Declaration of Source of Funds

and Income Tax affidavit

This information is for TMF Group internal use only and will be treated as strictly confidential!

The undersigned, in his/her capacity as Ultimate Beneficial Owner (UBO) of

______________________________________________________________________ (‘Client Entity’)

First name and surname:      

Private Address:      

Nationality:      

Date of birth:      

The type and number of

     
identification document:

hereby declares and confirms to TMF Group 1 (‘TMF’) as follows:

1) That I am making this declaration for my own protection as well as for the protection of TMF.

2) That the funds which are used to fund Client Entity represent funds obtained by myself from
the following source2:
______________________________________________________________________________
______________________________________________________________________________

3) That all monies that I may from time to time transfer into the name of the Client Entity either
directly or indirectly through another entity, have been derived from the following source:
______________________________________________________________________________
______________________________________________________________________________

4) That the monies are my personal property and that at the time of the transfer to Client Entity,
I am legally entitled to transfer such monies; and

5) That no such monies have been derived from any criminal activities of any nature whatsoever.

6) I confirm that I am a tax resident of (name country/countries):

______________________________________________________________________________

7) My Tax Identification Number (‘TIN’) is:

_____________________________________________

1
“TMF Group” means all companies ultimately beneficially owned by TMF Group HoldCo B.V., each of which is a separate legal
entity.
2
Descriptions in generic terms like investment proceeds, business proceeds, savings, life savings and or surplus funds are not sufficient and
must be supplemented by a description as to the activities and line of business that generated the funds. Full details of source are required,
e.g. exercise of stock options earned from employment (state its name and business), work bonus, sale of company (state its name and
business), etc. In case of inheritance the description should include information on the deceased from whom the funds were acquired.

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 Declaration of Source of Funds
and Income Tax affidavit

FATCA ELEMENTS (‘US INDICIA’)

 Were you born in the USA?

No Yes, indicate the place of birth: ______________________________________

 Do you hold the citizenship of the USA?

No Yes, indicate reference (e.g. social security number): _____________________

 Have you renounced your USA citizenship?

No Yes, indicate when and provide copy of your Certificate of Loss of Nationality:
________________________________________________________________

 Do you hold or have you ever held a passport issued by the USA?
No Yes, indicate reference: ____________________________________________

 Do you hold or have you ever held a Green Card issued by the USA?
No Yes, indicate reference: ____________________________________________

 Do you have a permanent or temporary (more than 30 days/year) residence in the USA?
No Yes, indicate where: _______________________________________________

 Do you have a ‘care of’ address in the USA?

No Yes, indicate address: ______________________________________________

 Do you have a USA phone number?

No Yes, indicate number: ______________________________________________

 Do you directly or indirectly (e.g. through a legal structure) hold a property/residence in the USA?
No Yes, indicate where: _______________________________________________

 Have you granted a power of attorney on your bank or investment account(s) to a person residing
in the USA?
No Yes, indicate to whom: _____________________________________________

 Do you have substantial professional activities or interests in the USA?

No Yes, indicate activities and location: ___________________________________

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 Declaration of Source of Funds
and Income Tax affidavit

TAX COMPLIANCE DECLARATION

I hereby certify that the shares I am the (ultimate) holder of, and/or the assets invested in, and/or the
assets settled in, and/or the assets held on my behalf, and/or the assets distributed to me by the
Client Entity to which TMF Group renders services, respectively for me, on my behalf or for my benefit,
are duly declared to the relevant tax authorities.

I further understand that I have a legal obligation to comply with the tax, compliance and reporting
requirements applicable to my personal situation in my own jurisdiction of residence (including
residence for tax purposes), domicile, business or citizenship. I have taken and will take independent
legal, accounting and tax advice, as appropriate, to fully comply with any such obligation in every
aspect. I acknowledge and confirm that I am responsible for the payment of any tax due or payable,
including any interest and penalties due thereon. In addition, I understand that TMF Group reserves
the right in its absolute discretion to require proof of the provision of tax and/or other professional
advice from me as it deems appropriate.

I confirm that I have not been advised by TMF Group in respect of any tax, investment or accounting
matters relating to my personal situation and to any Trust, Foundation, Company, Partnership or other
legal entity or relationship established at my request, including the effectiveness of such Trust,
Foundation, Company, Partnership or other legal entity.

I hereby commit to providing TMF Group with all supporting documentation upon first demand, if
requested in writing to do so.

INFORMATION REGARDING ANY CHANGE OF SITUATION

I undertake to immediately notify TMF Group of any changes in my personal situation relating to this
Tax Compliance Declaration. I furthermore understand that any misrepresentation will be cause for
TMF Group to consider the immediate termination of the relationship and may cause TMF Group to
report to the appropriate tax authorities.

Finally, under penalties of perjury, I declare that:

 I have examined the information on this form and hereby represent and warrant that the
information set out in this form is true, accurate and complete as of the date hereof and may be
relied upon by TMF Group; and

 I have consulted, as the case may be, when I was unsure about the information I am being asked
for, with an independent legal and tax adviser to fill out this form and further acknowledge that I
have not received any advice from TMF Group concerning the applicable legislation or taxation.

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 Declaration of Source of Funds
and Income Tax affidavit

FINAL DECLARATION
I confirm that the information disclosed herein is true, complete and accurate to the best of my
knowledge and belief as at the date hereof. I undertake to inform TMF Group immediately of any
changes concerning the above statements.
I understand that information supplied may be processed for the purposes of client administration by
any company within the TMF Group or by third parties who provide services to TMF Group.

SIGNATURE

Place/Date: __________________________________

___________________________________________
Signature

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