Form A

FORM A

Declaration of identity of the beneficial owner (A)

CLIENT NUMBER

Contracting partner

CONTRACTING PARTNER

THE CONTRACTING PARTNER HEREBY DECLARES THAT THE PERSON(S) LISTED BELOW IS/ARE THE BENEFICIAL OWNERS) OF THE ASSETS INVOLVED IN THE BUSINESS RELATIONSHIP. IF THE CONTRACTING PARTNER IS ALSO THE SOLE BENEFICIAL OWNER OF THE ASSETS, THE CONTRACTING PARTNER'S DETAILS MUST BE SET OUT BELOW.

SURNAME

FIRST NAME

f

DATE(S) OF BIRTH

NATIONALITY

OTHER NATIONALITIES

STREET

HOUSE NUMBER

CITY

POSTAL CODE

COUNTRY

THE CONTRACTING PARTNER HEREBY UNDERTAKES TO INFORM AUTOMATICALLY OF ANY CHANGES TO THE INFORMATION CONTAINED HEREIN.

PLACE

DATE

SIGNATURE

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IT IS A CRIMINAL OFFENCE TO DELIBERATELY PROVIDE FALSE INFORMATION ON THIS FORM (ARTICLE 251 OF THE SWISS CRIMINAL CODE, DOCUMENT FORGERY)