legal person questionnaire

LEGAL PERSON QUESTIONNAIRE
According to the anti-money laundering and tax administration laws of the Republic of Lithuania, the bank is obliged to collect customer information when establishing and/or expanding business
relationship with customers. In view of the requirements of such legislation, the bank takes decisions on establishing or expanding business relations. Further information may be requested on receipt
of this form for further verification purposes.
1. INFORMATION ABOUT LEGAL PERSON, INCLUDING ALL OTHER LEGAL ARRANGEMENTS
Full name of legal person
Date of registration
Company ID
UAB Prekyba Lietuvoje ir užsienyje
12-12-2012
Country where a legal person is registered
Country
City/District
121212121
Lithuania
Town/Village
Street name/ Number
Postal code
Taxpayer Identification Number
Legal address
Lithuania
Kaunas
Laisvė ave. 125A
44253
–
Business address
Lithuania
Vilnius
Konstitucija ave. 40
08105
–
Lithuania
Vilnius
Konstitucija ave. 40
08105
Residence address for income
tax purposes
Phone No., fax No.
E-mail
+3706666666
info@prekyba123.lt
Information about company‘s CEO
Phone No.
Internet website
121212121
Number of employees
www.prekyba123.lt
13
Name
Surname
Personal ID
Date of Birth
Citizenship
Vardenis
Pavardenis
38008080808
1980-08-08
Lithuania
Country
City/District
Town/Village
Street name/ Number
Postal code
Lithuania
Vilnius
Antakalnis str. 145
10200
+3705555555
E-mail
direktorius@prekyba123.lt
INFORMATION ABOUT THE CUSTOMER’S REPRESENTATIVE (PLEASE INDICATE IF FILLED IN NOT BY CEO)
Name
Surname
Personal ID
Date of Birth
Citizenship
Country
City/District
Town/Village
Street name/ Number
Postal code
Phone No.
E-mail
REPRESENTATIVE
holds the position of (please indicate the position)
acts on the basis of an authorization valid until
3. INFORMATION ABOUT CUSTOMER‘S ACTIVITY
Type of activities where your company is currently involved
Legal services, lawyer‘s practice, notary activities
Trade in means of transport
Real estate, construction
Audit
Personal health care
Tourism or travel agent activities
Wholesale in alcohol, alcohol products and tobacco goods
Pharmaceutical business
Information technologies
Telecommunication
Logistics
Farming
Organization and running of lotteries and gambling
Business related to ferrous, non-ferrous or precious metals, gems, jewellery, works of art
Organization and running of auctions
Oil product trading
Financial support, charity
Trade in arms and ammunition
Virtual currency trading/activities related to virtual currencies
Electronic money institution/activities related to electronic money
Payment institution/provision of payment services
Financial services and currency exchange/financial mediation
Other (please indicate)
retail of food products
PROVISION OF FINANCIAL SERVICES
No
Yes (specify what financial services the company provides and indicate GIIN code)
Specify which part (%) of total/gross income of the Company were passive income (interest, dividend, royalties, etc.) for the last financial period
For the last financial period passive income of the Company were:
Less than 20% of total/gross annual income
20% and more, but less than 50% of total/gross annual income
50% and more of total/gross annual income
4. INFORMATION ON FINANCIAL TRANSACTIONS
ACCOUNTS IN OTHER BANKS
AB SEB bankas
AB „Swedbank
AB „Citadele“
AB bankas „Finasta“
AB „Šiaulių bankas“
UAB „Medicinos bankas“
„Nordea Bank AB“ Lietuvos skyrius
„Danske Bank A/S“ Lietuvos filialas
BIGBANK AS filialas
Other (please indicate)
DNB bank Latvia
SERVICES YOU ARE PLANNING TO USE IN THE BANK
Bank accounts
Internet banking
Deposits
Loans
Leasing
Currency exchange
Payment/credit cards
Securities
Other services
(please indicate)
Safe box
PLANNED SOURCES OF INCOMING PAYMENTS
Proceeds from buyers
Proceeds from investments
into other companies
Investments from the
company owners
Loans
Other
(please indicate)
ARE YOU PLANNING TO PERFORM CASH DEPOSIT TRANSACTIONS?
No
Yes (please indicate monthly turnovers and origin of funds to be deposited)
up to EUR 3.000
Origin of inputs:
from EUR 3.001 to 30.000
from EUR 30.001 to 150.000
more than EUR 150.000
from EUR 30.001 to 150.000
more than EUR 150.000
received cash for sold goods in the shop (Vilnius)
ARE YOU PLANNING TO PERFORM CASH WITHDRAWAL TRANSACTIONS?
No
Yes (please indicate monthly turnovers and purpose of withdrawable funds)
up to EUR 3.000
from EUR 3.001 to 30.000
The purpose for which the withdrawn funds will be used:
per diem pay for truck drivers
PLANNED AVERAGE ACCOUNT TURNOVER PER MONTH:
up to EUR 30.000
from EUR 30.001 to 150.000
from EUR 150.001 to 300.000
from EUR 300.001 to 1 million
more than EUR 1 million
from EUR 150.001 to 300.000
from EUR 300.001 to 1 million
more than EUR 1 million
PREVIOUS YEAR‘S MONTHLY TURNOVER OF THE COMPANY:
up to EUR 30.000
from EUR 30.001 to 150.000
MAIN BUSINESS/OPERATIONAL COUNTRIES/REGIONS:
Lithuania
Baltic countries
USA
EU/EEA countries
CIS countries
Other
(please indicate)
MAIN BUSINESS PARTNERS
Partners from which funds will be received
Country
Partners to which funds will be sent
Name
Country
Name
Lithuania
AB Įmonė
Lithuania
UAB Verslo partneris
Latvia
SIA Kompanija
Poland
Firma s. r. o.
Estonia
OU Ettevote
Belarus
IP Ivan Ivanov
Russia
OAO Kompania
France
SARL Societe
5. INFORMATION ABOUT LEGAL AND/OR NATURAL PERSONS WHO CONTROL OR OWN 25% OR MORE OF THE SHARES (CAPITAL, OWNERSHIP OR
EQUIVALENT) OR VOTING RIGHTS.
Name
Vardenė
1.
Surname/Company name
Pavardenė
Country
Lithuania
Name
Vardenis
2.
Personal ID/ Company ID
49101010101
City/District
Town/Village
Surname/Company name
Name
38008080808
Town/Village
Personal ID/ Company ID
UAB Prekybos kontrolė
3.
Country
Lithuania
4.
Lithuania
Antakalnis str. 145
Surname/Company name
131313131
City/District
Country
City/District
10200
Citizenship
Postal code
Street name/ Number
Personal ID/ Company ID
Town/Village
Number of shares %
40%
Savanoriai ave. 290
Surname/Company name
30%
02-02-2002
Vilnius
Number of shares %
Postal code
Date of Birth
Town/Village
Name
Citizenship
Street name/ Number
Vilnius
30%
44253
Date of Birth
08-08-1980
Number of shares %
Postal code
Street name/ Number
Personal ID/ Company ID
City/District
Citizenship
Lithuania
Laisvė ave. 130
Pavardenis
Lithuania
01-01-1990
Kaunas
Country
Date of Birth
02301
Date of Birth
Street name/ Number
Citizenship
Number of shares %
Postal code
There are no legal and/or natural persons who own or control 25% or more of the shares (capital, ownership or equivalent) or voting rights. If this is the case, if possible please
write down main shareholders having the biggest share holdings.
If there is at least one or more legal persons who directly control the customer by holding 25% or more of the shares (capital, ownership or equivalent) or voting rights, please
explain the management structure and draw its chart.
I confirm that the management structure is attached to this Questionnaire.
6. INFORMATION ABOUT ULTIMATE BENEFICIAL OWNERS
Please indicate natural persons who ultimately own or control the customer (legal person) by holding or controlling, directly or indirectly, 25 % or more of the shares, ownership or voting rights; also,
the natural person(s) who otherwise exercises control over the management of a legal person:
Name
Vardenė
Surname
Pavardenė
Personal ID
49101010101
Date of Birth
01-01-1990
Country of birthplace
Lithuania
Citizenship
Lithuania
1.
Country
City/District
Town/Village
Street name/ Number
Postal code
Address
Lithuania
Kaunas
Laisvė ave. 130
44253
Residence address for
income tax purpose
Lithuania
Kaunas
Laisvė ave. 130
44253
Name
Vardenis
Surname
Pavardenis
Personal ID
38008080808
Date of Birth
08-08-1980
Country of birthplace
Lithuania
Citizenship
Lithuania
2.
Country
City/District
Town/Village
Street name/ Number
Postal code
Address
Lithuania
Vilnius
Antakalnis str. 145
10200
Residence address for
income tax purpose
Lithuania
Vilnius
Antakalnis str. 145
10200
Name
Name
Surname
Surname
Personal ID
07-07-1970
Date of Birth
07-07-1970
Country of birthplace
Ireland
Citizenship
Ireland
3.
Country
City/District
Town/Village
Street name/ Number
Postal code
Address
Ireland
Dublin
Dublin str. 1
989539
Residence address for
income tax purpose
Ireland
Dublin
Dublin str. 1
989539
Part of shares (%)
30%
Taxpayer
Identification
Number
49101010101
Part of shares (%)
30%
Taxpayer
Identification
Number
38008080808
Part of shares (%)
25%
Taxpayer
Identification
Number
1234567TW
Name
Surname
Personal ID
Date of Birth
Country of birthplace
Country
City/District
Town/Village
Street name/ Number
Citizenship
4.
Postal code
Part of shares (%)
Taxpayer
Identification
Number
Address
Residence address for
income tax purpose
There is no natural person who owns or controls 25 % or more of the shares (capital, ownership or equivalent) or voting rights.
Shares of the customer/its controlling company are traded on the stock exchange of the EU Member States (or the EU-equivalent).
Please indicate ISIN:
The customer is/is controlled (governed) by the Lithuanian state or municipal institution or establishment, state or municipal enterprise, public institution, whose owner or
stakeholder is the state or municipality.
7. INFORMATION ABOUT CUSTOMER‘S RELATIONS WITH POLITICALLY EXPOSED PERSONS
Are the customer’s (legal person’s) CEO, beneficial owner, shareholders, their close family members* or close associates** currently entrusted or were entrusted with prominent public functions (listed
below) in the Republic of Lithuania, European Union, international or foreign state institutions?
No
Yes (please indicate)
heads of State or of Government, a minister, a vice-minister or a deputy minister, Secretary of State, Chancellor of the Parliament, Government or Ministry;
a member of the parliament;
member on the Supreme Court, the Constitutional Court or any other judicial authority whose decisions are not subject to appeal;
a member of the management body of the professional organisation of auditors or of the board of the central bank;
an ambassador, a chargé d’affaires ad interim or a high-ranking military officer;
a member of the management or supervisory body of a publicly administered undertaking;
head of an international or inter-governmental organization, his or her deputy, a member of its management or supervisory body;
leader of a political party, his or her deputy, a member of management body.
Please indicate a politically exposed person(s):
Name, surname
Country, institution, position, year
Name Surname
Ireland, Ministry of Finance, vice-minister, 2015
Please indicate the relations with this person(s):
Head of the company
Beneficial owner
Please indicate the relations between head of the company/ beneficial owner and this person(s):
Close family member
Close associate
* Spouse, person with whom partnership has been registered (hereinafter referred to as a co-habitant), parents, siblings, grandparents, grandchildren, and children’s spouses, children’s co-habitants.
** Persons with whom you have a joint business or maintain other business relations.
By signing this Questionnaire I agree to be contacted by and/or receive information for direct marketing purposes from the Bank and the Bank’s subsidiaries (UAB DNB Investicijų
Valdymas, UAB DNB Būstas) to the address, phone number and e-mail provided by me in this Questionnaire.
Should you request not to receive information to the address, phone number or e-mail as provided, mark that below:
I request not to receive any information for direct marketing purposes.
I confirm that I’m fully authorized to sign this Questionnaire on behalf of the customer. I confirm that the information provided in this Questionnaire is correct and I undertake to
inform AB DNB Bankas in writing about any changes in the information provided. I undertake to use AB DNB Bankas services for legitimate purposes only and I understand that if
the information in this Questionnaire turn out inaccurate or misleading, AB DNB Bankas has the right to inform the law enforcement authorities of the Republic of Lithuania and
unilaterally terminate the business relationship.
Name, surname, signature of the customer’s representative and stamp
Name, surname, signature of the Bank employee who has accepted this Questionnaire
Vardenis Pavardenis
Date