 DATE : ……….. 200 TO : Program Trader REF. : Private Placement Program AFFIDAVIT OF OWNERSHIP - DERIVATION OF FUNDS I, (Name of Client / Authorised Signatory), (hereinafter referred to as “Affiant”), being of lawful age, hereby solemnly swear and testify under oath and make this “Affidavit”, under penalty of perjury, as follows: 1. Affiant makes this “Affidavit” knowing that the Recipient will rely on the contents thereof and agree to indemnify Recipient and all parties at interest against any and all claims resulting from any misrepresentation of a material fact; 2. Affiant confirms that Affiant is the current lawful owner of cash deposited funds hereinafter referred to as “Assets”, more specifically located in following Bank account specified herein and that are the subject of this Affidavit and described as follows: Bank: Address: S.W.I.F.T. Code: Account Number: Account Name: Amount: USD or EUR................... (in words) Telephone No.: Telefax No.: Signatory : Bank Officer: 3. Affiant states that said Assets were lawfully obtained by Affiant using clean cleared funds of non criminal origin, derived and generated from honest business endeavours and solid business transaction; 4. Affiant further states that Affiant has full and complete legal title and authority to transfer, pledge, lien, hypothecate or encumber said Assets; 5. Affiant states that there are no liens, contractual obligations, or encumbrances of any kind secured by or against said Assets; 6. Affiant further states that said Assets are authentic and verifiable, and that no significant factors exist which have or could lead to the non-validation of Assets; 7. Affiant makes said Assets exclusively available to complete this proposed transaction and all mutually agreed private placement and extension of it. 8. Affiant declares that facsimile documents are to be treated as originals, which originals are available upon request. Affiant says nothing further. So dates and sworn to this ……. 200 BY AFFIANT -------------------------------------------------------------------- FULL NAME OF CLIENT / AUTHORISED SIGNATORY PASSPORT NO. ON CLIENT'S LETTERHEAD (Full Address, Telephone, Facsimile and/or E-Mail) |
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