CUSTOMER INFORMATION SHEET
LEGAL ENTITY OR ENTREPRENEUR
Personal data collected through this Questionnaire will be processed for the purpose of customer due dilligence, in accordance with the Law on the Prevention of Money Laundering and the Financing of Terrorism and referent regulations. The Customer must provide, all the necessary and updated information, to allow toperform the Customer due diligence and the identification of the beneficial owners.
The Bank is obliged to identify and verify customers who carry out transactions in the amount equal to or higher than EUR 15,000.00:
-made in the context of a business relationship on behalf of third parties that are not identified before and during the established business relationship;
-when carrying out occasional transactions that the client can perform on their own behalf, and on behalf of third parties;
The customer must provide in writing all the information necessary for its identification, and the identification of the beneficial owner of the transaction
If the Bank cannot respect, for any reasons, the Customer due diligence obligations' it must not start business relationship or carry out operations and it also must close any relationship in place
Customer data:Company Name:______
Corporate ID number: ______VAT Number: ______
Date of incorporation: ______Country of registration: ______
Place of incorporation: ______
Registered Office:
Address: ______
Town: ______Postal code: ______Country: ______
Business Activity: ______
Phone: ______Fax: ______
E-mail address: ______
Additional information on the legal entity:
The customer performs as:
• Foreign non-resident private company • Trust • Special purpose entity
• Foundation • Charity
(More information at the end of the Questionnaire)
Type of beneficiary (only for non-profit organization):
• Social assistance • Healthcare assistance
•Education and training • Scientific research and social interest
•Safeguard of civil rights • Amateur sport
•Conservation, promotion e valorization of artistic, historic and cultural patrimony
•Conservation and valorization of nature, environment and territory
•General charities • Other activity /other beneficiaries
Country where the main business is carried out: ______
Countries with which the customer does business significantly?
1. ______2. ______3.______
The purpose of business relationship:
• Domestic and international payments • Payment based on the lines of credit released;
• Domestic commercial credit disinvesting • Foreign commercial credit disinvesting ;
• Corporate treasury managent • Foreign transactions management;
• Supply management • Employees salary management;
• Investments • Other ______
Type of business relationship:
• Current account • Saving account • Credit card
• Pledge policies • Security and/or bond deposit • Safe box/Safe deposit
• Loan • Insurance • Internet card
• Asset management • Other
Type of transactions that will be processed through the account:
• Cash transactions • Domestic currency wire transaction • International payments
• Term deposit and investment • Loans, guarantees, letter of credit • Financial instruments
• Other: ______
Customers who works in sectors benefiting from public funds, including EU funds (e.g. public contracts, healthcare, collection and disposal of waste, renewable energy production):
• YES • NO
Please specify the expected average level of in-payments to the account:
•Up to 100,000 Euros annualy • Up to 500,000 Euros annualy
•Up to 1,000,000 Euros annualy • Up to 1,000,000 Euros annualy
What are the expected sources of funds:
• Main activity • Sales of financial assets • Sales of real estate
• Reimbursement • Return of Capital from Abroad • Donation
• Winnings • Sales • Self-financing
• Grants from sponsors, partners etc. • Other :
Annual amount of expected other income: ______
Will the transactions on behalf of third persons be carried out through the account? If YES, please specify the beneficial owner of the funds and its country of origin:
______
Please specify the Customer’s main counter-parties to which the largest turnover is expected (name or description):
A. Suppliers:
•______
•______
•______
B. Customers:
•______
•______
• ______
Client cooperates with business partners who are engaged in the following activities:
• Real Estate Agencies and Brokers • Amateur Sports Associations
• Road transportation • Auctions and Art Galleries
• Wholesalers of Oil and Wheat • Dealers of Car, Accessoriesand Parts
• Dealers of High Tech Products (ex. PC, mobile phone, etc.)
• Trading of Precious Metals • Cash-for-Gold shops
• Advisory and Advertising • Custody and transportation of cash
• Building Industry • Foundations
• Foreign Trust Companies • Gambling
• Cosmetics • Money Transfer
• Earthmoving and Construction machinery/activities
• Renewable Energy Production • Production and sales of ferrous materials
• Cleaning and maintenance • Waste Collection and Disposal
• Credit Collection Agency • Healthcare
• IT trading of services and rights • Awards of Public Contracts
• Trust • Other
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DATA ON THE REPRESENTATIVE 1:
First name, Last name:______
Personal ID Number: ______Date of birth: ______
Place of birth: ______Country of birth: ______
Citizenship: ______Gender: M F
Residence (from the ID Document):
Address: ______
Place: ______Postal code: ______Country: ______
Domicile (if different from residence):
Address: ______
Place: ______Postal code : ______Country:______
ID Document:
Type: ______Number: ______
Issuer: ______Date of release: ______
Place of release: ______
Phone: ______Fax: ______
Employment status:
1) Employee 2) Freelancer 3) Executive 4) Entrepeneur
5) Self-employed 6) Retiree 7) Student 8) House wife
9) Unemployed 10) Other
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Additional information on the Representative 1:
Has the Representative or his/her close relative held at any time during last 12 months a public office, or has he/she been close associate of such person:
•Domestic Politically Exposed Person: YES NO
•Foreign Politically Exposed Person: YES NO
If you give positive answer to any of the questions bove, please answer the following:
Term of the public Office specify above: from ______to ______
Please briefly describe the public office specify above: ______
Type of business relationship with person who held a public office above (if that is a case):
______
Please specify the origin of funds and property underlying the customers business relationship with the Bank or trnsactions through the Bank:______
Country where the main business is carried out: ______
Power for representation of the Account Holder:
• Statutory Representative • Trust
• Trustee • Special Power ofAtorney
The relationship between a person who acts for the account of the client and the client:
•Managing Director • Member of Corporate Bodies • Employee
•Bankruptcy Trustee • Other
DATA ON THE REPRESENTATIVE 2:
First name, Last name:______
Personal ID Number: ______Date of birth: ______
Place of birth: ______Country of birth: ______
Citizenship: ______Gender: M F
Residence (from the ID Document):
Address: ______
Place: ______Postal code: ______Country: ______
Domicile (if different from residence):
Address: ______
Place: ______Postal code: ______Country:______
ID Document:
Type: ______Number: ______
Issuer: ______Date of release: ______
Place of release: ______
Phone: ______Fax: ______
Employment status:
1) Employee 2) Freelancer 3) Executive 4) Entrepeneur
5) Self-employed 6) Retired 7) Student 8) House wife
9) Unemployed 10) Other
Additional information on the Representative 2:
Has the Representative or his/her close relative held at any time during last 12 months a public office, or has he/she been close associate of such person:
•Domestic Politically Exposed Person: YES NO
•Foreign Politically Exposed Person: YES NO
If you give positive answer to any of the questions bove, please answer the following:
Term of the public Office specify above: from ______to ______
Please briefly describe the public office specify above: ______
Type of business relationship with person who held a public office above (if that is a case):
______
Please specify the origin of funds and property underlying the customers business relationship with the Bank or transactions through the Bank:______
Country where the main business is carried out: ______
Power for representation of the Account Holder:
• Statutory Representative • Trust
• Trustee • Special Power ofAtorney
The relationship between a person who acts for the account of the client and the client:
•Managing Director • Member of Corporate Bodies • Employee
•Bankruptcy Trustee • Other
Code: BIB.(1.11.0.0).PC.005 / Version: V/08.06.2016 / Page1/ 13
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DATA ON OWNERSHIP STRUCTURE:
Business entity is in the majority ownership of the state, local and regional self-government unit, public agency, public institution, public fund or chamber• YES • NO
If YES, please specify the name and the seat of the administration/institution:
______
Securities issued by the Customer’s majority owner are included in an reputable stock exchange:
• YES • NO
If YES, please specify the name of the owner and the stock exchange:
______
ULTIMATE BENEFICIAL OWNER1 (physical person):
First name, Last name:______
Personal ID Number: ______Date of birth: ______
Place of birth: ______Country of birth: ______
Citizenship: ______Gender: M F
Residence (from the ID Document):
Address: ______
Place: ______Postal code: ______Country: ______
Domicile (if different from residence):
Address: ______
Place: ______Postal code: ______Country:______
ID Document:
Type: ______Number: ______
Issuer: ______Date of release: ______
Place of release: ______
Additional information on the Beneficial Owner 1:
Percentage of ownership: ______%
Person is a direct owner of the Customer: YES NO
If NO, please specify the name and seat of a legal entity which is a direct owner:
______
Has the Beneficial Owner or his/her close relative held at any time during last 12 months a public office, or has he/she been close associate of such person:
•Domestic Politically Exposed Person: YES NO
•Foreign Politically Exposed Person: YES NO
If you give positive answer to any of the questions bove, please answer the following:
Term of the public Office specify above: from ______to ______
Please briefly describe the public office specify above: ______
Type of business relationship with person who held a public office above (if that is a case):
______
Please specify the origin of funds and property underlying the customers business relationship with the Bank or transactions through the Bank:______
Country where the main business is carried out: ______
The type of connection between the Customer and Beneficial Owner:
• Shareholder with more tha 25% of the company shares or rights of vote • Founder
• Managing Director /Chief Executive Officer • “De facto”controller
• Trustee • Beneficiary of the trust
• Settlor of the trust
• Protector of the trust
• Beneficiary or Holder of more than the 25% of the capital of association, foundation or Non Profit Organization
• Person in whose interest is established the Non profit organization
ULTIMATE BENEFICIAL OWNER2 (physical person):
First name, Last name:______
Personal ID Number: ______Date of birth: ______
Place of birth: ______Country of birth: ______
Citizenship: ______Gender: M F
Residence (from the ID Document):
Address: ______
Place: ______Postal code: ______Country: ______
Domicile (if different from residence):
Address: ______
Place: ______Postal code: ______Country:______
ID Document:
Type: ______Number: ______
Issuer: ______Date of release: ______
Place of release: ______
Additional information on the Beneficial Owner 2:
Percentage of ownership: ______%
Person is a direct owner of the Customer: YES NO
If NO, please specify the name and seat of a legal entity which is a direct owner:
______
Has the Beneficial Owner or his/her close relative held at any time during last 12 months a public office, or has he/she been close associate of such person:
•Domestic Politically Exposed Person: YES NO
•Foreign Politically Exposed Person: YES NO
If you give positive answer to any of the questions bove, please answer the following:
Term of the public Office specify above: from ______to ______
Please briefly describe the public office specify above: ______
Type of business relationship with person who held a public office above (if that is a case):
______
Please specify the origin of funds and property underlying the customers business relationship with the Bank or transactions through the Bank:______
Country where the main business is carried out: ______
The type of connection between the Customer and Beneficial Owner:
• Shareholder with more tha 25% of the company shares or rights of vote • Founder
• Managing Director /Chief Executive Officer • “De facto” controller
• Trustee • Beneficiary of the trust
• Settlor of the trust
• Protector of the trust
• Beneficiary or Holder of more than the 25% of the capital of association, foundation or Non Profit Organization
• Person in whose interest is established the Non profit organization
ULTIMATE BENEFICIAL OWNER3 (physical person):
First name, Last name:______
Personal ID Number: ______Date of birth: ______
Place of birth: ______Country of birth: ______
Citizenship: ______Gender: M F
Residence (from the ID Document):
Address: ______
Place: ______Postal code: ______Country: ______
Domicile (if different from residence):
Address: ______
Place: ______Postal code: ______Country:______
ID Document:
Type: ______Number: ______
Issuer: ______Date of release: ______
Place of release: ______
Additional information on the Beneficial Owner 2:
Percentage of ownership: ______%
Person is a direct owner of the Customer: YES NO
If NO, please specify the name and seat of a legal entity which is a direct owner:
______
Has the Beneficial Owner or his/her close relative held at any time during last 12 months a public office, or has he/she been close associate of such person:
•Domestic Politically Exposed Person: YES NO
•Foreign Politically Exposed Person: YES NO
If you give positive answer to any of the questions bove, please answer the following:
Term of the public Office specify above: from ______to ______
Please briefly describe the public office specify above: ______
Type of business relationship with person who held a public office above (if that is a case):
______
Please specify the origin of funds and property underlying the customers business relationship with the Bank or transactions through the Bank:______
Country where the main business is carried out: ______
The type of connection between the Customer and Beneficial Owner:
• Shareholder with more tha 25% of the company shares or rights of vote • Founder
• Managing Director /Chief Executive Officer • “De facto” controller
• Trustee • Beneficiary of the trust
• Settlor of the trust
• Protector of the trust
• Beneficiary or Holder of more than the 25% of the capital of association, foundation or Non Profit Organization
• Person in whose interest is established the Non profit organization
ULTIMATE BENEFICIAL OWNER4 (physical person):
First name, Last name:______
Personal ID Number: ______Date of birth: ______
Place of birth: ______Country of birth: ______
Citizenship: ______Gender: M F
Residence (from the ID Document):
Address: ______
Place: ______Postal code: ______Country: ______
Domicile (if different from residence):
Address: ______
Place: ______Postal code: ______Country:______
ID Document:
Type: ______Number: ______
Issuer: ______Date of release: ______
Place of release: ______
Additional information on the Beneficial Owner 4:
Percentage of ownership: ______%
Person is a direct owner of the Customer: YES NO
If NO, please specify the name and seat of a legal entity which is a direct owner:
______
Has the Beneficial Owner or his/her close relative held at any time during last 12 months a public office, or has he/she been close associate of such person:
•Domestic Politically Exposed Person: YES NO
•Foreign Politically Exposed Person: YES NO
If you give positive answer to any of the questions bove, please answer the following:
Term of the public Office specify above: from ______to ______
Please briefly describe the public office specify above: ______
Type of business relationship with person who held a public office above (if that is a case):
______
Please specify the origin of funds and property underlying the customers business relationship with the Bank or trnsactions through the Bank:______
Country where the main business is carried out: ______
The type of connection between the Customer and Beneficial Owner:
• Shareholder with more tha 25% of the company shares or rights of vote • Founder
• Managing Director /Chief Executive Officer • “De facto” controller
• Trustee • Beneficiary of the trust
• Settlor of the trust
• Protector of the trust
• Beneficiary or Holder of more than the 25% of the capital of association, foundation or Non Profit Organization
• Person in whose interest is established the Non profit organization
Hereby I confirm that all data given in this document are true and I am in full agreement with the Bank's right to check them. I will promptly inform the Bank on any change regarding the data given above. Hereby I give the consent to the processing of personal data mentioned in this questionnaire,
including particularly sensitive data. This consent is valid until revoked. Also, I confirm that the Bank inform me on the the possibility to check the details on mentioned processing of data in the Central Data File Register maintained by the Commissioner for Information of Public Importance and Personal Data Protection, available at Web address:
______, ______
Place and dateSignature of the Representative
Bank’s employee:
First name, Last name:______
Organisational unit:______
______
Place and date Signature
ADDITIONAL INFORMATION:
- Foreign non-resident private companyis a foreign entity in private ownership whose shares / shares are not traded on the open market, regardless of the size of the company, or there is no publicly available information about the company balancesheets, audit reports).
- Special purpose entityis a company established to accomplish a clear and well defined objective.
- Trustis a company that is engaged in providing for another person of the registered office / business addresses , management or secretarial services, etc. service, presenting as a designated shareholder / founder
- Politically Exposed Person” or “PEP”: a natural person who holds or who held in the past year a public office in a foreign country or international organisation, including:
- Heads of State and/or heads of government, members of government and their deputies or assistants;
- Elected representatives of legislative bodies;
- Judges of the supreme and the constitutional courts or of other high-level judicial bodies whose judgments are not subject to further regular or extraordinary legal remedies, save in exceptional cases;
- Members of courts of auditors or of the boards of central banks;
- Ambassadors, chargés d'affaires and high-ranking officers in the armed forces;
- Members of the managing or supervisory bodies of legal entities whose majority owner is the State.
- “PEP’s Close Associate”: any natural person who has benefit from a joint ownership or from business relations or who has any other close business relations with a PEP.
- “PEP’s Close Family Member”: a PEP’s spouse or extra-marital partner, the parents, the brothers and sisters, the children and their spouses or extra-marital partners
- „Ultimate beneficial owner“has the following meaning:
a)With respect to legal entities, representative offices , branches and other entities subject to the following national and foreign regulations applicable rules for the legal entity:
-natural person who is ultimately beneficial owner of the entity
-natural person who has control over a legal person by directly or indirectly owns at least 25 % of the capital of such legal person or