/ Customer interview form for
Legal entities
Page 1/6

Customer Number:

General Information

Company name
State of incorporation / Type: Standard
ING Luxembourg, S.A.
52, route d’Esch L-2965 Luxembourg / Registered in Luxembourg under no. B. 6041
TVA LU 11082217 / Telephone + 352 44 99 1
Fax +352 44 99 23 10 /
Swift CELLLULL / IN09066/31
/ Customer interview form for
Legal entities
Page 1/6

Contact Person

/

Business provider ResidentAgent Legal representative

Other:

Surname, Firstname, Company’s name:
Telephone number:
Reasons
- for joining ING: / ING Group/product reputation
ING Group references / Business provider
Resident Agent / Accountant

Other:

- foropeningan account inLuxembourg:
Business presence / registered office in Luxembourg Private Banking Incorporated in Luxembourg
Other:
- Does the customer, the country of incorporationas well as the activity of this companyfit in with the bank’s strategy?
[relative to "ING Business” principles, human rights, environmental compliance, money laundering => risk to[ the bank’s] reputation / Yes No

Is the customer a foreign company?

/

Yes No

Is the company in the initial stages of being formed?

/

Yes No

/

If YESplease provide the following data:

The founders (orbeneficiaries):
- Surname, firstname, company name,
- date of birth/incorporation
- country of birth/incorporation
- country of residence:
(code inKYC-Rôle)
Capital investedin the company: /

(amount andcurrency)

Origin of the funds / capitalinvested in the company
Economic:
Shares
Investments
Shareholders’ loans
Loan / Business income
Income from securities
Income from real-estate assets / Gifts
Inheritance
Sale of a company
Insurance policy
Other:
Operational(modality in which the money was invested in the company)
Inter-bank transfer(please specify the name and the countryof incorporation of the bank from which the funds originate)
Bank name and country:
Physical deposit: (cash and/orcheque and/or physical certificate)

Customer Number:

Is any PEP/REP (person who holds a public mandate / international personality) somehow involved in the company (shareholder, director, etc.)?
If there is a PEP/REP, please state their name and position

Activities of the company(in Luxembourg or abroad)

the company has a primarily financial activity (shareholding, holding securities, financing) Please fill in formII:Financial Activity

the company has a primarily commercial activity (delivery of goods or services)Please fill in form III:Commercial activity

If the company has both a commercialand a financial activity:
Please fill in form II: Financial Activityand form III:Commercial activity

Customer Number:

II.Financial Activity Form

Description of the company’s activity(if the company already exists please enclose the company’s [latest] balance sheet)

The company plans to invest in:
The following companies(company name,date & country of incorporation)
The following sectors of activity
The following countries / (main) / European Union
Other types of investments
Loans / purchases of claims / bonds
Other:
What is the primary purposein respect of the company’s activity?
Please describe the structure that has been set up and attach anorganisation chart

III.Commercial Activity Form

Description of the company’s activity(if the company already exists, please enclose the company’s latestbalance sheet as well as the profit & loss accounts)

Please give a detailed description of the company’s activity as well as on the specificitiesregarding the markets on which it operates
Main clients(company name,country)
Mainsuppliers(company name, country)

Customer Number:

IV.Description of the financial cashflows

Origin of the fundsthat are due to be received (throughout the banking relationship):
Economic (nature of the revenueor sources of financing)
loans / capital / interest / dividends / capital gains
billing / sales of services / income from securities / income from real-estate assets / operational income
Other:
Operational(nature of investment done by)
Inter-bank transfer
Physical deposit:(cash and/or cheque and/or physical certificate)
Geographical
Origin (country, economic block (e.g. EU)) / (main) / European Union
Amount/Frequency(provide an approximate indication, e.g.: between 10 and 20 thousand eurosper month)
Destination of fundswithdrawn from bank accounts (throughout the term of the relationship):
Economic(nature of the transaction)
Operational fees / investments / loans / dividends / wages
fees
Other:
Operational(nature of investment done by)
Inter-bank transfer
Physical Deposit: (cash and/or cheque and/or physical certificate)
Geographical
Origin(country, economic area(EU)) / (main) / European Union
Amount/Frequency(provide an approximate indication, e.g.: between 10 and 20 thousand euros per month)

* Supporting documents (invoices, purchase orders, contracts, etc.) maybe required

Customer Number:

V.Beneficiaries Form (1 form per economicbeneficial owner)

ID form(code in KYC-Rôle)

Initials

Date of birth

Questions to be answered by the “interviewer”:
Do you personally knowtheeconomicbeneficial owner? / Yes No
If not, how was he or she referred to you?
Which controlsdid you performed for verifying this reference?
Professional activity
Please give a detailed description of the professional / business activity ofthe economic beneficial owneras well as his position in the company
Does the economic beneficial ownerhold a public mandate (PEP)? / Yes No
If YES please state the economic beneficial owner’s role and the name of the organisation involved:
Is theeconomic beneficial ownera known international personality(REP)? / Yes No
If YES please state the economic beneficial owner’srole and the name of the organisation involved:
Origin of funds invested in the company(indication of the economic beneficial owner’sfinancial situation)

Date

Signature and stamp of the employee

Customer Number:

VI.Approvalof opening account

Stamps, dates and signatures of persons in charge of approving the account opening, depending on the type ofcustomer involved
PB / DRB S / DRB E – non-Luxembourg companies / DRB E – Luxembourg companies
COMACC
RM + 1 representative of the COMACC / DRB S manager (or Alternate) / DRB S manager (or Alternate)
+ Branch manager (orADA) / Branch manager (orADA)
If CRR 3 or 4, a signature from Compliance is required
ING Luxembourg, S.A.
52, route d’Esch L-2965 Luxembourg / Registered in Luxembourg under no. B. 6041
TVA LU 11082217 / Telephone + 352 44 99 1
Fax +352 44 99 23 10 /
Swift CELLLULL / IN09066/31