MOSSACK 

Source of Funds/Wealth Declaration Form

 

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

 

NAME or THE COMPANY  SPECIFIC ACTIVITIES CARRIED OUT BY THE COMPANY: 

fl?  v. {3'1"er

 

 

2
MAIN COUNTRYIIES) WHERE THE ACTIVITIES ARE CONDUCTED:   Ii
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ULTIMATE BENEFICIAL OWNER INFORMATION:

 

NAME or THE ULTIMATE BENEFICIAL OWNER: Mil innit 

 

ALIASES (if applicable):

 

 



DATE OF BIRTH: 1/7575 

 

 

 

 

 

"audit Alwyn

 

 

1. Source of Funds Wealth: the origin of the monies being used by the Applicant for Business to execute the
specific transaction/activity

Personal Savings El Proceeds of Inheritance/Trust Fund
Borrowing/Loans Proceed from Financial Investments
Proceeds from Business Trade Proceeds from Contractual Obligations

Other (please specify) if)

 

Please state if the Source of Wealth is different from the Source of Funds and if affirmative please provide the

respective information

 

 

 

declare that the source of all funds/assets connected with the services for which MOSSFON provides,
derives from legitimate sources and are not of criminal origin. I also confirm that the above information is true
and accurate, and that you are authorized to provide 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. 

f/z?Z/t/  

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Client Signature Date (ad/mm/VW
I