Celeb Format

Dear customer,
Please carefully read the content of the following form and fill out the required information.
Once completed, please upload the document (scanned or digitally signed) through any of the upload
fields available in the ‘Verify your account’ page on your Coinmama account.
1. Service Applicant Declaration Form
Your full name – including any middle name(s)

I, the undersigned, María Graciela Monforte , holder of the Identification
Your Identification Document – must be valid (preferably, an international passport)

○ International Passport ○ Driving License ○ National ID Card
Type of document:
Document indicated here: ○ Residence Permit ○ Other: ____________________________ ,
Country of issue: USA
Document number: 092150838
National Identification Number: [where applicable] 626-88-5591
Your complete address of residence

from Street, house number, apt.: 45 n Belmont st ,
City: Colorado Springs, ZIP code: 80911
State / province: Colorado Country: USA
hereby declare that: [mark your choice]
○ A. I wish to receive the currency conversion service for myself only.
○ B. I wish to receive the currency conversion service on behalf of another person/corporation:

Recipient(s) of the service:
Applicable Appended is the power of attorney or trust instrument from the recipient of the service,
only if ‘B’
is marked containing his/her identifying particulars. If the recipient is a corporation, the authorized
signatories letter and the identifying particulars of its holders of controlling interests.
The type of the requested services (as specified in Prohibition of Money Laundering Law, 5760-2000,
paragraph 11C. (a) is: Delivery of financial assets against currency.
I undertake to inform the provider of currency services in writing as soon as possible of any change
in the details noted above and sign a renewed declaration if the said details were changed, including
acting on behalf of another service recipient.
I am aware that providing false information, including the failure to deliver an update of details
required to be delivered, in order to avoid the filing of reports or filing an incorrect report under
Section 7 of the Prohibition of Money Laundering Law is a criminal offense.
Date: ________________
01-04-2023 Signature: _____________________
María Graciela Monforte
Page 1 of 2
2. Know Your Customer Questionnaire
Full name: María Graciela Monforte E-mail address: [email protected]
Date of birth: 03/24/1974 Nationality: USA Phone number: +1 7198226523
Information about your estimated activity

○ $0 – $10,000
Estimated amount of intended activity:
○ $10,000 – $25,000
The amount of money with which you intend
○ $25,000 – $50,000
to buy Virtual Currency from Coinmama in
○ $50,000 – $100,000
the upcoming 12 months (in USD).
○ above $100,000
○✔Holding cryptocurrency
○ Investing for profits with an account manager/broker/third
party (specify which): ____________________________________
Purpose of buying Virtual Currency:
○ Short-term trading on digital exchange(s) (specify which):
The reason you buy Virtual Currency; how
✔
______________________________________________________
binance and bitmex
you intend to use the Virtual Currency
○ Online gambling
purchased from Coinmama.
○ Investing in an ICO (specify which): ________________________
○ Buying goods (please specify): ____________________________
○ Other (specify): ________________________________________
○✔ Work salary
○ Inheritance
Source of the funds with which you
○✔ Private savings
intend to buy Virtual currency:
○ Loan (granted by: ______________________________________)
How you obtained the money with which you
○✔ Profits on investments in stock markets or Virtual Currency
plan to buy Virtual Currency from Coinmama.
○ Given by a third-party to make purchases on their behalf
○ Other (specify): ________________________________________
Information about your line of business and income
○ Employee ○ Self-employed ○ Student
Employment status ○ Homemaker ○ Unemployed ○ Soldier
○ Retired ○ Other (specify): ___________________________
Monthly income (your monthly income in US ○ $0 – $2,000 ○ $2,000 – $5,000

dollars) ○ $5,000 – $10,000 ○ above $10,000
Profession and job title or position (e.g. legal secretary, taxi driver,
bank clerk, software engineer - IT manager, accountant - CFO, etc.)
Field of activity of employing company or own business (e.g.
law firm, insurance company, telecommunication company etc.)
Name of employing company or own business (e.g. Coinmama)
URL to the website of employing company or own business
(e.g. www.coinmama.com) [where applicable]
I certify that the information provided in this questionnaire is true and complete. I understand that the
provider of currency services will rely on the provided information. I also understand that any provision
of false information and/or wilful or negligent provision of inaccurate information may constitute the
termination of our relationship.
I authorize the provider of currency services to make inquiries it may deem necessary or appropriate in
order to determine suitability for a business relationship. I undertake to actively inform the provider of
currency services, in writing, as soon as possible, of any change in the details noted above, as well as to
complete and sign a renewed questionnaire in the event of such changes.
Date: ________________
01/04/2023 Signature: _____________________
María Graciela Monforte
Page 2 of 2

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Celeb Format

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Dear customer,

1. Service Applicant Declaration Form

Your full name – including any middle name(s)

Your Identification Document – must be valid (preferably, an international passport)

Your complete address of residence

hereby declare that: [mark your choice]

○ A. I wish to receive the currency conversion service for myself only.

○ B. I wish to receive the currency conversion service on behalf of another person/corporation:

Information about your estimated activity

Monthly income (your monthly income in US ○ $0 – $2,000 ○ $2,000 – $5,000

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