Affidavit - Statutory Declaration

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ЗАКРЫТОЕ АКЦИОНЕРНОЕ ОБЩЕСТВО
«____»
ОГРН ____ ИНН ____ ОКПО ____ ОКАТО ____
124489, г.Москва, г._____, E-mail:
___
Тел./факс +7495___________, Моб. +7______________
AFFIDAVIT - STATUTORY DECLARATION
Date:
I, _________________, holder of Passport Number ____________ on behalf of,
_____________ residing at ____________________ solemnly and sincerely declare
as follows:
A) That I make this declaration knowing that the lawful recipient will rely on the
contents thereof:
B) That I further state that the funds were lawfully obtained by me and are clean,
cleared and of commercial origin and legally generated. I further arrant and
attest, under the penalty of perjury (and/or criminal or civil action), that the
information supplied in my documentation and the funds are not in breach of
the “Money Laundering Regulatory Accord of 1993”, however interpreted,
defined and enacted, whether the host state of the transaction or internationally.
C) That I confirm that I have full and complete authority as signatory on the
funds.
D) I confirm that I have initiated my actions of my own free will, without any
solicitation or influence.
E) I further declare that there are no liens, contractual obligations or
encumbrances of any kind effecting or touching the said funds and there are no
other currently valid or pending commitments.
F) That I further state to my best knowledge that there are no significant factors
which could lead to non-validation of the said funds.
G) That I state to the best of my knowledge that the said funds are valid.
Initials : ______

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