ORDER FORM FOR OFFSHORE COMPANY FORMATION
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- Preston Barnett
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1 Ntice: We are cllecting the infrmatin n this frm fr the purpse f administering yur accunt and prviding the services which yu are requesting. This infrmatin will be retained and used fr thse purpses and may be passed t anther party t achieve these gals. If yu agree, we may elect t use this infrmatin t infrm yu f specific prducts and/r services that we r ur assciates prvide based n the prbable relevance t yur needs if yu check this bx. I agree. (G t t read ur plicy in full.) Cmpletin f this frm is necessary t facilitate Hilda Le Assciates in perfrming the service(s) yu require. Once signed, this frm becmes a legally binding cntract, fr this reasn, Hilda Le Assciates s Terms and Cnditins shuld be reviewed first. Please (ps@hildale.cm) r fax cmpleted frm t (SIN) *Hilda Le Assciates reserves the right nt t nbard ptential clients that d nt prvide us with the dcuments r infrmatin necessary fr cmpliance duties with regards t this rder frm. ORDER FORM FOR OFFSHORE COMPANY FORMATION Part A: Cmpany Infrmatin & Services Required * In which jurisdictin wuld yu like t incrprate yur ffshre cmpany? (Select ne) 1. Anguilla British Virgin Islands Ck Islands Delaware LLC Marshall Islands Sama Others Belize Delaware Crpratin Seychelles 2 Prpsed Cmpany Name (Name must end with Limited, Ltd., Inc. r Crpratin) a. b. c. Page1
2 3. Name & shrt descriptin f business activities:- (Please d nt indicate just Trading, be specific e.g.: Trading f Textiles) 4. Gegraphical Area f Operatin 5a. Lcatin where Accunting Recrds are kept. (Please indicate full address) 5b. Lcatin where Original Register f Members & Directrs are kept. (Please indicate full address) 6. D yu need HLA t prvide Nminee Directr and/r Cmpany Secretary fr the prpsed Cmpany? YES as Directr Natural Persnal frm Singapre (SGD 750/USD 575 per year) YES as Directr - BVI Bdy Crprate (SGD 500/USD 375 per year) YES as Directr Hng Kng Bdy Crprate (SGD 650/USD 485 per year) YES as Directr - Singapre Bdy Crprate (SGD 650/USD 485 per year) T issue Pwer f Attrney t (SGD 175/USD 130, witnessed by Singapre Lawyer) NO, please use my directr inf as indicated at Part B. YES as Cmpany Secretary - BVI Bdy Crprate (SGD 450/USD 350 per year) NO, please use my directr inf as indicated fr Cmpany Secretary as well Authrized Capital (indicate currency): at $1.00 par value per share. - Ttal Number f Shares: If left blank we will base n the standard amunt fr the jurisdictin invlved. Page2
3 8. D yu need HLA t prvide Nminee Sharehlder fr the prpsed Cmpany? YES as Sharehlder Natural Persnal frm Singapre (SGD 750/USD 575 per year), and t allt shares YES as Sharehlder - BVI Bdy Crprate (SGD 500/USD 375 per year), and t allt shares YES as Sharehlder Hng Kng Bdy Crprate (SGD 650/USD 485 per year), and t allt shares T issue Declaratin f Trust witnessed by Staff (SGD 125/USD 100 per Sharehlder) T issue Declaratin f Trust witnessed by Singapre Lawyer (SGD 175/USD 130 per Sharehlder) NO, please use my Sharehlder inf as indicated at Part B 9. Bank Accunt Opening SGD 975/USD 750 per accunt. Nte visit t Singapre r Hng Kng is required fr Singapre and Hng Kng banks) Available Banks: Asia Banks: OCBC Bank Singapre DBS Bank Singapre HSBC Singapre MayBank, Singapre Citibank Singapre Island Banks ABC Bank Mauritius Capital Security Bank Ck Islands Eur Pacific St. Vincent & Grenadines CIBC First Caribbean Internatinal BVI Central America Banks Belize Bank Int l Eurpean Bank C I M Banque Switzerland Chice Bank Belize Part B: Persnal Infrmatin Nminatr & Sharehlder 1 Infrmatin (Individual r Crprate) 1. Are yu acting as a Nminatr wh signs ur Nminee Agreement, nminates & instructs the appinted Nminee Directr? Yes N Are yu als acting as a directr? Yes If yes, yu can skip Directr infrmatin sectin n page 6. N 2. Number f shares t be alltted Page3
4 3. Full Name (As per passprt r Certificate f Incrpratin if crprate sharehlder) 4. Date & Place f Birth r Incrpratin (Please indicate bth city and cuntry) Date (dd/mm/yyy) City Cuntry 5. Natinality 6. Passprt / ID number r Cmpany Number 7. Residence Address r Registered Address 8. Cuntry f Dmicile (If multiple, please prvide all cuntries) 9. Cuntry, Name n ID & ID N. fr each cuntry f which yu are a citizen. 10. Telephne ID 11. D yu have an alternate address fr mailing r ther functins? Yes N If Yes, please prvide 12. Are yu a Plitically Expsed Persn (PEP) #? Yes N If Yes, please prvide details f the psitin held and assciatin Page4
5 # A Plitically Expsed Persn is smene wh, thrugh their prminent psitin r influence, nw, r in the past, is mre susceptible t being invlved in bribery r crruptin. In additin, any clse business assciate r family member f such a persn will als be deemed as being a risk, and therefre culd als be added t the PEP list. Fr mre infrmatin see: D yu have any pending r threatened claims r have yu ever been cnvicted f any crimes / fraud under a curt f law r under any investigatin f any nature r invlved in legal prceedings? Yes N If Yes, please prvide details 14. Are yu a United States (US) persn*? (as defined here fr US tax purpses) Yes N If Yes, Please prvide Duly signed Frm Affidavit (T be prvided separately) One f the fllwing (Please mark X) ITIN Number Visa number Green Card Number SSN 15. Surce f Wealth (SOW) Infrmatin Please tick all that apply: Surce f Wealth/ Incme Investment Incme Business Prceeds Dividend Incme Directr s Fees Emplyment Incme Pensin Scheme Agent s Cmmissin Intellectual Prperty Ryalties Lan Principal/Interest Lease Rents Insurance Savings Others (If any please state) Prperty Security Equity Others (If any please state) Inheritance & Gift Please furnish with supprt dcuments (E.g. Death Certificate) Page5
6 Nminatr & Sharehlder 2 Infrmatin (Individual r Crprate) 1. Are yu acting as a Nminatr that signs ur Nminee Agreement, nminates & instructs the appinted Nminee Directr? Yes N Are yu als acting as a directr? Yes If yes, yu can skip Directr infrmatin sectin n page 8. N 2. Number f shares t be alltted 3. Full Name (As per passprt r Certificate f Incrpratin if crprate sharehlder) 4. Date & Place f Birth r Incrpratin (Please indicate bth city and cuntry) Date (dd/mm/yyy) City Cuntry 5. Natinality 6. Passprt / ID number r Cmpany Number 7. Residence Address r Registered Address 8. Cuntry f Dmicile (If multiple, please prvide all cuntries) 9. Cuntry, Name n ID & ID N. fr each cuntry f which yu are a citizen. 10. Telephne ID Page6
7 11. D yu have an alternate address fr mailing r ther functins? Yes N If Yes, please prvide 12. Are yu a Plitically Expsed Persn (PEP) #? Yes N If Yes, please prvide details f the psitin held and assciatin # A Plitically Expsed Persn is smene wh, thrugh their prminent psitin r influence, nw, r in the past, is mre susceptible t being invlved in bribery r crruptin. In additin, any clse business assciate r family member f such a persn will als be deemed as being a risk, and therefre culd als be added t the PEP list. Fr mre infrmatin see: D yu have any pending r threatened claims r have yu ever been cnvicted f any crimes / fraud under a curt f law r under any investigatin f any nature r invlved in legal prceedings? Yes N If Yes, please prvide details 14. Are yu a United States (US) persn*? (as defined here fr US tax purpses)? Yes N If Yes, Please prvide Duly signed Frm Affidavit (T be prvided separately) One f the fllwing (Please check ) ITIN Number Visa number Green Card Number SSN Page7
8 15. Surce f Wealth (SOW) Infrmatin Please tick all that apply Surce f Wealth/ Incme Investment Incme Business Prceeds Dividend Incme Directr s Fees Emplyment Incme Pensin Scheme Agent s Cmmissin Intellectual Prperty Ryalties Lan Principal/Interest Lease Rents Insurance Savings Others (If any please state) Prperty Security Equity Others (If any please state) Inheritance & Gift Please furnish with supprt dcuments (E.g. Death Certificate) Directr 1 Infrmatin 1. Full Name (As per passprt r Certificate f Incrpratin if crprate directr) 2. Date & Place f Birth r Incrpratin (Please indicate bth city and cuntry) Date (dd/mm/yyy) City Cuntry 3. Natinality 4. Residence Address r Registered Address 5. Cuntry f Dmicile (If multiple, please prvide all cuntries) 6. Cuntry, Name n ID & ID N. fr each cuntry f which yu are a citizen. Page8
9 7. Telephne ID 8. D yu have an alternate address fr mailing r ther functins? Yes N If Yes, please prvide 9. Passprt / ID number r Cmpany number 10. Are yu a Plitically Expsed Persn (PEP)#? Yes N If Yes, please prvide details f the psitin held and assciatin # A Plitically Expsed Persn is smene wh, thrugh their prminent psitin r influence, nw, r in the past, is mre susceptible t being invlved in bribery r crruptin. In additin, any clse business assciate r family member f such a persn will als be deemed as being a risk, and therefre culd als be added t the PEP list. Fr mre infrmatin see: D yu have any pending r threatened claims r have yu ever been cnvicted f any crimes / fraud under a curt f law r under any investigatin f any nature r invlved in legal prceedings? Yes N If Yes, please prvide details Page9
10 12. Are yu a United States (US) persn*? (as defined fr US tax purpses) Yes N If Yes, Please prvide Duly signed Frm Affidavit (T be prvided separately) One f the fllwing (Please check ) ITIN Number Visa number Green Card Number SSN Directr 2 Infrmatin 1. Full Name (As per passprt r Certificate f Incrpratin if crprate directr) 2. Date & Place f Birth r Incrpratin (Please indicate bth city and cuntry) Date (dd/mm/yyy) City Cuntry 3. Natinality 4. Residence Address r Registered Address 5. Cuntry f Dmicile (If multiple, please prvide all cuntries) 6. Cuntry, Name n ID & ID N. fr each cuntry f which yu are a citizen. 7. Telephne ID Page10
11 8. D yu have an alternate address fr mailing r ther functins? Yes N If Yes, please prvide: 9. Passprt / ID number r Cmpany Number 10. Are yu a Plitically Expsed Persn (PEP) #? Yes N If Yes, please prvide details f the psitin held and assciatin # A Plitically Expsed Persn is smene wh, thrugh their prminent psitin r influence, nw, r in the past, is mre susceptible t being invlved in bribery r crruptin. In additin, any clse business assciate r family member f such a persn will als be deemed as being a risk, and therefre culd als be added t the PEP list. Fr mre infrmatin see: D yu have any pending r threatened claims r have yu ever been cnvicted f any crimes / fraud under a curt f law r under any investigatin f any nature r invlved in legal prceedings? Yes N If Yes, please prvide details 12. Are yu a United States (US) persn*? (as defined fr US tax purpses)? Yes N If Yes, Please prvide Duly signed Frm Affidavit (T be prvided separately) One f the fllwing (Please check ) ITIN Number Visa number Green Card Number SSN Page11
12 Part C: Ultimate Beneficial Owner Infrmatin (MUST BE A NATURAL PERSON) *This sectin must be cmpleted if yu are neither the Sharehlder nr Directr listed at Part B, abve.* 1. Full Name (As per passprt) 2. Date & Place f Birth (Please indicate bth city and cuntry) Date (dd/mm/yyy) City Cuntry 3. Natinality 4. Passprt / ID number 5. Residence Address 6. Cuntry f Dmicile (If multiple, please prvide all cuntries) 7. Cuntry, Name n ID & ID N. fr each cuntry f which yu are a citizen. 8. Telephne ID 9. D yu have an alternate address fr mailing r ther functins? Yes N If Yes, please prvide 10. Are yu a Plitically Expsed Persn (PEP) #? Yes N Page12
13 If Yes, please prvide details f the psitin(s) held and assciatin(s) # A Plitically Expsed Persn is smene wh, thrugh their prminent psitin r influence, nw, r in the past, is mre susceptible t being invlved in bribery r crruptin. In additin, any clse business assciate r family member f such a persn will als be deemed as being a risk, and therefre culd als be added t the PEP list. Fr mre infrmatin see: D yu have any pending r threatened claims r have yu ever been cnvicted f any crimes / fraud under a curt f law r under any investigatin f any nature r invlved in legal prceedings? Yes N If Yes, please prvide details 12. Are yu a United States (US) persn*? (as defined here fr US tax purpses)? Yes N If Yes, Please prvide Duly signed Frm Affidavit (T be prvided separately) One f the fllwing (Please mark X) ITIN Number Visa number Green Card Number SSN Page13
14 13. Surce f Wealth (SOW) Infrmatin Please tick all that apply: Surce f Wealth/ Incme Investment Incme Business Prceeds Dividend Incme Directr s Fees Emplyment Incme Pensin Scheme Agent s Cmmissin Intellectual Prperty Ryalties Lan Principal/Interest Lease Rents Insurance Savings Others (If any please state) Prperty Security Equity Others (If any please state) Inheritance & Gift Please furnish with supprt dcuments(e.g. Death Certificate) Part D: Declaratin 1. I/We (hereinafter the Client) cnfirm that the Client has been infrmed that the structure that the Client is setting up culd be reprtable and taxable in the cuntry f residency/citizenship, and therefre the Client shuld btain apprpriate legal and tax advice in the hme jurisdictin and all ther relevant jurisdictins. The Client hereby declares that the Client will fllw the advice received and cmply with the reprting bligatins if any. 2. In the event that Hilda Le Assciates Pte. Ltd. (HLA), as service prvider, is at any time under the legal bligatin t any applicable gvernmental authrity, directly r indirectly t reprt the structure r becmes tax liable tgether with me in relatin t the assets held in the structure, HLA may be bligated t enquire r ensure that the Client has sught r implemented any such tax and/r legal advice and that the Client will reprt all relevant infrmatin t the Tax Authrities. In the event f such reprting, the Client shall hld HLA harmless fr any damages r actins resulting frm such reprting. 3. The Client cnfirm that nne f the assets prpsed t transfer t the Structure has been derived frm r relate t any f the Designated Categries f Offences (see 5 belw). Page14
15 4. The Client and the undersigned, cnfirm that the services requested are nt used fr illegal purpses and hereby cnsent t act as nminatr and/r directr and/r principal cntact f the Cmpany. Where the infrmatin prvided in Part A t B is changed frm any time hereafter, the Client and the undersigned agree t infrm Hilda Le Assciates Pte. Ltd. immediately. The Client and undersigned hereby cnfirm and declare that all details prvided abve are true and crrect t the best f their knwledge. Name Signature Date Place Cntact Number 5. Designed Categries f Offences List f Designated Categries f Offences as per Frty Recmmendatins n Mney Laundering prepared by the Financial Actin Task Frce (FATF). Participatin in an rganized criminal grup and racketeering. Terrrism, including terrrist funding. Human trafficking and migrant smuggling r sexual explitatin, including that f children. Illicit trafficking f narctics and psychtrpic substances, arms r stlen gds. Bribery and crruptin. Fraud, cunterfeiting currency and the cunterfeiting r piracy f prducts. Envirnmental Crime. Murder and Grievus bdily injury. Kidnapping, illegal restraint and hstage-taking. Theft, rbbery r smuggling (including thse related t custm excise duties and taxes) Tax crimes (Related t direct taxes and indirect taxes) Extrtin, frgery r piracy. Insider training an market manipulatin. Please ensure the fllwing dcuments are attached r have already been sent t Hilda Le Assciates: Scanned cpy f identificatin in the frm f a passprt r natinal ID fr each nminatr, directr, sharehlder & ultimate beneficial wner OR a cpy f the Certificate f Incrpratin & Certificate f Incumbency r similar fr Crprate Sharehlders/Nminatr. Scanned cpy f utility bill r credit card/bank statement as prf f current address fr each nminatr, directr. sharehlder & ultimate beneficical wner. Payment fr incrpratin, nminee services and bank accunt pening (if applicable). Thank yu fr chsing Hilda Le Assciates Pte Ltd Page15
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