V.21.03.

2018

*D5-V180321-R* A
DECLARATIONS OF IDENTITY OF THE BENEFICIAL OWNER 

AND ACCOUNT HOLDER


I hereby declare that the person listed below is the account holder and the sole
beneficial owner of the assets to be deposited on the account.

Last name(s), First name(s):

Lupascu Viorel
_____________________________________________________________________




Date of birth :



15.07.1999
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Citizenship: 



Romania
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Home address:



_____________________________________________________________________
Bl.bucuresti 34, 100568 Ploiesti, Romania



I understand that it is a criminal offence to deliberately provide false information on this
form (article 251 of the Swiss Criminal Code, document forgery).

I expressly confirm that I am not a “US person” as defined in the Title 22 of the United
States Code i.e. I am not a US citizen (by single or multiple citizenship) and I do not have
the “resident alien” status (by holding a “Green Card” or meeting the "Substantial Presence
Test" requirements as stated in: https://www.irs.gov/individuals/international-taxpayers/
substantial-presence-test ).

I have read, understood and agreed with General Terms and Conditions for Current
Accounts published on https://www.dukascopy.com/swiss/english/about/docs/ including
confidentiality waiver in favour of Dukascopy Group (chapter 27).



I hereby undertake to immediately inform the bank of any changes.



Date Signature

15th of March 2019

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