Natural Person Financial Profile Form

I. GENERAL INFORMATION

Name

Company / Foundation

1. Position of the natural person within the Company or Foundation

2. Origin of your assets

Business product

Real estate activities

Sale of properties, assets or companies

Savings and salaries from your professional activity

Inheritance, donation or gift

Investment return

Other. Please specifyOther. Please specify

Expand details of origin of wealth

Example: Provide as much detail as possible, include dates and names of major companies that generated the wealth, and verifiable information such as newspaper or internet media articles, documents, websites; In case of inheritance, please detail the full name of the people who generated the wealth, type of business and names of the companies, important dates, amount inherited, percentage of the inheritance; detail the family relationship of the heirs, support information with documentation and in the event of the sale of an asset, send documentation that supports the sale.

3. Estimated net worth (assets minus liabilities)

Less than US$1,000,000.00

Between US$1,000,001.00 and US$5,000,000.00

Above US$5,000,000.00*

If it is greater than US$5,000,000.00, please specify the approximate amount:

Comments / Observations

DECLARATION

I declare that the information provided is true and correct, and I authorize it to be verified, in witness whereof I sign this application.

DIGITAL SIGNATURE

Signature

Clear

(Please sign the same as on your personal identity card/passport)

No. ID

Date

Are you human?

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