Currency Transaction Form

Currency Transaction Form

Parties

Recitals

WHEREAS, Remitter is desirous of transferring currency to Recipient and requires documentation of the transaction, including currency type, amount, source of funds, and terms of delivery and payment; and

WHEREAS, Recipient agrees to accept the specified currency and to comply with all recordkeeping and lawful reporting obligations; and

WHEREAS, the parties desire to set forth the material terms, representations, covenants and certifications governing the currency transfer in this Currency Transaction Form.

Transaction Identification

Transaction Reference Number:

Transaction Date:

Scope of Transaction

Describe the nature of the currency transfer, services (if any) performed in connection with the transfer, and obligations of each party:

Transaction Details

Exchange Rate (if applicable): Equivalent Amount:

Cash    Wire transfer    Check    Other:

Payment Terms

Total Consideration:

Late Payment: If any payment is not received when due, the unpaid amount shall accrue interest at a rate of and an administrative late fee of . Parties agree that such fees represent a reasonable estimate of the costs of collection.

Term and Termination

Effective Date:

Termination Date or Event:

Either party may terminate this agreement upon written notice to the other party given at least days prior to the effective date of termination, except that termination shall not relieve either party of obligations accrued prior to termination.

Representations, Warranties & Compliance

Each party represents and warrants that it has full authority to enter into this Currency Transaction Form and that the funds transferred are not derived from illegal activity. Each party agrees to comply with applicable anti-money laundering, sanctions, tax and reporting obligations and to provide, upon reasonable request, documentation necessary to substantiate identity and source of funds.

The parties further certify that this transaction is not structured to avoid reporting requirements and will promptly notify the other if any material fact or representation contained herein becomes untrue.

Confidentiality

Except as required by applicable law or lawful order, each party shall keep confidential the terms of this transaction and all nonpublic information obtained in connection with the transaction. Confidential information may be disclosed to affiliates, legal counsel, auditors and financial institutions on a need-to-know basis provided such recipients are bound by confidentiality obligations no less protective than those contained herein.

Notices

Governing Law; Entire Agreement

This Currency Transaction Form shall be governed by and construed in accordance with the laws of , without regard to principles of conflicts of law. The parties submit to the exclusive jurisdiction of the courts in that jurisdiction for disputes arising hereunder.

This document constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, understandings and agreements, whether written or oral, relating to the currency transfer. Any amendment or modification must be in writing and signed by both parties.

Acknowledgements and Certifications

By signing below, each party certifies under penalty of perjury that the information provided in this form is true, complete and correct to the best of their knowledge; that the funds involved are from legitimate sources; and that each party will retain records of the transaction as required by law.

Identification Provided:

Recordkeeping & Reporting

The parties acknowledge that certain currency transactions may be subject to mandatory reporting or recordkeeping under applicable law. Each party agrees to retain records and to provide such records or assistance to the other party or competent authorities as required by law.

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