Source of Funds/Wealth Declaration Form Pursuant to Section of the SW Anti-money Laundering and Terrorist Financing Code,2008 NAME OF THE COMPANY GOLD BLACK LIMITED SPECIFIC ACTIVITIES CARRIED BY THE COMPANY: MAIN COUNTRYUES) WHERE THE ACTIVITIES ARE CONDUCTED: 1. Source of Funds Weoith: the origin of the monies being used by the Appiicont for Business to execute the specific transaction/activity Memorial Savings El Proceeds of lnheritancefTrust Fund BorrowingiLoans Proceed from Financial Investments Proceeds from Business Trade Proceeds from Contractual Obligations Other (please specify) Please state if the Source of Wealth is different from the Source of Funds and if affirmative please provide the respective information l/We decla the source of all fundslassets connected with the services for which MOSSFON provides, derives fro Itimate sources and are not of criminal origin. I also confirm that the above information is true that you are authorized to provide any or all of such information for due diligence purposes to so requested by them. We also undertake to notify you of any future changes to the above Client Per Records? Signature Date information