Form Review – Ownership Structure Declaration

Ownership Structure Declaration

Declaration passed by all the Directors/Members/Shareholders of:

Registered name / Name of incorporation

Registration / Incorporation number

That the Shareholding/Voting Rights/Membership Interest is correctly reflected in the below as statedownership structure.

Shareholding/Voting Rights/Membership Interest

NAME OF RELATED PARTY

RELATED PARTY TYPE*

IDENTIFICATION/ PASSPORT NUMBER OR REGISTRATION NUMBER

SHAREHOLDING/ VOTING RIGHTS/ CONTROLLING INTEREST

ADDRESS AND CONTACT DETAILS

As per the above declaration, The Ultimate Beneficial Owner/s (UBO/s)** are as follows:

Ultimate Beneficial Owner/s

NAME & SURNAME

ID NUMBER / PASSPORT

ADDRESS AND CONTACT DETAILS