Financial UBO Form

FINANCIAL UBO FORM

Entity Information

Entity Name:

Entity Type

Corporation Limited Liability Company (LLC) Partnership Trust Sole Proprietorship Other:

Is the entity listed on a regulated market or public exchange? Yes No

Ownership Declaration

The entity declares the natural persons who ultimately own or control, directly or indirectly, 25% or more of the ownership interest or exercise ultimate control. If no such natural person exists, provide details of the senior managing official below.

Does any natural person hold 25% or more ownership or control? Yes No

Ultimate Beneficial Owner (UBO) Details

Provide details for each UBO. If necessary, attach an additional sheet using the same format and include supporting documents.

UBO 1

Passport National ID Other

Politically Exposed Person (PEP)? Yes No

UBO 2

Passport National ID Other

Politically Exposed Person (PEP)? Yes No

Additional UBOs

Use the fields below to provide further UBOs. If more space is required, attach additional pages with the same format and supporting documentation.

Supporting Documents

Provide certified copies as applicable. Check all that are attached:

Passport copy (UBO) Proof of address (UBO) Certificate of incorporation Shareholder register / ownership ledger

Declaration and Certification

I, the undersigned, certify on behalf of the entity named in this form that the information provided in this Financial UBO Form is true, complete and correct to the best of my knowledge and belief. I acknowledge that this information will be used for anti-money laundering, counter-financing of terrorism and customer due diligence purposes. I further certify that:

• The natural persons identified are the ultimate beneficial owners who directly or indirectly own or control the entity or, if no such natural person exists, the senior managing official(s) are identified.
• I will provide promptly any additional documentation reasonably requested to verify the identity or ownership of the persons named herein.
• I understand that knowingly making a materially false statement or omission may expose the entity and the signatory to civil or criminal penalties under applicable law.
• I consent to the verification of the information provided and the disclosure of this information to banks, auditors, regulatory authorities and other parties where required for lawful compliance purposes.
• The entity will notify the recipient of any material changes to the information in this form within 30 days of such change.

By signing below, I affirm that I am duly authorized to execute this form on behalf of the entity named above and that I have read and understood the certifications and consents contained herein.

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