COMPLIANCE FORM

(Type using this document)

We, a Corporation organized in the Country of

(hereinafter the “Applicant”) hereby disclose and confirm under penalty of perjury the following:

Applicant Personal Information

Funds Available for this Transaction

Applicant’s Name

:
Passport # / Issue Date / Expire Date

:
Driver’s Licence No.

:
Social Security No. / Identification :
Address :
Phone / Fax / Mobile / Email :
Business Information
Business Name :
Business Address :
Mail / Courier Address :
Phone / Fax / Mobile / Email :
Nature of Business :
Business Domicile / Organization Date

:
Business Registration No.

:
Tax Identification No. (TIN) :
In existence since (date) :
Ownership (1 , 2 , etc.) (Owners,
st nd

partners, principals, directors, trustees, and

attach resumes)
Name :
Page 1 of 3 ( Initials)
 Home Address (physical & mailing)

:
Home Phone / Fax / Mobile / Email

:
Nationality / Date of Birth / Birth Place

:
Passport No / Issue Date / Expire Date

:
References (at least two verifiable)
Name :
Address :
Phone / Fax / Email :
Name :
Address :
Phone / Fax / Email

Page 2 of 3 ( Initials)
 Accountant / Financial Counsel
Firm’s Name :
Contact Name :
Address :
Phone / Fax / Mobile / Email :
Attorney / Legal Counsel
Firm’s Name :
Contact Name :
Address :
Phone / Fax / Mobile / Email :
Current Bank (holding funds)
Name of Bank :
Branch Name and Address :
Bank Officer’s Name :
Phone / Fax / Mobile / Email :
Account Number :
ABA Number :
S.W.I.F.T. Code :
DTC Number :
Bank Account Name (Beneficiary) :
Account Beneficiary Address :
Name of all signatory(ies) :
Is there clear title to these funds? :
Origin of these funds :
Prior Bank (if current bank holding funds for less than 10 years)
Name of Bank :
Branch Name and Address :
Bank Officer’s Name :
Phone / Fax / Mobile / Email :
Account Number :
ABA Number :
S.W.I.F.T. Code :
DTC Number :
Bank Account Name (Beneficiary) :
Account Beneficiary Address :
Reason for transfer :
Transfer date :

Page 3 of 3 ( Initials)
Certification
1) Applicant certifies funds are legally earned, taxed, and include no independent third- party
managed funds, having been transferred to the Applicant’s account from
(describe where
funds came from and $ amount) .
2) Purpose, scope, and objective of applicant’s business activities (what does this
company do?):
(one sentence)
3) Applicant warrants and attests that all the information supplied in the documentation
submitted, and the cash involved, are not in violation of the Patriot Act of October 26, 2001, and
amendments thereto, with its related financial crimes counterparts, however interpreted, defined and enacted,
whether within the host state of this statement or internationally.
4) Applicant has not placed, or tried to place, these funds elsewhere into similar matters, and
has no current valid or pending commitments or agreements of any kind relating to said cash funds.
5) Applicant declares that the subject funds have no liens, commercial obligations, or
encumbrances of any kind pertaining to said cash asset.
6) There are no affiliates of Applicant who will benefit from this transaction, nor any
interrelated parties that could affect the outcome of this contemplated transaction.
7) The Applicant is not a party to a law suit or pending adverse legal action, further, there
are no pending contracts existing, or about to exist, that could affect the outcome of this contemplated
transaction.
8) Applicant hereby declares that the undersigned is the authorized signatory and owner of the
funds, or the duly appointed personal representative with full signatory power on the bank account to
transfer, assign, pledge or reserve the cash upon terms satisfactory to Applicant, further that vested with
fully authority to execute all documents and agreements relating to the same.
9) Applicant hereby grant(s) permission to contact all parties and institutions named
within this document including the authorization to verify funds at Applicant’s bank.

Signature of applicant:
Name:
Passport Number:

Notary acknowledgment: I do hereby certify that ,

known to be the individual described herein, personally appeared before me as to the above date and
presented the documents indicated. Subscribed to and sworn to before me this day of
, 20 .

Notary signature & seal

Page 4 of 3 ( Initials)