Politically Exposed Person-Declaration

1. Please fill in the details below:

First and Last Name: …………………………………. Citizenship country: ………………………………….
Passport number: …………………………………. Country of Residence: ………………………………….

2. Please tick the box below that applies (a, b or c):

(a) Do you qualify as a politically exposed person (“PEP”)? Please select your occupation, either currently held or held
within the last 18 months, from below list:

 Head of State or government, ministers and deputy
or assistant ministers
 Member of governing body of a political party
 Member of courts of auditors or boards of central banks
 Member of administrative, management or
supervisory body of state-owned enterprises
 Ambassador, chargé d’affaires or high-ranking
officer in armed forces
 Member of supreme court, constitutional court or
other high-level judicial body1
 Member of parliament or similar legislative body
 Director, deputy director, board member or
equivalent function in an international organization

(b) I am an immediate family member or close associate to a person that qualifies as a PEP, either currently or within the
last 18 months, as per above list and am/have:
 A spouse or equivalent of a PEP
 A child or spouse (or equivalent) to a child of a PEP
 A parent of a PEP
 Joint beneficial ownership of legal entities or legal arrangements or other close business relations with a PEP
 Sole beneficial ownership of legal entities or legal arrangements to have been setup for the de facto benefit of a PEP

If you have ticked any box under (a) or (b), please answer the following questions regarding your (or this person’s)
position:
Name (if point 2) ……………………………………………………………………………………………...
PEP function ……………………………………………………………………………………………...
Country ……………………………………………………………………………………………...
Role/responsibilities ……………………………………………………………………………………………...
Start date function ……………………………………………………………………………………………...
End date if applicable ……………………………………………………………………………………………...
The funds I intend to use for my Rewire account and my net worth are generated from the following economic
activities2:……………………………………………………………………………………………...…………………………………………………………………
…………………………...……………………………………………………………………………………………...……………………………………………………

If none of the above under points (a) or (b) applies, please tick only the below box (c):
(c)  I am neither considered to be a PEP nor am I an immediate family member or close associate to a PEP.

Further to the above, I, the undersigned, also bind myself to notify Rewire immediately of any change to any declaration made
or information provided in accordance with the above.

Date................................ Signature.................................

1 The decisions of which are not subject to further appeal, except in exceptional circumstances.
2 The activity, event, business, occupation or employment from which the funds used in operating the account are generated. We may ask
you to provide further documentation in relation thereto.

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