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SOURCE OF FUNDS DECLARATION

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									                        Source of funds declaration

Company code: (internal use only)   ………………………………………………………………………..


                                    Please state the full name, company registration number or
REMITTER:                           personal ID no., and registered address.

                                    Company name………………………………………………………

                                    Registration number…………………………………………………


                                    Registered Address………………………………………………….
                                    ………………………………………………………………………….
                                    ………………………………………………………………………….

                                    Please state the name, account number, and address of the bank
REMITTING BANK:                     concerned.

                                    Bank name…………………………………………………………….

                                    Adress………………………………………………………………….
                                    …………………………………………………………………………..

                                    Bank manager Name…………………………………………………


                                    Bank manager Telephone……………………………………………


                                    IBAN n°………………………………………………………………….

                                    BIC n°…………………………………………………………………...


CURRENCY & AMOUNT
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DATE OF TRANSFER
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                                    Please state the purpose of funds transfer.
PURPOSE:
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SOURCE OF FUNDS:                    Please use one or more of the options listed below:
                                    Please describe the activities concerned
Trading Activity                    …………………………………………………………………………..
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                   Fidulex-Engineering SA – Source of Funds declaration                                                   1
Financial Income                              Please describe the income concerned

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                                              Please insert description
Savings                                       ………………………………………………………………………….
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                                              Please insert description
Inheritance/Gift                              ………………………………………………………………………….
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                                              Please describe the source concerned
Other                                         ………………………………………………………………………….
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________________________
Signature*
Name: .......................................................
Position:.....................................................
Date:.........................................................


* This declaration must be signed in the manner which is legally binding in the country of the
remitter.




                       Fidulex-Engineering SA – Source of Funds declaration                 2

								
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