Enhanced Due Diligence Form （Natural Person）

This from will not provide to any third party.

This from is for unfreeze account and ECDD procedure ONLY
SECTION 1: BENEFICIAL OWNER’S DETAILS
Full Name Dr // Mr Ms Mrs Mdm

REZA SALEKI ‫رﺿﺎ ﺳﺎﻟﮑﯽ‬

ID/ NRIC / Passport No. Country of Issue Country of Birth
UOZ834222 UNITED ARAB EMIRATES ABU DHABI
Nationality
Gender // Male Date of Birth
2 1 0 1 1 9 9 1 UNITED ARAB EMIRATES
Female

Academic Degree: Bachelor

//
 Master
 Doctor

Have you ever been engaged in OTC（Over- Yes // No

the-counter）before?

Second ID document (e.g., if ID card was submitted, then passport must be provided too)

Contact Details (At least One)

(Home)
+ + 9 7 − 1 2 8 2 6 6 7 8
(Country Code) (Numbers)
(Office)
+ −
(Country Code) (Numbers)

(Mobile)
+ −
(Country Code) (Numbers)

(Email) saeid1367mahroo@gmail.com

(Residential address)
street ;box no.16253city;dubai state;dubai zip code;16253 country;united arab emirates

(Proof of Residential Address within the last 3 month, please attach screens / photo / doc at the end of this form)
 Bank Statement Lease Agreement
 Utilities Agreement  Telecommunications Bill

Country/Jurisdiction of Tax Residence * Taxpayer Identification Number (TIN)

Page 1/3
 BENEFICIAL OWNER’S EMPLOYMENT DETAILS

Name of Employer

Occupation (please tick one)

Accounting/Finance Engineering Professional Services Student
Consulting Executive/Senior Management Research & Development Unemployed
Retired Government/Military // Sales/Marketing/Advertising

// Self-Employed (please specify nature of business) Others (please specify)

Annual Income $
(Please tick one) 30,000 - 60,000 100,001 - 150,000 200,001 - 300,000
// Less than 30,000 60,001 - 100,000 150,001 - 200,000 Above 300,000

Source of Funds to be invested

（Please attach screenshots / picture / doc of your main bank account statement at end of this form，at least 3 months）

（Please attach related bank account statement that you used to buy crypto at the end of this from)
Salary Investment Earnings Sale of Real Estate
Gift/Inheritance // Business Profits Others, Please specify

BENEFICIAL OWNER’S ADDITIONAL DUE DILIGENCE

1. Location Yes No
Are you / do you: //
1) incorporated in the following countries / jurisdiction;
2) have registered address in the following countries / jurisdiction;
3) have a mailing address in the following countries / jurisdiction; or
4) born in / a citizen of the following countries / jurisdiction.

Bahamas,Botswana, Democratic People's Repubic of Korea, Ethiopia, Ghana, Pakistan, Sri Lanka, Syria, Trinidad and Tobago, Tunisia, Yemen, Democratic People's Repubic of
the Congo, Eritea, Iran, Lybia, Somalia, South Sudan, Sudan, Cuba, Zimbabwe, Iraq, Central African Republic, Bosnia and Herzegovina, Lebanon, Myanmar

2. Occupation / Nature of business Yes No

Are you involved in the business of / employed by the following activities / employers that are:
//

Money changers; remittance agents; pawnbrokers; internet-based stored value facility holders.

3. Politically Exposed Person (“PEP”) Yes No

Are you a PEP / close associate of a PEP / family member of a PEP? //
PEP means a domestic PEP, foreign PEP or international organization PEP;
“Close associate” means a natural person who is closely connected to a PEP, either socially or professionally;
“Domestic PEP” means a natural person who is or has been entrusted domestically with prominent public functions;
“Family member” means a parent, step-parent, child, step-child, adopted child, spouse, sibling, step-sibling and adopted sibling of the PEP;
“Foreign PEP” means a natural person who is or has been entrusted with prominent public functions in a foreign country;
“International organization” means an entity established by formal political agreements between member countries that have the status of
international treaties, whose existence is recognized by law in member countries and which is not treated as a resident institutional unit of the
country in which it is located;
“International organization PEP” means a natural person who is or has been entrusted with prominent public functions in an international
organization;
“Prominent public functions” includes the roles held by a head of state, a head of government, government ministers, senior civil or public
servants, senior judicial or military officials, senior executives of state owned corporations, senior political party officials, members of the
legislature and senior management of international organizations.

Page 2/3
 Questions
1. Please tell us the source of your funds: tell us where the money is coming from, which can be proven through bank
statements, tax returns or the company financials, etc. (Include Fiat and Crypto)
trust wallet

2. Please tell us where did your funds go?

i bough lace token and it was deleted at exchange kucoin

3. Please explain why you deposit and withdraw without any trade. (Please answer this question if you don’t have any
trade on our platform)

i have been trading in your exchange for a long time

4. Please explain your recent 5 transactions include fiat transaction, deposit crypto, and withdraw crypto.

mc/ oddz/ usdt /bnb/lace

REZA SALEKI And the account is used by the owner only? (Yes or No)
5. This account is owned by_________,
YES

6. Where is your current residential country? Have been to other country(ies) recently? Have you been changing your login
device recently?

YES,I entered a with computer and went on a trip (i usually travel)

7. What the main using purpose for your account?

transaction and investments and expenses

DECLARATION

I hereby declare and warrant that the information submitted to you are complete, true, and accurate and that I have not willfully withheld
anymaterial fact/information.

Beneficial Owner Signature

Sign:

Date: 2023/08/13

Page 3/3