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Cis Form - Valéria Zólio

This document provides client information for paymaster services, including personal details of Valéria Regina Campos Zólio. It lists her name, nationality, passport number, date of birth, place of birth, contact information, bank account details at Caixa Econômica Federal in Brazil, and a signature swearing the information is accurate. The document is classified and confidential.

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Gilson Lopes
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509 views4 pages

Cis Form - Valéria Zólio

This document provides client information for paymaster services, including personal details of Valéria Regina Campos Zólio. It lists her name, nationality, passport number, date of birth, place of birth, contact information, bank account details at Caixa Econômica Federal in Brazil, and a signature swearing the information is accurate. The document is classified and confidential.

Uploaded by

Gilson Lopes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

CLIENT INFORMATION SHEET

FOR PAYMASTER SERVICES


DATE: February 06, 2019

In accordance with Articles 2 and 5 of the due diligence and federal banking commission
circular of December 1999, concerning the prevention of money laundering, and Article 305 of
the Swiss Criminal Code, the following information may be supplied to banks and to financial
institutions for purposes of verification of identity and activities of the investing member, and
the nature and origin of the funds which are to be utilized.

Client Full Name VALÉRIA REGINA CAMPOS ZÓLIO


Nationality BRAZILIAN
Passport Number FX938038
Issued By SR/PF/RJ
Issue Date 17/JAN/2019
Expiration Date 18/JAN/2029
Social Security Number (MEDICARE NO:) if N/A
any
LICENCES HELD(IF ANY) N/A
Phone no 55 21 99836-2478
E mail address [email protected]
Skype address N/A
Date of Birth 15/JULY/1958
Place of Birth BELO HORIZONTE – MINAS GERAIS

Attorney ( if you have one)


Address
Telephone
Fax
Mobile
Email Address

Origin Of Funds re this activity


Are Funds Free and Clear
Brief Corporate Activity

Facilitator and/or Intermediary for


transactions between groups and/or Buyers
and Sellers of:

Commodities/Banking
Instruments/Bonds/Currency Exchange

CLASSIFIED AND CONFIDENTIAL


Page 1 of 4
BANK NAME: CAIXA ECONÔMICA FEDERAL

BANK ADDRESS: R1B, Loja H/I/J, Av. Rio Branco, 1 - Centro, Rio de Janeiro - RJ,
CEP: 20090-003
IBAN: BR36 0036 0305 0019 9000 5124 803P 1

SWIFT CODE: CEFXBRSP

BANK OFFICER: ANGELO AUGUSTO DE OLIVEIRA

BANK PHONE No: 55 21 3849-2600

BANK FAX No:

A/C NUMBER: 0199 013 00512480-3

EMAIL: [email protected]

I hereby swear under penalty of perjury that the information given above is accurate and true.
Any information, work or service conducted hereunder is that of a private placement
transaction that is exempt from the Securities Act and not intended for the general public but
for Private Use Only.

___________________________________________________
SIGNATURE AND SEAL

Signatory: VALÉRIA REGINA CAMPOS ZÓLIO

Passport: FX938036

Country: BRAZIL

Date: 06/FEBRUARY/2019

CLASSIFIED AND CONFIDENTIAL


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COPY OF BENEFICIARY PASSPORT.

CLASSIFIED AND CONFIDENTIAL


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PROOF OF RESIDENTIAL ADDRESS (Note that P.O.BOX is not acceptable)
To validate the home addresses of all parties, please provide at least ONE COPY of the
following:
(a) Original and recent bank statement from a recognized bank
(b) Original and recent credit card statement
(c) Letter from your employer (on headed paper) confirming your permanent address
(d) Utility bill

CLASSIFIED AND CONFIDENTIAL


Page 4 of 4

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