Financial Transaction Questionnaire

FINANCIAL TRANSACTION QUESTIONNAIRE

This Financial Transaction Questionnaire collects information necessary to assess and process the proposed financial transaction. All information provided herein must be true, complete, and accurate to the best of the applicant's knowledge. Providing false information or omitting material facts may result in refusal to process the transaction, regulatory reporting, account restrictions, or other legal action.

1. APPLICANT / INITIATOR INFORMATION

Client Name:

Individual Corporation Partnership Trust Non-profit Other:

Type: Number: Issuing Country:

2. TRANSACTION DETAILS

Proposed Transaction Date: Expected Settlement Date:

Wire Transfer ACH / Direct Debit Domestic Check International Check Cash Deposit/Withdrawal Securities Transfer Loan Proceeds Other:

Related Party Unrelated Unknown If related or special relationship, describe:

One-time Recurring — Period: Expected number of occurrences:

3. SOURCE OF FUNDS / SOURCE OF WEALTH

Employment Income Savings Sale of Property Inheritance Loan / Financing Investment Proceeds Business Revenue Gift Other:

Are you able to provide documentary evidence for source of funds? Yes No If yes, list documents:

4. BENEFICIAL OWNERS & CONTROL

Does the applicant have any beneficial owner(s) owning 25% or more of the entity? Yes No

List up to three beneficial owners (if applicable)

5. SANCTIONS, PEP AND COMPLIANCE DECLARATIONS

Is the applicant, any beneficial owner, or counterparty a Politically Exposed Person (PEP)? Yes No If yes, provide name, position, and jurisdiction:

To your knowledge, is any party subject to economic sanctions, embargoes, or regulatory restriction? Yes No If yes, provide details:

6. SUPPORTING DOCUMENTS

Please indicate which documents you will provide with or prior to the transaction (documents may be required to complete our review):

Government-issued ID Proof of Address (utility bill, bank statement) Corporate Documents (articles, certificate of formation) Evidence of Source of Funds Signed Authorization / Powers of Attorney Other:

7. CERTIFICATION, CONSENT AND AUTHORIZATION

By signing below, I certify under penalty of perjury that all information provided in this Financial Transaction Questionnaire is true, complete and correct. I authorize the financial institution and its agents to verify any information provided, to obtain additional information as required, and to share information with regulatory or law enforcement authorities in accordance with applicable law. I understand that the institution may refuse or delay the transaction if information is incomplete or inconsistent, and that failure to disclose material facts may subject me to civil or criminal penalties.

I further acknowledge that the institution may retain copies of documents provided, and may retain this questionnaire as part of its compliance records. I consent to such retention and to processing of personal data for the purposes of transaction processing, compliance, risk assessment, and regulatory reporting as permitted by law.

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