Legal AML Questionnaire

LEGAL AML QUESTIONNAIRE

This Legal AML Questionnaire (the "Questionnaire") is executed as of Effective Date: by and between Client Name: with Address: and Service Provider Name: with Address: (each a "Party" and collectively the "Parties").

Recitals

WHEREAS, the Parties seek to document information necessary for compliance with applicable anti-money laundering, counter-terrorist financing, and sanctions laws and regulations; and

WHEREAS, the Service Provider requires the Client to provide accurate identification, ownership and source of funds information to enable the Service Provider to conduct due diligence, ongoing monitoring and reporting required by law; and

WHEREAS, the Parties intend that the representations, warranties and certifications contained in this Questionnaire will be relied upon by the Service Provider for risk assessment and regulatory compliance purposes.

NOW, THEREFORE, in consideration of the mutual covenants and representations contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows:

1. Definitions

For purposes of this Questionnaire, the following definitions apply: "Beneficial Owner" means any natural person who ultimately owns or controls, directly or indirectly, 25% or more of the equity interests or voting rights in the Client, or who otherwise exercises ultimate effective control over the Client. "PEP" means a Politically Exposed Person as defined under applicable law or regulation.

2. Client Identification

Corporation Partnership Trust Individual Other:

3. Beneficial Ownership

Identify all natural persons who are Beneficial Owners. If more space is required, attach additional pages and reference them below.

Date of Birth:   Nationality:   % Ownership:

Date of Birth:   Nationality:   % Ownership:

4. Source of Funds and Wealth

Provide a clear description of the anticipated source(s) of funds and the origin of the Client's wealth relevant to the relationship and expected transactions.

5. Politically Exposed Persons (PEP)

For each natural person identified in this Questionnaire, state whether that person is a PEP, family member of a PEP, or a close associate of a PEP.

Yes    No

6. Sanctions, Adverse Media and Regulatory Actions

Disclose whether the Client or any Beneficial Owner is subject to any sanctions, has been the subject of adverse media identifying serious allegations, or is currently or has been within the past five years subject to regulatory or criminal investigation relating to financial crime.

Yes    No

7. Documents and Evidence Provided

Indicate which documents accompany this Questionnaire. Originals or certified copies may be requested by the Service Provider for verification.

Passport    Driver's License    Certificate of Incorporation / Formation

Articles of Association / Operating Agreement    Beneficial Owner Identification Documents    Other:

8. Representations and Warranties

The Client hereby represents and warrants to the Service Provider that: (a) all information provided in this Questionnaire and in any attachments is true, correct and complete in all material respects, and no material fact has been omitted; (b) the Client has disclosed all Beneficial Owners and any person exercising effective control over the Client; (c) the funds and assets described are derived from lawful sources and are not the proceeds of criminal activity; and (d) the Client will promptly notify the Service Provider in writing of any change in the information supplied.

9. Certification and Authorization

The undersigned certifies, under penalty of perjury or equivalent under applicable law, that the information provided in this Questionnaire is true, correct and complete to the best of the undersigned's knowledge and belief, and that the undersigned is authorized to provide this information on behalf of the Client.

10. Notices; Amendments; Waiver

All notices required or permitted under this Questionnaire shall be in writing and delivered to the addresses set forth herein or to such other address as a Party may designate by notice. This Questionnaire may be amended only by a written instrument signed by both Parties. No failure or delay by either Party in exercising any right under this Questionnaire will operate as a waiver.

11. Governing Law; Entire Agreement; Severability

This Questionnaire shall be governed by and construed in accordance with the substantive laws of the jurisdiction specified by the Service Provider for governing law: , without regard to conflict of law principles. This Questionnaire, together with any attachments, constitutes the entire agreement between the Parties with respect to the subject matter hereof. If any provision of this Questionnaire is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

12. Counterparts

This Questionnaire may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Facsimile or electronic signatures shall be treated as original signatures for all purposes.

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