STATEMENT ABOUT BENEFICIAL OWNERS
J
Client’s ID ....................................................
Dear client!
According to requirements of the law "Law on the Prevention of Laundering the Proceeds from Criminal Activity (Money Laundering) and of Terrorist Financing", Clients of the Bank
must submit to the Bank filled and signed Statement about Beneficial Owners.
Beneficial Owner (BO) is a private individual who owns or controls, directly or indirectly, at least 25 per cent of the Client’s share capital or total number of voting shares, or who
otherwise controls the Client’s business; or who has, directly or indirectly, the right to the Client’s property, or who controls, directly or indirectly, at least 25 per cent of a legal entity other
than a merchant; or for the benefit or interests of which business relationships are established /a transaction is performed with the Bank. A political party, association or cooperative
society shall be deemed the beneficial owner of the respective political party, association or cooperative society.
The Bank guarantees that the Clients' personal data, data on the Clients' accounts, deposits and deeds will be kept secret. Please fill in block letters where it is necessary.
Thank you for understanding!
1. INFORMATION ABOUT THE CLIENT
Name
.........................................................................................................................................................................................................................................................................
Certificate of registration No ....................................................................................................... Date of registration* ..........................................................................................................
2. INFORMATION ABOUT BENEFICIAL OWNERS (BO) INCLUDING THIRD PERSONS
BO are persons mentioned hereafter:
2.1. BO name, surname .........................................................................................................................................................................................................................................................................
Identity number **
............................................................................................................. Date of birth *
Address
.........................................................................................................................................................................................................................................................................
...............................................................................................................
street, house, flat, city, country, postal code
Identity document No.*
Identity document
issuing authority*
............................................................................................................. Date of issue*
...............................................................................................................
Identity document
............................................................................................................. issuing country*
...............................................................................................................
2.1.1. If Client’s beneficial owner is a politically exposed person¹, family member of a politically exposed person², or person closely associated with a
politically exposed person³, please provide following information:
BO is politically exposed person
BO is a family member of a politically exposed person or a person closely associated with a politically exposed person
Name, surname of a politically exposed person*** ............................................................................................................................................................................................
The country where person is currently/were formerly holding a politically exposed position ..........................................................................................................
Position (please tick):
Head of State
Head of state
administrative unit
(municipality)
Head of government
Minister, deputy of
minister or deputy of
minister’s deputy
State secretary
Other high level official in government or state
administrative unit (municipality)
Ambassador or chargés d’affaires
Member of Central bank’s council or board
Member of parliament or member of other similar
legislative bodies
Member of governing bodies (board) of a political party
Judge of constitutional court, higher court or judge in a
different level court (member of court institutions)
Member of highest revision (audit) institution council or
board
Chief officer in the armed forces
Member of management or supervisory bodies of
State – owned enterprises
Director, deputy director and member of the board or
equivalent function of an international organization or a
person who is in a similar position in this organization
*- for Latvian non residents, **- for Latvian residents, *** to be filled in if BO is a family member of a politically exposed person or a person closely associated with a politically exposed person
2.2. BO name, surname .........................................................................................................................................................................................................................................................................
Identity number **
............................................................................................................. Date of birth *
Address
.........................................................................................................................................................................................................................................................................
...............................................................................................................
street, house, flat, city, country, postal code
Identity document No.*
Identity document
issuing authority*
............................................................................................................. Date of issue*
...............................................................................................................
Identity document
............................................................................................................. issuing country*
...............................................................................................................
2.2.1. If Client’s beneficial owner is a politically exposed person¹, family member of a politically exposed person², or person closely associated with a
politically exposed person³, please provide following information:
BO is politically exposed person
BO is a family member of a politically exposed person or a person closely associated with a politically exposed person
Name, surname of a politically exposed person*** ............................................................................................................................................................................................
The country where person is currently/were formerly holding a politically exposed position ..........................................................................................................
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........................................................................................
Signature
Position (please tick):
Head of State
Head of state
administrative unit
(municipality)
Head of government
Minister, deputy of
minister or deputy of
minister’s deputy
State secretary
Other high level official in government or state
administrative unit (municipality)
Ambassador or chargés d’affaires
Member of parliament or member of other similar
legislative bodies
Chief officer in the armed forces
Member of governing bodies (board) of a political party
Judge of constitutional court, higher court or judge in a
different level court (member of court institutions)
Member of highest revision (audit) institution council or
board
Member of Central bank’s council or board
Member of management or supervisory bodies of
State – owned enterprises
Director, deputy director and member of the board or
equivalent function of an international organization or a
person who is in a similar position in this organization
*- for Latvian non residents, **- for Latvian residents, *** to be filled in if BO is a family member of a politically exposed person or a person closely associated with a politically exposed person
2.3. BO name, surname .........................................................................................................................................................................................................................................................................
Identity number **
............................................................................................................. Date of birth *
Address
.........................................................................................................................................................................................................................................................................
...............................................................................................................
street, house, flat, city, country, postal code
Identity document No.*
Identity document
issuing authority*
............................................................................................................. Date of issue*
...............................................................................................................
Identity document
............................................................................................................. issuing country*
...............................................................................................................
2.3.1. If Client’s beneficial owner is a politically exposed person¹, family member of a politically exposed person², or person closely associated with a
politically exposed person³, please provide following information:
BO is politically exposed person
BO is a family member of a politically exposed person or a person closely associated with a politically exposed person
Name, surname of a politically exposed person*** ............................................................................................................................................................................................
The country where person is currently/were formerly holding a politically exposed position ..........................................................................................................
Position (please tick):
Head of State
Head of state
administrative unit
(municipality)
Head of government
Minister, deputy of
minister or deputy of
minister’s deputy
State secretary
Other high level official in government or state
administrative unit (municipality)
Ambassador or chargés d’affaires
Member of parliament or member of other similar
legislative bodies
Chief officer in the armed forces
Member of governing bodies (board) of a political party
Judge of constitutional court, higher court or judge in a
different level court (member of court institutions)
Member of highest revision (audit) institution council or
board
Member of Central bank’s council or board
Member of management or supervisory bodies of
State – owned enterprises
Director, deputy director and member of the board or
equivalent function of an international organization or a
person who is in a similar position in this organization
*- for Latvian non residents, **- for Latvian residents, *** to be filled in if BO is a family member of a politically exposed person or a person closely associated with a politically exposed person
2.4. BO name, surname .........................................................................................................................................................................................................................................................................
Identity number **
............................................................................................................. Date of birth *
Address
.........................................................................................................................................................................................................................................................................
...............................................................................................................
street, house, flat, city, country, postal code
Identity document No.*
Identity document
issuing authority*
............................................................................................................. Date of issue*
...............................................................................................................
Identity document
............................................................................................................. issuing country*
...............................................................................................................
2.4.1. If Client’s beneficial owner is a politically exposed person¹, family member of a politically exposed person², or person closely associated with a
politically exposed person³, please provide following information:
BO is politically exposed person
BO is a family member of a politically exposed person or a person closely associated with a politically exposed person
Name, surname of a politically exposed person*** ............................................................................................................................................................................................
The country where person is currently/were formerly holding a politically exposed position ..........................................................................................................
Position (please tick):
Head of State
Head of state
administrative unit
(municipality)
Head of government
Minister, deputy of
minister or deputy of
minister’s deputy
State secretary
Other high level official in government or state
administrative unit (municipality)
Ambassador or chargés d’affaires
Member of parliament or member of other similar
legislative bodies
Chief officer in the armed forces
Member of governing bodies (board) of a political party
Judge of constitutional court, higher court or judge in a
different level court (member of court institutions)
Member of highest revision (audit) institution council or
board
Member of Central bank’s council or board
Member of management or supervisory bodies of
State – owned enterprises
Director, deputy director and member of the board or
equivalent function of an international organization or a
person who is in a similar position in this organization
*- for Latvian non residents, **- for Latvian residents, *** to be filled in if BO is a family member of a politically exposed person or a person closely associated with a politically exposed person
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........................................................................................
Signature
¹ A politically exposed person
– a natural person, who in the Republic of Latvia or in foreign countries occupies or has been entrusted with prominent public functions : head of State,
head of state administrative unit (municipality), head of government , minister, deputy of minister or deputy of minister’s deputy, state secretary or other upper level official in
government or state administrative unit (municipality), member of parliament or member of other similar legislative bodies, member of governing bodies (board) of a political party,
judge of constitutional court, higher court or judge in a different level court (member of court institutions), member of highest revision (audit) institution council or board, member of
central bank’s council or board, ambassador, charge affaires, chief officer in the armed forces, member of management or supervisory bodies of State – owned enterprises, directors,
deputy directors and member of the board or equivalent function of an international organization (director, deputy director), or a person who is in a similar position in this organization.
² Family member of a politically exposed person - politically exposed person’s spouse or a person similar to spouse status (considered as such only if the law of according state
stipulates this status), child, or a child of politically exposed person’s spouse or a person similar to spouse status, his spouse or a person similar to spouse status, parent, grandparent,
grandchild, brother or sister.
³ Person closely associated with a politically expose person – natural person who has business or other type of close relationship with politically exposed person, who is a
shareholder in the same legal entity as politically exposed person, or who has sole beneficial ownership of a legal arrangement which is known to have been set up for the de facto
benefit of a politically exposed person.
2.5.
There is no BO (because no one private individual owns more than 25%), but I agree to indicate owners known to me
I disagree
I agree (indicte)
Source of information (describe)
2.6.
...................................................................................................................................................................................................................................................
...................................................................................................................................................................................................................................................
BO is not known (explain) .......................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................................................
2.7.
I refuse to provide written information about BO (indicate reason) ........................................................................................................................................................
.....................................................................................................................................................................................................................................................................................................................................
Yes
2.8. Is Client (legal entity) a part of BO owned commercial entities group?
If Yes, please indicate (name, country, business activity sector and Client’s role in the group)
No
.....................................................................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................................................................
3. INFORMATION ABOUT PERSON WHICH FILLS THE STATEMENT
Relations with the Client
BO of the Client
Client’s authorized person
I hereby certify that the information provided in this Statement is complete and true and I am aware I will be held liable according to applicable
laws for providing false or misleading information. I undertake to inform the Bank immediately about changes in the information provided in
the Customer questionnaire.
In accordance with article 195.1 of the Criminal Code of the Republic of Latvia the person who intentionally renders untrue information to the Bank,
which is authorized by the law to request information about a real owner or actual beneficiary of transaction and funds involved or other property, can
be brought to criminal responsibility.
Name, surname
.................................................................................................................................................................................................................................................................
Date of birth *
............................................................................................................ Identity number** ........................................................................................................
Identity document No.* ............................................................................................................ Date of issue*
........................................................................................................
Identity document
Identity document
issuing authority*
............................................................................................................ issuing country*
........................................................................................................
*- for Latvian non residents, **- for Latvian residents
.....................................................................................................................................................................................................................................................................................................................................
Signature
Date
Account No:
........................................................................................................
Fill in if the Questionaire will be send to the Banka by FAX:
Digipass number
........................................................................................................
(Only for the Banks’s client!)
Key 1: K
....... .......
Key 2:
....... ....... ....... ....... ....... ....... ....... ....... ....... .......
Bank remarks
Seal
Representative of the Bank .......................................................................................................................
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