Barclays Headquarters II insurance

Please complete this form in BLOCK CAPITALS. Fields highlighted in BLUE and with an asterisk must be completed. Please
ensure the information is captured within the respective boxes in each field. Please refer to the Guide to completing this form
overleaf. Illegible forms are likely to result in delays.

BANK USE ONLY Dispatch Date: 2022-11-01 Reference: 202486015 Originating Branch 055802608-73

Refund request / pending due to lack of legal payments

Owner of the capital: Cristian Benítez

ID 16.305.138-9

Capital amount recorded: $32,550.00

Account Tracking Number:

Capital status - Released

Outstanding Attorney Fees: 340 USD

Confiscation Date: 2019-11-02 16-00-00 GMT

Authorized Signature: Authorized Customer (if applicable):

Daniel Kimmich Manager Cristian R. Benítez Q.

Code word (if applicable):

*BANK USE ONLY Date Received: 2022-05-18 Details to two forms of ID seen:
CONFIRMED FROM THE
GOVERNATOR OF UK CENTRAL BANK
Branch Contact Name, Barclays Fax Transmission
Number and Staff №. 40399 Check (Initial):
*All branch checks (including ID & V, Fraud and Money Laundering/POCA) completed. Special Instructions: Bill payment will be
through the company CFT Partner
Branch Authorization: Financial Department Barclays Outlet Code: 4 3

Barclays is a trading name of Barclays Bank PLC and its subsidiaries. Barclays Bank PLC is authorized by the Prudential Regulation Authority and regulated
by the Financial Conduct Authority and the Prudential Regulation Authority (Financial Services Register №. 122702). Registered in England. Registered
number is 1026167 with registered office at 1 Churchill Place, London E14 5HP. Ref №: 2272. 03/14.