Financial Polis

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I, Name of Authorized Signatory, holder of Country Passport No.: XXXXXX with expiry date of day Month Year, having a residential address at Full Street Address, City, Province/State Postal/Zip Code, Country, make this Affidavit, with full legal, personal and corporate responsibility, under penalty of perjury, THAT:

 

A. OWNERSHIP OF FUNDS

 

1.      I make this Affidavit knowing that any recipient hereof will rely on the contents hereof, and I agree to indemnify said recipient and all parties relying thereupon against any and all claims resulting from any misrepresentations of a material fact herein.

 

2.      I am a director and officer of Name of Company, a company duly formed and existing pursuant to the laws of Jurisdiction of Incorporation (hereinafter referred to as “the Company”).

 

3.      As per the Company’s exclusive “Letter of Intent and Non-Solicitation” datedxxx and other documents issued in support of its request for participation in a private placement opportunity (“Private Placement”) under its Investor Transaction Code: xxxxx   , the Company currently holds a minimum of U.S. $XX,000,000.00  (In Words Million United States Dollars) in cash funds on deposit  currently held at  :

          with Name of Bank, Bank Branch, City, Province/State, Country. under

Account Name, Account No.: XXXXXXXX

 I am a bank acknowledged signatory for the Company’s above-referenced bank account.

 

4.      The Company has full legal and beneficial title to the above-referenced cash deposit (said cash deposit hereinafter referred to as “the Asset”); and I have complete authority and control to commit the Asset on the Company’s behalf pursuant to my sole instructions.

 

5.      The Asset is not subject to any loan facility, nor is it otherwise encumbered in any way whatsoever. There are no liens, charges, restrictions on transfer, third party interests or holds against the Asset, whether legal, equitable or contractual.

 

6.      Neither the Company nor I have entered into any financial agreement, joint venture or other contractual arrangement concerning the use and availability of the Asset; nor do I or the Company require the approval of any third party in order to commit the Asset for purposes of advancing the Company’s Private Placement participation.


B. SOURCE/HISTORY OF FUNDS

 

7.      The Asset represents good, clean, cleared and fully tax paid dollars that were earned as a result of legitimate business activity and were not derived from any criminal activity or source, or from any dealings in drugs, controlled substances, arms, munitions or terrorist activities, or from any other illegal activities.

 

8.      The Company and I are willing and able, upon request, to provide documentary evidence confirming the representations contained herein.

 

C.  USE OF FINANCIAL BENEFITS

 

9.         Neither the Company, nor any of its officers or director, are engaged in, nor intend to engage in, any military, illegal or immoral enterprise, or any scheme of “money laundering” or criminal (or civil) fraud, to include tax fraud, in violation of applicable United States and European law. The financial benefits derived by the Company as a result of it being afforded Private Placement participation will not be used for such purposes either now or at any time in the future.

 

I hereby agree that facsimile or other electronically transmitted copies of this Affidavit are to be treated for evidential purposes as originals.

 

I HEREBY make this Affidavit, with full legal, personal and corporate responsibility, under penalty of perjury, address at ( Give full address )

                                               

)

                                                                        )                                  

Signed:                                                          )

 

 

                                                           

Name of Authorized Signatory

Passport No.:

Expiry Date                                                                                                                                                             :

 

Witnessed by :

Signature:                                                          Date :

Name :

Address: