Insert Your Logo and Letter Head Here
FUNDS OWNERSHIP DECLARATION
Date: March 1, 2011
To: Fund Manager
Transaction Code Private Placement Number:
I, Mr. I.M. Investor (for and on behalf of corporate name, if using a corporation), hereby
solemnly and sincerely declare as follows:
I hereby make this declaration knowing that its contents will be relied upon by way of
I hereby confirm and declare that I am the current lawful account holder signatory of
funds/assets in or issued by Forest Commercial Bank in United States Dollars
(USD$1,000,000.00) as described in the attached exhibit and that these funds are good, clean,
and clear and of non-criminal origin.
I further declare that said funds/assets have been earned in the course of normal commercial
business and of commercial origin and legally generated.
I further warrant and attest under penalty of perjury, and/or criminal or civil action, that the
information supplied in this documentation, and the funds/as