GXI Ultimate Beneficial Owner Form

As a company supervised by the Bangko Sentral ng Pilipinas (BSP), GXI wants to know more about its customers before establishing a relationship.
In order to do so, kindly complete this beneficial owner form and submit all the documents requested.

Company Information
1) Entity Legal Name / Registered Business Name:

2) “Doing Business As” Name(s) (DBA) (If different than legal business name) / Trade Name:

3) Entity Type:
Sole Proprietorship
Partnership
Corporation
Non-government organization/Non-profit organization
Credit Union or cooperative
Publically traded, please indicate stock exchange: _____________________

Ownership Information
Due diligence will be performed:
On all companies, government entities, and individuals who directly own 20% or greater of the applicant. These are first-tier owners.

On all companies, government entities, and individuals who own 20% or greater of a first-tier company. These are second-tier owners.

On all companies, government entities, and individuals who own 20% or greater of a second-tier company, third-tier company, fourth-tier
company, etc. These are higher tier owners.

On all individuals who are exercising control over the applicant by means of trusts, agreements, arrangements, understandings, or practices, or
when an individual can exercise control through making decisions about financial and operating policies. The control also includes: (a) power to
appoint or remove the majority of the members of the board of directors or equivalent governing body; (b) power to cast the majority votes at a
meeting of the board of directors or equivalent governing body; or (c) any other arrangement similar to any of the above. These are considered
as controlling ownership owners.

On all individuals who hold the position of senior managing official or equivalent ranks. These are senior managing official.

Providing required layers of ownership allows G-Xchange Inc. to identify and perform due diligence on the ultimate beneficial owner(s) of the
applicant company as mandated by BSP.

First-Tier Ownership:
4) Are there any individuals who own 20% or greater of the applicant? Yes No
If Yes, please add each person who owns 20% or more to the Individual Ownership Information page
5) Are there any companies or government entities that own 20% or greater of the applicant? Yes No
If Yes, please add each person who owns 20% or more to the Corporate Ownership Information page

Second-Tier Ownership:

6) Are there any individuals who own 20% or greater of a first-tier company? Yes No
If Yes, please add each person who owns 20% or more to the Individual Ownership Information page
7) Are there any companies or government entities that own 20% or greater of a first-tier company? Yes No
If Yes, please add each person who owns 20% or more to the Corporate Ownership Information page

Higher Tier Ownership: (Third-tier, fourth-tier etc.)

8) Are there any individuals who own 20% or greater of a second-tier company, Yes No
third-tier company, etc.?
If Yes, please add each person who owns 20% or more to the Individual Ownership Information page
9) Are there any companies or government entities that own 20% or greater of a second-tier Yes No
company, third-tier company, etc.?
If Yes, please add each person who owns 20% or more to the Corporate Ownership Information page

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Controlling Ownership:

10) Are there any individuals who are exercising control over the applicant? Yes No
If Yes, please add each person who has control over the applicant to the Individual Ownership
Information page
11) Are there any companies or government entities that are exercising control over the applicant? Yes No
If Yes, please add each person who has control over the applicant to the Corporate Ownership
Information page

Senior Management Official:

12) Are there any individuals who hold the position of senior managing official(s) or equivalent Yes No
Rank, where no person under those stated above?
If Yes, please add each person to the Senior Management Information page

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 Individual Ownership Information
Add additional copies of this page for additional individual ownership
Full Legal Name (First, Middle, and Last) *NOTE* Please include any previous names:

Address: Nationality:

Nature of Work: Source of Funds*:

Full Legal Name (First, Middle, and Last) *NOTE* Please include any previous names:

Address: Nationality:

Nature of Work: Source of Funds*:

Full Legal Name (First, Middle, and Last) *NOTE* Please include any previous names:

Address: Nationality:

Nature of Work: Source of Funds*:

Full Legal Name (First, Middle, and Last) *NOTE* Please include any previous names:

Address: Nationality:

Nature of Work: Source of Funds*:

Full Legal Name (First, Middle, and Last) *NOTE* Please include any previous names:

Address: Nationality:

Nature of Work: Source of Funds*:

* Source of Funds are e-money wallet, bank account, cash on hand, loans, interest income, proceeds of sale or property,
inheritance and remittance.
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 Corporate Ownership Information
Add additional copies of this page for additional individual ownership
Legal Business Entity Name:

Website (if applicable):

City: Country :

Please list the business this company owns:

AND the percentage they own

Legal Business Entity Name:

Website (if applicable):

City: Country :

Please list the business this company owns:

AND the percentage they own

Legal Business Entity Name:

Website (if applicable):

City: Country :

Please list the business this company owns:

AND the percentage they own

Legal Business Entity Name:

Website (if applicable):

City: Country :

Please list the business this company owns:

AND the percentage they own

Legal Business Entity Name:

Website (if applicable):

City: Country :

Please list the business this company owns:

AND the percentage they own

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 Senior Management Information
Please identify and provide the below information for the top 3 Senior Management positions at your company.
(i.e. Chief Executive Officer, Chief Financial Officer, Chief Operating Officer or their equivalent).

Full Legal Name (First, Middle, and Last):

Position: Date and Year of Birth (DD/MM/YYYY):

Address: Country of Birth:

Nationality: Source of Funds

Full Legal Name (First, Middle, and Last):

Position: Date and Year of Birth (DD/MM/YYYY):

Address: Country of Birth:

Nationality: Source of Funds

Full Legal Name (First, Middle, and Last):

Position: Date and Year of Birth (DD/MM/YYYY):

Address: Country of Birth:

Nationality: Source of Funds

Customer Declaration
I certify that all information I have provided on this form is true and correct to the best of my knowledge. I hereby authorize GXI to verify, any and
all information provided herein. I agree to promptly notify GXI of any changes in the information which I have provided at any time after the date of
this declaration. I fully understand that any misrepresentation or failure to disclose information on my part as required herein, may result in the
disapproval of my application for GXI products and services, and that GXI is not under any obligation to share with me the reason/s or rationale for
such disapproval.

_________________________________________ _________________________________________ _____________________

Signature above printed name Title/Position Date
(Corporate Secretary or Authorized Signatory)

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