NOMBRE DEL BENEFICIARIO

Address:xxxxxxxxxx, street:xxxxxxxxxxxx city: xxxxxx – country: xxxxxxxxx

Phone number: + xxxxxxxxxx
E-mail address: xxxxxxxxxxxxx

CLIENT INFORMATION SHEET

In accordance with Articles 2 through 5 of the Due Diligence Convention and the Federal
Banking Commission Circular of December 1998, and under the US Patriot Act of 2002, as
amended in February 2003 concerning the prevention of money laundering and 305 of the Swiss
Criminal Code, the following information may be supplied to banks and/or other financial
institutions for purposes of verification of identity and activities of the Client described below, and
the nature and origin of the funds which are to be utilized. The foregoing is subject to agreement by
all parties to whom this information is provided that they are obligated to respect the privacy rights
of the Client and all individuals described herein, as well as the generally accepted professional
standards relating to the maintenance of confidential information, and to take all appropriate
precautions to protect the confidentiality of the information contained herein, This legal obligation
shall remain in full force indefinitely without restriction.

DETAILS OF SIGNATORY (SUB-FEE BENEFICIARY) –INDIVIDUAL

First Name :
Middle Name :
Last Name :
Gender :
Date of Birth :
Social Security Number : NA
Country of Citizenship :
Languages : CASTELLANO
Tel :
E-mail :

PASSPORT INFORMATION

Passport Number :
Date of Issue :
Date of Expiry :
Issuing Authority :
Do you speak English? :
 NOMBRE DEL BENEFICIARIO
Address:xxxxxxxxxx, street:xxxxxxxxxxxx city: xxxxxx – country: xxxxxxxxx
Phone number: + xxxxxxxxxx
E-mail address: xxxxxxxxxxxxx

I, xxxxxxxxxxx xxxxxxxxxx xxxxxxx, hereby declare with full personal and corporate
responsibility under penalty of perjury that the information given above is accurate and
true, as of this date: xxxxx xx, 2022

Signature: __________________________________ Fingerprint: ________

SEAL OF COMPANY

Name / Title :
Passport Number :
Date of Issue :
Date of Expiry :
Issuing Authority :
Country of Issuance :

PRIVATE AND CONFIDENTIAL INFORMATION

This communication may contain information that is legally privileged, confidential or exempt from disclosure. The
information transmitted is intended only for the person(s) or entity to which it is addressed. Any review,
retransmission, dissemination or other use of, or taking of any action in reliance upon, this
information by persons or entities other than the intended recipient(s) is strictly prohibited. If you
received this message in error, please contact the sender and delete the materials from any
computer. This electronic communication is covered by the Electronic Communications Privacy Act
of 1986, Codified at 18 U.S.C. §§ 1367, 2510-2521, 2701-2710, 3121-3126. Also, see:
http://www.ftc.gov/privacy/glbact/glbsub1.htm - Gramm-Leach-Bliley Act 15 USC, Subchapter I,
Sec. 6801-6809.

INFORMATION SELLER AND BUYER / ICC WARNING (ICC Commercial Crime Services)
This is a very important message to anyone involved in the commodities industry on the new measures with respect to the Buyers and Sellers
conducting old and other commodities transactions. If an ICPO, LOI, RWA or BCL is issued and the documents are not real, the Buyer will be
able to inform the FBI, ICC and INTERPOL. In addition, after an FCO is sent to the Buyer, there should be a formal answer to the Seller from
the Buyer. If there’s no response from the Buyer in a timely manner, the buying company will be reported to the FBI, ICC and INTERPOL. If
this action is repeated by the sellers, they will also be reported because of abuse of the NCND, LOI, ICPO AND RWA OR BCL, FOR THIS IS
A FEDERAL OFFENSE. It is important to transmit this to all clients that work with providers that are members of the ICC, FBI and other
international organizations, From this point forward, the international codes will be strictly enforced to exclude all intruders that send out false
information. Those who submit false NCND/IMFPA, LOI, ICPO, RWA OR BCL OR FCO, as well as FALSE PROOF OF PRODUCT (POP),
WILL BE CHARGED WITH A CRIME. This went into effect November 15, 2008 after a meeting was held between the Federal Reserve,
European Central Bank, Interpol, Federal Bureau of Investigation and Central Intelligence Agency.
 NOMBRE DEL BENEFICIARIO
Address:xxxxxxxxxx, street:xxxxxxxxxxxx city: xxxxxx – country: xxxxxxxxx
Phone number: + xxxxxxxxxx
E-mail address: xxxxxxxxxxxxx

COLOR COPY OF PASSPORT

PRIVATE & CONFIDENTIAL – NOT FOR CIRCULATION

This document (and any enclosures or attachments) is intended only for the parties named on this agreement,
or their Bank´s and contains confidential and legally privileged info
August xx, 2022
END OF DOCUMENT