MOSSACK FONSECA


Source of Funds/Wealth Declaration and Accounting information Form

NAMEOFULTIMATEBENEFICIALOWNER: fit? lift?: (is; PICIAG. Quart/??7
(if applicable):

 

DATE or BIRTH: (dd/mm/vwvl
ADDRESS:

 

 

a
NAME OFTHE COMPANY: hag/mm A4
2/ 
COMPANYACTIVITY: I in?rm fq/(s
MAIN OF ACTIVITY: CJ N44

 

1. Source of Funds Wealth: the origin of the monies being used by the Applicant for Business to execute the specrfic
transaction with MOSSFON BVI.
Proceeds of Inheritance/Trust Fund

Personal Assets . .
Proceed from Fmancra Investments

CI Borro 
wmg/ oans Proceeds from Contractual Obligations

Cl Proceeds from Business Trade CI Other (please specify)

 

 

 

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

 

 

 

l/We declare that the source of all funds/assets connected with the services for which MOSSFON provides service derives
from legitimate sources and are not of criminal origin. I also confirm that the above information is true 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.

Name of the person who maintains/controls the company?s records and underlying documentation:

Location of the original registers, records and underlying documentation of the company (physical address):

L7 if?) Ava-J1 [up (u Laser/mi 7, W) 71/ (mutt, 

Client/Applicant for Business Name

 

   

Client/Applicant for Business Signature

b/ 9'

IDate (dd/mm/yyvv)