CONNECT PLUS BUSINESS LIMITED

FUND ORIGIN STATEMENT

FORM OF LEGAL ORIGIN OF FUNDS AND CASH TRANSACTIONS BY THE AUTHORITIES REQUIREMENTS

1,503.00
1. TRANSACTIONS IDENTIFICATION OF HOLDER SENDER

Name and Surname / Business Name:

Identifications Number Phone Number

26696

Home Address
FLAT 4 113 OXFORD ROAD COWLEY OXFORD OX42GY

Activity and/or Profession

CLEANER
City Total Deposit Operations No Date Credit
LONDON 186129 17/02/2016 0000

ALEXANDRE PEREIRA_______________________________________ __
2. - DECLARATION OF FUNDS

THE FUNDS OF THIS TRANSACTION COME FROM OR ARE A PRODUCT OF

447516220427/ 5511984221011

THE FUNDS OF THIS TRANSACTION WILL BE USED FOR:

RELEASE OF FUNDS: DECLARE THAT THE RECEIVED FUNDS WILL NOT BE USED FOR ANY ACTIVITY RELATED TO THE
PRODUCTION, CONSUMPTION, MARKETING OF NARCOTIC SUBSTANCES, PSYCHOTROPIC OR ANY OTHER ACTIVITY
DEFINED BY THE LAW OF NARCOTICS AND PSYCHOTROPIC SUBSTANCES.

EXPRESSLY AUTHORIZE CONNECT PLUS LIMITED TO ENGAGE IN ANY RELEVANT BUSINESS AND DOCUMENTS ANALISYS
AND INFORM THE AUTHORITIES IN CASE OF INVESTIGATION AND / DETERMINATION OF ANY UNUSUAL OR SUSPICIOUS
TRANSACTIONS.

INCOME SUPPORT ALLOWANCE AND FUNDS SAVER

CASHIERS SIGNATURE
CLIENTS OR PERSON WHOS MAKING THE (NAME AND SIGNATURE)
TRANSACTION SIGNATURE
(COPY OF ID ATTACHED)

REVIEWS BY COMPLIANCE OFFICER

(NAME AND SIGNATURE)

A HOUSE CONSTRUCTION