Takeover Statement Form

I, as signed below:

Full Name :
PTSMI Username :
Email :

Hereby declare that I have taken over all authority, ownership and responsibility over the broker
account of the following:

Full Name :
PTSMI Username :
Email :

With the broker account details:

Broker :
Username :
Email :
MT4 ID :

With the signing of this form, I am fully aware that I am fully responsible for all matters regarding the
account stated above with the effective date being the date of signing this letter. I am willing to take
on all lawsuit or any legal actions regarding any disputes over the ownership of the account stated
above indefinitely.

______________, ___ ___, 2022

The submitter,

Materai Rp. 10,000,-

(_________________________________)