

Trade name

Physical address

Country of domicile

Country of constitution

Type of legal structure

Year of constitution

Contact email

Main company activity

If the main company activity is other, write what

Website

Name of the contact person in Active Re

Tax ID number

BOARD OF DIRECTORS

Director 1

Physical person Company

Name and Surnames

ID Card / Passport No.

Birthdate (dd/mm/yyyy)

Nationality

Residence

Profession

PEP

Director 2

Physical person Company

Name and Surnames

ID Card / Passport No.

Birthdate (dd/mm/yyyy)

Nationality

Residence

Profession

PEP

Other Director

Company

Legal name

Nationality

Birthdate (dd/mm/yyyy)

ID Card / Passport No.

Residence

Profession

PEP

SHAREHOLDERS

Controlling Shareholder

Physical person Company

Name and Surnames

Share percentage

ID Card / Passport No.

Birthdate (dd/mm/yyyy)

Nationality

Residence

Profession

PEP

Other Shareholder

Physical person Company

Name and Surnames

Share percentage

ID Card / Passport No.

Birthdate (dd/mm/yyyy)

Nationality

Residence

Profession

PEP

Other Shareholder

Physical person Company

Name and Surnames

Share percentage

ID Card / Passport No.

Birthdate (dd/mm/yyyy)

Nationality

Residence

Profession

PEP

*PEP: Person politically exposed

Data from (Person authorized to sign this document)

Legal Proxy Legal Representative

Name and Surnames

Profession

ID Card / Passport No.

PEP

Birthdate (dd/mm/yyyy)

Nationality

Telephone / Fax

Residence

DECLARATION OF SOURCE AND ORIGIN OF RESOURCES OF THE TRANSACTION

Products and services:

Entity used for transfers:

Please detail the Origin of the Funds:

Indicate whether the Legal Representative, Proxy or the Company itself are or have been the subject of investigation, enquiry or conviction for unlawful activities, or money laundering or terrorist financing crimes. *

Yes No

If yes, please explain:

Does the firm have policies or practices for the indetification and reporting of inusualy transaciones that are required to be report to the authorities.

Yes No

SOURCE OF FUNDS (“SOF”) DECLARATION

Other revenue

Please provide a detailed description of the source of the funds (e.g. if you checked the option ‘loan’ you should confirm the name of the Bank / financial institution that is extending the loan and the total amount of the same, if this is ‘salary’, the name of your employer, the nature of the company etc.):

2. The Transfer has been done from the following account:

Name of the Bank

Address of the Bank

Name account holder

Account number

Copy of proof of transfer

3. The funds are to be used for:

4. Third Party Declaration (if applicable)

When paying by a third party (including a (your) legal entity), we must fully identify this third party. In addition, we need a statement explaining the reason why this third party is paying on your behalf. Lastly, we need underlying documents (in many cases for example a loan agreement).

The funds have been transferred on behalf of:

the undersigned a 3rd party, namely (full name 3rd party):

SOURCE OF WEALTH (“SOW”) DECLARATION

Confirmation Sources of Wealth / Funds

Description of Source(s) of Wealth

Necessary Information

Please describe the requested information or refer to attachments (mandatory)

Family fortune

Specify: e.g. (former) entrepreneurial, inheritance, other resources; if possible detailed and documented description

Active entrepreneurial

Company name
Short description of business activities
Statutory seat
Name company website (if applicable)

Former entrepreneurial

If “sold to a third party”: Name of purchaser and approximate date
If other: Detailed and documented description

Business Profits

Name and address of company
Nature of company
Amount of annual profit
Copy of latest audited financial statement

Loan

Please specify:

name of lender
amount of loan
date received

Please provide us copy of the relevant information and supporting documentation, which support the sources of wealth that have been mentioned by you.

The following documents have been sent to support the above:

DOCUMENTATION REQUIRED

Only files type jpg, jpeg, png, pdf, bmp, itiff, doc, docx, gif, xls or xlsx. Max 1Mb per file
License or Registration of Incorporation of the Company and License or Registration of the Regulatory Body - Notarized

Certificate of Incumbency. List of directors, officers, shareholders, beneficial owners, addresses - Notarized

Color copy of identity card, ID or passport of directors, shareholders, and beneficial owners

Audited Financial Statements of the last period. Max 1Mb

Document stating person(s) proof of permanent residence

Corporate structure chart (ending in natural person or stock listed company)

PEP and Sanctions Screening reports (not older then 3 months)

STATEMENT

"I DECLARE THAT THE INFORMATION CONTAINED IN THIS FORM IS TRUE, COMPLETE AND PROPORTIONATE. RELIABLE AND UP-TO-DATE INFORMATION ON ALL ASPECTS ON WHICH QUESTIONS HAVE BEEN ASKED."

The applicant declares that:

Has not been involved in, has not been convicted of or is under investigation anywhere in the world for offences related to the production, trafficking, consumption of drugs or any other offence associated with drugs; or money laundering.
I (we) confirm that I (we) have and verify the due diligence evidence of all beneficial owners, attorneys, beneficiaries, directors, officers and signatories of the services necessary for INTEGRA; and agree to provide such information and/or documentation requested by INTEGRA.
I declare under penalty of perjury that this statement has been examined by me and is true, correct and complete to the best of my knowledge and belief.

Please complete the form and print and send signed to the e-mail [email protected]