DECLARATION OF THE LEGAL PERSON
Dear customer! Completely filled in Declaration is a mandatory prerequisite for account opening or for updating of customers’ information. The obligation to submit
the requested data arises from the Law of the Republic of Lithuania on the Prevention of Money Laundering and Terrorist Financing, other legal acts and in
observance of the standards of international banking activities and in fulfilling the obligation of the bank to implement the principle “Know Your Customer”. We
hereby confirm that we guarantee that the customer data provided will be kept confidential and banking secrecy observed according to the applicable normative
acts.
DATE OF PROVISION OF INFORMATION (YYYY-MM-DD):
1. INFORMATION ABOUT THE CUSTOMER
CUSTOMER NAME
WEBSITE ADDRESSES
REGISTRATION COUNTRY
REGISTRATION NUMBER (CODE)
E-MAIL ADDRESSES
TAX RESIDENCE COUNTRY
TAX ID NUMBER (TIN)
COUNTRY CODE OF
PHONE NO. (ISO)
PHONE AND FAX NUMBERS
(please indicate the country codes!)
LEGAL (REGISTRATION) ADDRESS
Street, house, room No.
City
Postal code
Country
ACTUAL BUSINESS PLACE ADDRESS
Street, house, room No.
City
Postal code
Country
ONLY FOR NON-RESIDENTS OF LITHUANIA
IS YOUR COMMERCIAL ACTIVITY RELATED TO LITHUANIA? (for example, business partners in Lithuania, goods movement across Lithuania)
No
Yes (please specify!) _________________________________________________________________________________________________________________________
2. INFORMATION ABOUT THE CUSTOMER’S MANAGER
Name: ___________________________________________________________________
Citizenship: _______________________________________________________________
Surname: ________________________________________________________________
Person’s country of residence: ________________________________________________
Personal ID Code: _________________________________________________________
ID document number: _______________________________________________________
Date of birth: ______________________________________________________________
ID document issuing country: _________________________________________________
3. INFORMATION ABOUT THE CUSTOMER’S REPRESENTATIVE ACTING ON THE BASIS OF AUTHORISATION / PROCURACY
Name: ___________________________________________________________________
Citizenship: _______________________________________________________________
Surname: ________________________________________________________________
Person’s country of residence: ________________________________________________
Personal ID Code: _________________________________________________________
ID document number: _______________________________________________________
Date of birth: ______________________________________________________________
ID document issuing country: _________________________________________________
4. INFORMATION ABOUT THE CUSTOMER’S BUSINESS:
MAIN BUSINESS AREAS (please specify, e.g., in case of trade – retail and (or) wholesale and in what goods and (or) raw materials; for manufacturing – type of products; for advisory and
(or) services – specific area, etc., please specify in the field below!)
Does the economic activity require a special registration or a license?
No
Yes
PLEASE INDICATE WHETHER YOU ARE ENGAGED IN ANY OF THE BELOW LISTED ECONOMIC ACTIVITIES.
No
Yes (please indicate the activity by selecting the respective checkbox!)
Legal services
Organisation of tourism and (or) travels
Sales of real estate
Audit services
Individual health care / provision of medical
services
Trade in oil products
Pharmaceutical activities
Trade in arms and ammunition
Charity / sponsorship
Online (internet) sales (of goods)
Activities of professional sports teams and clubs
Sales of virtual currencies / activities related to virtual currencies
Wholesale trade in alcohol and tobacco
products
E-money institution / electronic money related activities
Sales of motor vehicles
Payment institution / provision of payment services
Services of establishment and (or) administration of
legal entities
Organisation and conducting of lotteries, gambling
Activities related to ferrous and (or) non-ferrous
metals
Activities related to precious metals, gems,
jewellery, works of art
Organisation and conducting of auctions
COMPANY IS NOT ENGAGED IN BUSINESS ACTIVITIES (e.g. it is established for the purpose of funds accumulation)
Please provide a detailed description in the part of this Declaration “COMMENTS OF THE CUSTOMER” (including information on the source of wealth/funds).
CUSTOMER IS AN ASSOCIATION OR AN ESTABLISHMENT (organization has been created for non-profit purposes).
NUMBER OF EMPLOYEES: _____________________
ACCOUNTS AT OTHER BANKS
No
NUMBER OF YEARS IN THE BUSINESS
Less than 1 year
Yes (please indicate the name and the country of its location!)
NAME OF THE BANK
COUNTRY
NAME OF THE BANK
COUNTRY
NAME OF THE BANK
COUNTRY
1 - 3 years
More than 3 years
MAIN COUNTRIES / REGIONS OF CUSTOMER’S BUSINESS (please choose or specify!):
Lithuania
Baltic States
EU Member States
Russia
USA
Other (please specify!):
_______________________________________
MAIN BUSINESS PARTNERS WITH WHICH TRANSACTIONS WILL BE MADE BY USING THE ACCOUNTS AT „SWEDBANK“, AB
NAME OF PARTNER
REGISTRATION COUNTRY
TYPE OF COMMODITY OR DESCRIPTION OF SERVICE
5. INFORMATION ABOUT THE PLANNED TRANSACTIONS
PLANNED MONTHLY TURNOVER (please specify!):
Up to EUR 15 000
From EUR 30 001 to EUR 150 000
From EUR 15 001 to EUR 30 000
More than EUR 150 001
PLANNED TRANSACTIONS PARTS (%) FROM TOTAL 100% OF TRANSACTIONS PER MONTH (please specify!):
%
%
Cash deposits
%
Cash payouts
IF CASH TRANSACTIONS ARE PLANNED:
Please explain the most frequent origin of deposited cash!:
%
%
Payments from Lithuania
%
Payments to Lithuania
Payments from abroad
Payments to abroad
Please explain the most frequent uses / purpose of withdrawn cash!:
No
WILL THE TOTAL CASH TURNOVER EXCEED EUR 15 000 PER MONTH?
Yes (please specify the economic reason in the field below!)
ARE YOU PLANNING TO MAKE TRANSACTIONS ON BEHALF OF THIRD PERSONS OR PLACE THIRD PERSON FUNDS IN ACCOUNTS?
No
Yes (please specify): __________________________________________________________________________________________________________________________
6. INFORMATION ABOUT BANKING SERVICES PLANNED TO BE USED
ELECTRONIC BANKING (INTERNET BANK)
CARD ACQUIRING (POS TERMINALS)
LEASING
PAYMENT CARDS
CASH TRANSACTIONS
TRADE FINANCE
DOMESTIC PAYMENTS
CURRENCY EXCHANGE OPERATIONS
DOCUMENTARY OPERATIONS
INTERNATIONAL PAYMENTS
TERM DEPOSITS
INVESTMENT PRODUCTS
EMPLOYEE SALARY PAYMENTS
LOANS
TRANSACTIONS WITH SECURITIES
7. INFORMATION ABOUT LEGAL PERSONS IN THE CUSTOMER’S MANAGEMENT (SHAREHOLDER’S) STRUCTURE HOLDING 25% OR MORE SHARES OF THE
CUSTOMER
No.
Legal person’s name
Legal person’s
registration
country
Legal person’s
code
Shareholding, in
per cent
Only for companies, which shares are traded on an EU member state (or EUequivalent third country) stock exchange:
Name of the stock exchange
Country of the stock
Company’s
exchange
securities No –
ISIN No.
1
2
3
4
8. INFORMATION ABOUT THE CUSTOMER’S BENEFICIAL OWNERS
Are there are any natural persons who directly or indirectly own or control at least 25% of the share capital or voting rights of the customer (legal person) or exercise other control over the
customer’s (legal person’s) operations or for whose benefit or in whose interest the business relationship is established?
There are no such persons (none of them own or control 25% or more). In this case in the table below specify four major shareholders.
There are no such persons - Customer is an association or an establishment (non-profit organization).
Customer’s / its controlling company’s shares are traded on an EU member state (or EU-equivalent third country) stock exchange.
Customer / its controlling company is the Republic of Lithuania, a derived public person, an institution of the Republic of Lithuania or of an indirect administration or a capital company
controlled by the central or a local government.
The beneficial owners are the below listed persons:
Name and Surname
Personal code and date of
birth
Tax residence country*
and citizenship
Tax ID (payer’s) number
(TIN)
ID document
issuing country*
Ownership type and the
share amount (%)
Directly
1
Indirectly**
Directly
2
Indirectly**
Directly
3
Indirectly**
Directly
4
Indirectly**
* If there are other beneficial owners’ tax residence countries and ID documents issued in other countries please specify the data in the part of this Declaration “COMMENTS OF THE
CUSTOMER”.
**Indirectly – through another legal entity which is a shareholder of the company. Please specify in the part of this Declaration “COMMENTS OF THE CUSTOMER” if the ownership type
“indirectly” applies.
I hereby declare that the above listed beneficial owners only have the tax residence countries and ID documents issued countries specified above.
9. INFORMATION ABOUT THE CUSTOMER’S RELATIONSHIPS WITH POLITICALLY EXPOSED PERSONS
Are the customer’s (legal person’s) manager, beneficiary, their close family members* or close associates**, who are performing prominent public functions persons now or performed
such prominent public functions during the last 12 months (the prominent public functions are listed below) in the Republic of Lithuania, European Union, international or foreign institutions?
* Close family members – means the spouse, the person with whom partnership has been registered (hereinafter – cohabitant), parents, brothers, sisters, grandparents, grandchildren,
children and children’s spouses, children’s cohabitants.
** Close associate - means a person who participates in the same legal entity or maintains other business relations.
No
Yes (please specify!):
Head of the State, the Head of the Government, a minister, a vice-minister or a deputy minister, Secretary of State, the Chancellor of the Parliament, Government or Ministry
Member of the Parliament
member on the Supreme Court, the Constitutional Court or any other judicial authority whose decisions are not subject to further appeal
member of the management body of the professional organisation of auditors (Chamber of Auditors) or of the board of the central bank
Ambassador, a chargé d’affaires ad interim or a high-ranking military officer
member of the administrative, management or supervisory body of a state-owned enterprise
Head, deputy head, member of the administrative, management or supervisory body of international intergovernmental organization
Leader, deputy leader, member of the administrative, management body of the political party
Please specify the politically exposed person:
Name, surname: _____________________________________________ Country, institution, position: ____________________________________________________
Please specify which customer’s representative is or is related with above mentioned person:
Manager
Beneficial owner
Close family member*
Close associate**
1
APPLICABLE ONLY FOR LEGAL PERSON WHOSE BENEFICIAL OWNER IS CITIZEN OF THE UNITED STATES OF AMERICA (U.S.) OR U.S. RESIDENT2 OR THE
TAX PAYMENT COUNTRY OF BENEFICIAL OWNER1 IS U.S.
INFORMATION ON PASSIVENESS AND ACTIVENESS OF CUSTOMER ACCORDING TO FATCA (The Foreign Account Tax Compliance Act adopted by US)
Please confirm or deny the following statement (by marking “Yes” or “No”).
ATTENTION. At least one statement is marked as “Yes” further statements are not applicable!
Yes
No More than 50 % of the Legal Person’s gross income for the preceding calendar year or Legal Person’s financial year is active income3 and more than 50 % of assets held
by entity during the said year are assets that produce or are held for the production of active income3.
Yes
No
The stock of the Legal Person or Related Legal Person6 of the Legal Person is traded on an established securities market.
Yes
No
The Legal Person is organized in a U.S. Territory4 and all of the owners of the Legal Person are residents of that U.S. Territory4.
Yes
No The Legal Person is a government (other than the U.S. government), a political subdivision of such government (state, province, country or municipality), or a public body
performing a function of such government or a political subdivision thereof, a government of a U.S. Territory4, an international organization, a central bank or an entity wholly owned by one
or more of the foregoing.
Yes
No Substantially all of activities of the Legal Person consist of holding the outstanding stock of, or providing financing services to, one or more subsidiaries5 that are not
Financial Institutions7.
Yes
No The Legal Person was not a Financial Institution7 in the past five years, and is in the process of liquidating its assets or is reorganizing with intent to continue business
operations other than that of a Financial Institution7.
Yes
No The Legal Person primarily engages in financing and hedging, transactions with, or for, Related Legal Persons6 that are not Financial Institutions7.
_____________________
1
Beneficial Owner – natural person who directly or indirectly owns or controls 25% or more of the share capital or voting rights of the Legal Person or exercises other control over the Legal
Person’s operations (for whose benefit or in whose interest the business relationship is established).
2
U.S. Resident– person who is deemed the U.S. Resident under the laws of the U. S.
3
Active income – income that are not Passive income. Passive income – dividend, interest, rents, annuities, capital gain from assets, which generates such Passive income, income from
swap-contracts and other Passive income.
4
U.S. Territory – means American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, the Commonwealth of Puerto Rico, or the U.S. Virgin Islands.
5
Subsidiary- a Legal Person which meets at least one the following criteria: 1) a Legal Person in which another Legal Person holds a majority of shareholders or other participants’ voting
rights; 2) a Legal Person in which another Legal Person controls a majority of shareholders or other participants voting rights; 3) a Legal Person in which another Legal Person has the right
to elect or remove majority of members of Administration, the Board or Supervisory Board; 4) a Legal Person to which another Legal Person may exercise a dominant influence according to
Memorandum of Association, Act of Establishment or other Contract.
6
Related Legal Person – a Legal Person is a Related Legal Person of another Legal Person if either Legal Person controls the other Legal Person, or the two Legal Persons are under
common control. For this purpose control includes direct or indirect ownership of more that 50% of the vote or value in a Legal Person.
7
Financial Institution – means a Custodial Institution, a Depository Institution, an Investment Entity, or an Insurance Company.
Custodian Institution – means any Legal Person that holds, as a substantial portion of its business, financial assets for the account of others..
Depository Institution - means any Legal Person that accepts deposits in the ordinary course of a banking or similar business..
Investment Entity – means any Legal Person that conducts as a business one or more of the following activities or operations on behalf of a customer: 1) trading in money
market instruments (cheques, bills, certificates of deposit, derivatives, etc.); 2) individual and collective portfolio management; 3) otherwise investing, administering, or managing funds or
money on behalf of other persons.
Insurance Company – means a Legal Person that is an insurance company that issues, or is obliged to make payments with respect to, a Cash Value Insurance Contract or an
Annuity Contract.
COMMENTS OF THE CUSTOMER
By signing this Declaration:
I/we confirm that the information provided in this Declaration is correct (current, complete and accurate).
I/we agree to immediately advice „Swedbank”, AB of any changes in this Declaration and provide „Swedbank”, AB in writing with the updated information.
I/we confirm that the services of „Swedbank”, AB will be used for valid purposes (to refrain from using the services of the bank for the purpose of money laundering and (or) terrorist
financing, or other illegal purposes).
I/we apply for concluding the bank account agreement (in case of Declaration filled in for the purpose of concluding a new bank account agreement).
Signature (and stamp) of the Customer representative:
Signature, name, surname and the position of the Bank’s Employee:
Name, Surname of the representative:
Date:
Date: