Source of Funds/Wealth Declaration Form

Pursuant to Section 19(3)(d) of the Anti-money Laundering and Terrorist Financing Code,2008

 

NAME OF APPLICANT FOR BEN EFICIAL OWNER: ANNA SIGURLAUG 
ALIASES (if applicable): 

DATE OF BIRTH: 09/12/1974 dd?mm/DW)



 

NAME OF ASSOCIATED COMPANY: WINTRIS INC
COMPANY ACTIVITY: PASSIVE NON-FINANCIAL ENTITY

 

I. Source ofFuna's/ VVea/t/r: the on'gin oft/re monies being used by the Applicant for Business to execute the
specific transaction with OSSFON VI.

Personal Assets

El Borrowing/Loans

Cl Proceeds from Business Trade

Proceeds of Inheritance/F rust Fund
DProceed from Finzmeial Investments
DProceeds from Contractual Obligations

Other (please specify)

 

 

Please state if the Source of Wealth is di?'erentfrom the Source of Funds and if af?rmative please provide information

 

 

 

 

 

declare that the source of all funds/assets corureetcd with the services for which MOSSFON BVI provides
service derives from legitimate sources and are not of criminal origin. I also con?rm that the above information is
and accurate, and you are authorized to supply any or all of such information for due diligence purposes to the
Regulators if so requested by them. We also undertake to notify you of any future changes to the above
information.

AnnaSrguriaug' Palsd .,
om  

Client/Applicant for Business Name Writ/Applicant for Business Signature

7 /6 fo/S

Date (dd/