BCSI to be completed by the branch Form Complete your details and the origin of your assets as a “Politically Exposed Person” 1. Identification tistrore ontsurane). Annan jEoteacin E Date of birth OV/0419%0 lace ofbirth THiS. tegaladdress Steet Aue Weodere ob CiyKimoer (73, ton 4 Postcode Oo Toun Aresse/5... Country . BE 2. The origin of your assets «. Please tick the category or categories that correspond) to the origin of your assets: F Otigin-of your assets Savings from professional income Oo Income fiom movable assets o Rental income oO Inheritance oO Gift oO Sole of areal estate property o Sole of abusiness oO Pensionilife Annuity ag ote Family mer Ber oF piplemed puted Te Belgrim b, Please provide more details in the upper section of the box below: 2 Le Acabencl 08.0. Depa ty Head, ot [M951 en of George te NATO Examples: + Savings from professional income: monthly income or bonus amount, professioniposition, name of employer (eg. ,000 EUR, CFO, company X) + Income from movable assets: amount, investment company name (e.g. 20,000 EUR, company X) + Rental income: amount, address, how the building was acquired (e.g. 2,000 EUR per month for two ‘apartments, X street nr Y in Z, inherited from mother in early ’80s who also inherited the building from her parents) + Inheritance: amount, from whom, when, the initial source (e.g, 100,000 EUR, from father, in 2001, initial source was activity of my father who was CEO of international chemical company X) + Gift: amount, from whom, when, the intial source (e.g, 25,000 EUR, from mother, in 2005, inital source was activity of mother who was independent lawyer) + Sale of a real estate property: amount, date of sale, address of the real estate property (e.g. 200,000 EUR, in 2010, X street nr ¥ in Z) + Sale of a business: amount, name of the company, date of sale, business activity of the company (e.g, 100,000 EUR, company X, in 2016, manufacture of car parts) + Pension/Life annuity: monthly income, name of the insurance company if fe annuity (eg. 2.500 EUR, company X) Read more overeat3. “Politically Exposed Person” (PEP) ‘As you are considered a “Politically Exposed Person" (PEP), please fillin the fields below: + Public office description and role: + Date when first public office was assumed: ys etae + Public office is the main activity: Yes / No (please circle as appropriate) + Other(s) profession(s}: Please note: the following persons are considered PEP + Anyone who holds an important public office or has exercised a function ofthis type (in the course of the post ‘year at national or international level, + Anyone who is close (direct family member or a closely connected person) to « private individual who holds or has held an important public office (in the course of the past year’. pate 07 202) Your signature: / !f you ticked any of boxes in table 2.2. above, please provide one of the corresponding forms of evidence as listed below: Savings from professional income + Copy of a payslp (or bonus payment} + Tox return (fF self-employed) Income from movable assets + Bank statement clearly showing receipt of funds ond investment company name Rental income + Copy of the rental contract Inheritance + Grant of probate (with o copy of the wil), which must include the value of the inheritance + Signed letter from notary including amount, year and parties involved Gift + Letter from the donor confirming terms and conditions ofthe gift + Bank statement clearly showing receipt of funds and name of donor Sale of a real estate property + Copy of the notarial deed Sale of o business + Copy of the sole contract, plus bank statements showing proceeds of sale PensionJLife annuity + Copy of a pension statementife annuity contract " Bromples: Head of sote, head of government, minister, deputy minster and secretary of tote, member of patamentary assembly, member f supreme ‘our, conttuional court or other high cout where ro appels possible agcne the dacions token, rebar of a court of ours Ga ofthe management of central bats, embessodoychorgé offs ond serio officer i heared forces, member ofthe administrative, monayernent or sabes Bowes UD orpration, deputy director end member ofthe board of decors or equivalent function n on international ergariztion, mayor of town or iy of over 5,000 Inhabitants, posinl governor * Examples: pause, any member equated toa spouse under national legit, chien (and ther pause or member and parents any rv indie knoe tohawe a connection too PE, namely the beneficial ones of ets of legal constructions with anestocate ar member who pot exposed prcon, any ate inva! Known to mein any athe professiond, business or close odvsayrelotonehip wth a PEF, ony private india who isthe sole Seni ‘une of egal entity oof eegl construction Known to have bee, deft, cected fo the benefit ofa person wha olds or hos Mek on imprtant ple ofThe information communicated via this form is processed by ING Belgium SA/nv (avenue Marnix 1000 Brussels, Belgium) for the purposes of operational management and the prevention of irregularities, The information is stored for 0 period ‘oF 10 years following the end of the relationship, according to the applicable legislation. The information can be communicated to other companies within the ING group established in the European Union and performing banking, insurance, financial andlor other activities (list available upon request for the purpose of controlling operational regularity (including the prevention of irregularities). It can also be communicated to insurance companies Outside the ING group and established in the European Union and to any of their representatives in Belgium, for which the bank acts as an insurance intermediary (ist available upon request), as long as its required to control operational regularity (including the prevention of irregularities) Moreover, the information required in this regard by companies within the ING group, established within or outside the European Union, legal or regulatory provisions (including those arising from an FSMA bulletin) relating to money ‘aundering or the financing of terrorism {including the duty of vigilance with regard to the clientele, the prevention of Use of the financial system for money laundering purposes and to finance terrorism, and to prevent the financing of the proliferation of weapans of mass destruction}, are also exchanged between these companies to this end. ING Bank NV (Bijlmerplein 888, 1102 MG, Amsterdam Zuidoost, The Netherlands), acting as joint processing manager, ensures the management of information exchanges within ING group companies participating in the exchange of information for the ‘oforementioned purposes. Finally, the oforementioned informetion can be communicated to credit providers, financial institutions and equivalent establishments as set forth in article 5.6. of the general operating rules of ING Belgium according to the conditions defined in this article, The data can thus be communicated to the credit institutions and financial institutions pursuant to Article 2, paragraph 1, 1) and 2), of Directive 2015/849 (“Directive of 20 May 2015 on the prevention of the use of the financial system for the purposes of money laundering or terrorist financing"), established in a Member State of the European Union and not belonging to the ING Group as well as equivalent institutions not belonging to the ING Group, established in third countries imposing obligations equivalent to those laid down in Directive 2015/849, when said institutions are acting in relation to the same person and in connection with the same transaction, provided the Information exchanged concerns this person or this transaction, is used exclusively for the purposes of preventing ‘money laundering or terrorist financing and the receiving institution is subject to obligations equivalent to those laid down in Directive 2015/849 on prohibition of disclosure and personal data protection. Subject to the opplicable legal provisions, any private individual can read and rectify information which concerns them. Subject to the same provisions, they can also ask for the data to be deleted, place restrictions on the processing of these data and object to the processing, Subject to the same provisions, they also have a right to data portability, For more information, please consult article 5 (Professional discretion) and 6 (Protection of privacy) of ING Belgium's General Regulations and its Privacy Statement (both available from ING branches and via www.ing.be). For any matters relating to this Appendix. please contact the Privacy Officer by e-mail at ing-be-PrivacyOrfice@ing,com or by post to ING Privacy Office, Cours Saint Michet 60, 1040 Brussels). For any matters relating to this form, please contact the KYC Pl team (KYC-PI@ing.com) ‘The undersigned agree to provide the above information relating to the protection of privacy of the Beneficial Owners (including shoreholders, controllers and senior managing officials) or any legal representatives, and the members of your management.CSI Form - Update of your identification particulars My professional activity * Please tick your main professional activity in the table below. Type 1 employee f worker /public- ; CODE Seageneiibgervant or employee / CODE Type 2 - other profession 228 CLERCK 591 BELGIAN AMBASSADOR ABROAD 551 COMPANY DRECTOR EMPLOYEE) 580. BELGIAN DIPLOMATIC PERSONNEL ABROAD 213___ EMPLOYEE PRIVATE SECTOR sl EU COMMISSIONER 223 EMPLOVEEPUBLICsecTOR ——S|SC*d EU MEMBER OF PARLIAMENT 212 EXECUTIVE PRA SECTOR 566 __ FU NATIONAL EXPERT TEMPORARILY ATACHED 222 EXECUTIVE PUBLIC SECTOR 505 EUOFACER 720 __ HOUSEWIFE HOUSEMAN iv] S65 EU TRAINEE 7%6_UDGE 565 EUROPEAN ORGANIZATION OFFICAL NOT ED) [225 MAGISTRATE al 581___ FOREIGN AMBASSADOR 214 MANUAL WORKER PRWATE SECTOR jl 57% _ MS OFFAL 2b __ MANUAL WORKER PUBLIC SECTOR 575__INTL OFFICIAL WITH DIPLOMATIC PRNLEGE 700___ NO OCCUPATION 579 MEMBER OF STAFF OF INTL ORGANIZATION 720 PENSIONER | OUTSIDE EUROPE 769 SCHOOLING NOW-COMPULSOR i 576 __ MEMBER OF THE NATO SECRETARIAT 760__ STUDENT I _S7A__ NATO OFFICIAL a 763 STUDENT WITH APPRENTICESHIP CONTRACT —_| 572 OFFICIAL OF INTL ORGANIZATION OUTSIDE. 7a) WORKLESS | $7 _ eurore - 589__ PERSONNEL FOREIGN REPRESENTATION CODE Type 3*- (bert) profession SaRESre oom [a account CODE Type 4*- self-employed 170 ARCHITECTSURVEVOR valine 463 _BAUFF 800 ACTIVITY OF SPORTSMAN AGENT. 81 CORPORATE AUDITOR t 653 AUTHOR ARTIST : 143 OENIST 620 BUSNESSMAN 141 GENERAL PRACTITIONER (630 __ COMPANY DIRECTOR (INDEPENDENT) 164 _ LAWYER [610 CRAFTSMAN i 162__NOTARY PUBLIC S21 FARMER 140 OTHERLIBERAL PROFESSION 655 JOURNALIST 145 PHARMACIST 801 PROFESSIONAL FOOTBALLER 146 __PRYSIOTHERAPIST 654 SPORTSMAN 142__ SPECIALIST fae | [SSLOAEEATRAREE LONER * If your professional activity is type 3 or 4: 144 VET Ci Compony registration numer (CBE) Read more overeat.My legal address Please indicate your legal address: BCS swawe Rae Teodtre oe Cyper wumbe [FF to 4 rostacode: /ZOO wunnipaity. Woke Sout. Larnbad countrys: PE “IF you are staying outside of Belgium, please provide one of the documents below as proof of address. vate?) 03; Z2/ Signature: Te ) EU citizens Identity card (indicating the address) or Driving license (indicating the address) or Tax return less than 1 year old (indicating the address) or ‘Tax demand less than 1 year old {indicating the address) or Electoral summons less than 1 year old (indicating the address) or Social security document less than 1 yeor old (indicating the address) or Electricity, gas or water bill ess than 3 months ld {not a phone bil) or Notary statement or notarised deed compiled in the EU less than 3 months old (indicating the address) Identity card (indicating the address) or Driving license (indicating the address) or Tox teturn less than 1 year old (indicating the ‘adatress) or ‘ox demand less than 1 year old (indicating the address) or Electoral surnmons less than 1 year old {indicating the address) o Social security document less than 1 year old (indicating the address). INGacs! The law of 16 December 2015. governs the disclosure of information on financial accounts in the context of an international and automatic exchange of information for tax purpases. The law requires Belgian financial institutions to report on customers with one or more fiscal residences abroad in countries participating n this exchange of information, ‘The self-certfication form below will low you to provide us with the required data, For more information, consult our website on wwwing.belinternationalRegulations IF you require further assistance in filing inthis form, please contact a tax advisor, 7 Cudaaeva amg A2 leguladiress sweet Ave, Zeonbre We Cyc wavner 72 4 esupte, 1200 u els. connie 0 BN semtiion IEE AEE Bes PEI E Place of bi Please provide ALL the country(ies), including Belgium where applicable, where you are considered to be a tox resident and the corresponding Tax Identification Number(s) (TIN). : c {1A SNe ‘Your fiscal residence fs located inthe country where you are, cs you want to get more informction about the TIN fr a given resident, lable to incame tax. country its structure and syntax, you can visit the websites ‘ofthe European Commission or the OECD, which ore easily ‘ccessble via wnwing,be/TIN and wwvu.ing.beTiNcheck Geergits OVO2Z4O/E BSF 4 5 Explanation in case you are not able to provide a TIN if applicable. Frat applicable, you may leave this field empty: | the undersigned, + Declare thatthe information provided on ths formis, to the best of my knowledge, true, accurate and complete + Commit to advise ING Belgium of any change which causes the information in this document to become incorrect, ond providing ING Belgium with an updated self-certification within 30 days of the occurrence of such change. + agree to the collection, processing and disclosure of personal data and of financial information forthe purposes explained above. + Understand that Belgian financial institutions are legally equired under CRS and FATCA to report account information ‘on foreign tox residents to the Belgian tax authorities. This means that if my tax rsidence(s) sfare outside Belgium, ‘my account information will be reported to the Belgian tax administration, which may in turn transmit the information to the US. Intemal Revenue Service andior to the respective tax administrations ofthe relevant Participating CRS, Sursciction(s) where | am considered to be a tax resident. ocumentsignedin.. BF S224.. on AP Saas D(a (ofthe egal repre fifa odrinstrator ifaplcable: Read move overeat sree rustica et ett NE Begin ont penny nn ois Foreign count Tax Corplonce Ac FTA] and Coron Raporting tan “tarelnt communist des rernegnemert seus copes france prs stiutions fans beget SF Fnanees, danse cate un change cutrtinucdererpalghereie ou veo ernaonl es de fe freaer “et tot egelng vane tededcig on nelson Sects nonce relennger, door de beigsche feoncilinsteingen en Je 00 Financ net ode vores automate uwsseteg ane Mage op ‘terreno ive en oor beltingelanden”!F you declare on your document that you have a country for tax purposes whichis different from your legal ‘address, we need you to provide us with the adequate documentation based on your situation. +Hereunder, you wil find some certain number of particular cases and the requited corresponding documentation: i if ec Diplomat (and spouse /chidren of diplomats) __ Copy of the cplomatc Dor passport EUINATOISHAPE/INS civil servant on mission in. Form HIS276/ NATO276/ SHAPE276/ IMS276 Belgium (and spousefchidren of cul servants) Chilservant for an intemationel organization Certificate issued by the organization which clearly stipulates (EU, UN, NATO, IMF) where the fiscal residence has been fixed in accordance with the International legislation determining the status ofthe civil servant. Status of “foreign manager in Belgium (Belgion 1 Proof of recognized “foreign manager" status issued by the MISSION AUPRES DE LOTAN Pays : GEORGIE Détenteur de ta carte didentité diplomatique N°: D1953766 valable du 1670912020 jusqu' au 09/09/2028, réside temporalrement en Belgique en qualité de diplomato a adresse suivante Rue, N tue Théodore De Cuyper, 173 N° postal: 1200 Commune: WOLUWE-SAINT-LAMBERT et ce depuis fe: 0310912020 (suivant les données fournies par la Mission Diplomatique concemée) LLintéressé(e) est dispensé(e) de inscription dans le registre des élrangers de sa commune de résidence temporaire en Belgique et ce conformément 4 fart. 13 de TAR, du 30/70/1991 Les membres résident(s) de son ménage (détenteur(s) d'une carte d'identité diplomatiquo) sont: NOW et PRENOWS [TIEN paTE NAS. [ NroaRrTE PL, jUTSAEVA, Anna ae a EPOUSE 07/07/1980 D1983773 NARDAIA, Atxsandre Fis zartorovs | p1963780 RARDAIR. Gog [Eris | srovcon | bteesror Bruxelles, le 06/10/2020 Pour le Ministre, Le Chef du Protocole ‘ou gon Délegué Ee Gan ama a cmp aman | {()Suvante note ciculareconcemant fatlestton de composition de ménage ecu de rsidence tempore en Belgique 2 telecharger sur: lp sv dptomate befvatidkaarth pat