GENERAL INFORMATION
BOARD OF DIRECTORS
Director 1
Director 2
Other Director
SHAREHOLDERS
Controlling Shareholder
Other Shareholder
Other Shareholder
*PEP: Person politically exposed
DECLARATION OF SOURCE AND ORIGIN OF RESOURCES OF THE TRANSACTION
SOURCE OF FUNDS (“SOF”) DECLARATION
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:
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).
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)
- Specify: e.g. (former) entrepreneurial, inheritance, other resources; if possible detailed and documented description
- Company name
- Short description of business activities
- Statutory seat
- Name company website (if applicable)
- If “sold to a third party”: Name of purchaser and approximate date
- If other: Detailed and documented description
- Name and address of company
- Nature of company
- Amount of annual profit
- Copy of latest audited financial statement
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
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]
