Illustrative Customer Due Diligence Templates Page 14

EP 200 IG 2

FORM C

(Agents)

Client/Agent’s Declaration

I declare that the information provided in these forms is true and correct. I am aware that I may be subject

to prosecution and criminal sanctions under written law if I am found to have made any false statement

which I know to be false or which I do not believe to be true, or if I have intentionally suppressed any

material fact.

Name of client/agent:

Identity/passport number:

Date:

Signature:

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Verification (for office use)

The authority of an agent to act on behalf of the client shall be verified. This may be done by obtaining

documentary evidence that the client has appointed the agent to act on his behalf or a summary of the

oral instructions given to the agent by the client; and the specimen signatures of the person appointed.

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