Source of Funds/Wealth Declaration Form Pursuant to Section 19(3) of the BVI Anti-money Laundering and Terrorist Financing Code, 2008 NAME OF THE COMPANY: Palmer Equities Limited SPECIFIC ACTIVITIES CARRIED OUT BY THE COMPANY: Company is the holder of 50% of shares of the Company and acts as its Creditor MAIN COUNTRY (IES) WHERE THE ACTIVITIES ARE CONDUCTEDM ULTIMATE BENEFICIAL OWNER INFORMATION: NAME OF THE ULTIMATE BENEFICIAL OWNER: Mr. Pavel Zadorin ALIASES (if applicable): DATE OF 119607, Russia 1. Source of Funds Wealth: the origin of the monies being used by the Applicant for Business to execute the specific transaction/activity I Personal Savings Proceeds of Inheritance/T rust Fund Borrowing/Loans Proceed from Financial Investments Proceeds from Business Trade CI 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 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 informati Pavelg'vdi opIn (Beneifi ary Owner) Date: 21.10.2015 PART B. Ptease execute one page for every Ultimate Bene?cial Owner Palmer Equities Limited 11. Ultimate Bene?cial owneris) Beneficiai Owner means the naturai person or natural persons. who uitlmaieiy own or controi the customer andfor the naturai person on whose behaif a transaction or activity is beth conducted. NameiSurname:Mr.Valery Ei. Zadorin .. ID Card! Russian Local Passport: Passport No: Work Address: .. Home Address: Moscow. Russia - - Telephone No. Mobiie: Docu ment_s_ attached for the bene?cial ownertsi: ta) at i at assport copies duly legatized .. Short CM. BanitiLavryEriAccountant Reference (Zenit Bank) .. {di fresh utility Bill i Russian Local Passport for proof of res. Address .. .. is) Business card. if available 12. Documents required and attached for a legal entity being a shareholder: Full set of incorporation documents, duly legalized Scanned decision of Directors to set up Cypriot subsidiary to) BankiLawyeriAocountant Reference Company profits (include website reference If available) is] Last audited ?nancial statements - - - - - . - Describe in brief principal objects and activities of the legal entity being a shareholder. 13. Source of Funds and source of wealth to). From what source or sources have the funds to be introduced into the Company been derived? {How did yr acquire the assets that will be held by the Company?) lV SaiaryiF?ersonai Earnings (Please provide details of employmentiearnings belowj oLoan {Please indicate name of bank below.) olnheritanoe (Please Indicate how funds inherited were derived prior to inheritance} oasis of Assets (Please provide details of assets sold below.) nSpousai Support (Please provide details of spouses employmentieamings below.) maOther {Please provide a clear and self-explanatory description below.) Saving.pro?tfrom the owing and managing ofthe real property Please con?rm whether the Ultimate Beneficial Owner . or any immediate family member . or any legal physical person mentioned in this Questionnaire as related In any way with the Company. is. or at any time it been. or has been related to. a Potitically Exposed Person - such as government of?cials. high ranlt govemmen of?cer. politicians. executives of state owned companies and their immediate family members or close associates. HES (v1 NO If yes. please provide details . Please provide a certi?ed copy of the passport of the Relevant Individual. including a clear photograph. Please provideiattactt a codi?ed ?Proof of Address? for the Relevant Individual. 14. Please answer: is) Have you ever been convicted at any time and in any country for any criminal offence? YES (VJ N0 (bi Have you ever been declared bankrupt at any time in any country? hit] it} Have you even been the subject of any investigation for Money Laundering by the Law enforcement authorities of any country? HES {Vi NO Have you ever been banned from being eligible to be a director or company of?cer by any regulatory body it anyjurisdiction ez PART C. Please execute one page for every Bene?cial Owner. 15. Declaration Consent i am the uttimate bene?cial owner of the proposed private company and I hereby declare and con?rm the following: 1. The above information Is full. true and accurate. I have the responsibility to keep you fully updated in case of any change in the information provided herein, within reasonable time. for your prior approval and client acceptance procedures under the applicable laws. I will not transfer any bene?cial rights andior interests in the Company without informing you in advance and acquiring your prior approval and client acceptance procedures under the applicable laws. and i shatl remain as bene?ciary in all respects till such approval of yours. 2. The above information can be disclosed to any relevant supervisory or other authority of the Republic of Cyprus. if such disclosure is required by Law. a court order or by an official Investigation. 3. I have not and will not bene?t directly or indirectly from any criminal conduct anywhere in the world and i or bene?t from any funds which consist of proceeds of criminal conduct. 4. I hereby con?ne that the company will not: a) Carry on banking business unless licensed by the Central Bank of Cyprus Law er unless licensed to do so under the applicable legislation. b) Carry on business as an insurance or reinsurance company c) Engage in mutual funds business. offer ?nancial or investment services or ?duciary services unless licensed to do so under the applicable legislation d) Be used for. or engage in. any fraud or money laundering activities. or any other illegal activity. 5. Any power of attorney issued by the said company will never be used for any unlawful purposes including but not limited to fraud. or money laundering activities. and if such power of attorney is used for unlawful purposes then there is no valid agency relation between a so called ?attomey-in-fact' and the said company andior its officers. and therefore i declare and accept that any actions. obligation. agreements shall not be binding upon the Company andlor its of?cers in any respect . and that the so called ?attomey-in-fact' will be personally liable and responsible against third parties. and under the laws. 6. In case of breach of para 4 andl'or 5 above. I shall be personally liable and responsible against third parties and under the laws and my actions will not be binding upon the Company andior its of?cers. 7. I read and accept the Terms of Cooperation with your office as posted on your professional website. 15. Other information which the applicant considers as important and relevant to be mentionedName: Mr. Valery B. Zadorln Anti tang. hereby certify as a lawyer (attorney) practisrng in registration No 7712189 in uru?ed . registry of alleEYS in Moscow oily, (417?, i l5 true {zany of oriqlna? i_ . if; Iggy, )1 [sit M. r? ,2 t. I. PART B. Please execute one page for every Ultimate Bene?cial Owner Palmer Equities Limited 1 1. Ultimate Beneficiai ownerte) Bene?cial Owner means the naturai person or natural persons. who ultimately own or control the customer and/or the natural person on whose behalf a transaction or activity is being conducted} NametSumame: Mr. Pavel B. Zadorin .. ID Cardt Russian Local Passport: -- Passport Work Address: .. Home Address: Moscow. Russia Telephone No. i Documents attached forthe bene?cial ownerts): In a i at asspori copies duty legalized .. Short C.V. .. .. BanktLewyertAccountant Reference (Zenit Bank) .. fresh utility Bill Russian Local PasSport for proof of res. Address Business card. ifavailable .. 12. Documents required and attached for a legal entity being a shareholder: Full set of incorporation documents. duly legalized .. Scanned decision of Directors to set up Cypriot subsidiary .. BanktLawyettAccountant Reference .. Company pro?le {include webslte reference it available) .. Last audited ?nancial statements .. Describe in brief principai objects and activities of the legal entity being a shareholder. 13. Source of Funds and source of wealth From what source or sources have the funds to be introduced into the Company been derived? (How did you acquire the assets that witl be held by the Company?) ILSalaryi?Petsonal Earnings {Piease provide details of below.) mLoan (Please indicate name of bank below.) nlnheritance (Please indicate how funds inherited were derived prior to inheritance.) oSaie of Assets (Please provide details of assets sold below.) oSpousal Support (Please provide details of spouses employmentteamings below.) nnOther (Please provide a clear and self-expianatory description below.) Saving. pro?t from the owing and managing of the real property .. Please con?rm whether the Ultimate Bene?cial Owner . or any immediate family member . or any legal of physical person mentioned in this Questionnaire as related in any way with the Company. is. or at any time has been. or has been related to. a Politically Exposed Person such as govemment of?cials. high rank governmental of?cer. politicians. executives of state owned companies and their immediate family members or close associates. 1 NO If yes. please provide detaiis . Please provide a certi?ed copy of the passport of the Relevant Individual. including a clear photograph. Please providetattach a certi?ed "Proof of Address" for the Relevant Individual. 14. Please answer: is) Have you ever been convicted at any time and in any country for any criminal offence? (it) NC lb) Have you ever been declared bankrupt at any time in any country? i YES (it) N0 it} Have you even been the subject of any investigation for Money Laundering by the Law enforcement authoritiea of any country? (V) ND Have you ever been banned from being eligible to be a director or company officer by any regulatory body i" any jurisdiction? YES ND PART C. Please execute one page for every Bene?cial Owner. 15. Declaration Ii Consent I am the ultimate bene?cial owner of the proposed private company and I hereby declare and confirm the follov 1. The above Information Is full. true and accurate, I have the responsibility to keep you fully updated in case I change in the Information provided herein. within reasonable time. for your prior approval and client acce; procedures under the applicable laws. I will not transfer any bene?cial rights andfor Interests in the Company in informing you In advance and acquiring your prior approval and client acceptance procedures under the appl laws. and I shall remain as bene?ciary in all respects till such approval of yours. 2. The above information can be disclosed to any relevant supervisory or other authority of the Republic of Cy; such disclosure Is required by Law. a court order or by an o?icial investigation. 3. I have not and will not bene?t directly or Indirectly from any criminal conduct anyWhere In the world an bene?t from any funds which consist of proceeds of criminal conduct. 4. I hereby con?rm that the company will not: a) Carry on banking business unless licensed by the Central Bank of Cyprus Law or uniess licensed to under the applicable legislation. b) Carry on business as an insurance or reinsurance company c) Engage in mutual funds business. offer ?nancial or investment services or ?duciary services licensed to do so under the applicable legislation d) Be used for. or engage in. any fraud or money laundering activities. or any other Illegal activity. 5. Any power of attorney issued by the said company will never be used for any unlawful purposes Including l: limited to fraud. or money laundering activities. and if such power of attorney is used for unlawful purpose.- there is no valid agency relation between a so called ?attorney-ln-fact" and the said company andror its of?cer therefore I declare and accept that any actions. obligation. agreements shall not be binding upon the Cor andlor its of?cers in any respect . and that the so called "attomey-in?fact? will be personally liable and respo against third parties. and under the laws. 6. In case of breach of para 4 andlor 5 above. I shall be personally liable and responsible against third panic under the laws and my actions will not be binding upon the Company andlor its officers. I read and accept the Terms of Cooperation with your of?ce as posted on your professional website. 16. Other information which the applicant considers as Important and relevant to be mentionedSignature of the ltlmate Bene?cial Owner: I Km?; hereby certify as a lawyer (attorney) practismg in Moscow. its" registration No TFINBQ in uni?ed Name: Mr. Pave! El. Zadorin registry of attorneys in Moscow city. that is a true copy of the original gigs 2 {7.3 - 141?