FORM DECLARATION OF ORIGIN OF ASSETS FOR INDIVIDUALS

FORM OF DECLARATION OF ORIGIN OF ASSETS FOR INDIVIDUALS

Declaration of Origin of Assets Form for Individuals

Complete this form to declare the origin of your financial assets.

PLEASE COMPLETE AND SEND

GENERAL DATA PHYSICAL PERSON *

DATE OF BIRTH *

DOCUMENT TYPE *

• IDENTIFICATION CARD
• PASSPORT
• ID
• OTHER

NATIONALITY *

EXPEDITION DATE

ADDRESS *

AREA AND POSITION

PROFESSION / JOB / OCCUPATION

ESTADO CIVIL *

• SINGLE
• MARRIED
• WIDOWER
• FREE UNION

CELLPHONE NUMBER *

SURNAMES *

PLACE OF BIRTH

NUMBER *

EXPEDITION PLACE

SECTOR *

WORK COMPANY *

CITY AND COMPANY SECTOR

COMPANY ADDRESS

PHONE NUMBER

SPOUSE OR PARTNER INFORMATION

PLACE OF BIRTH

DOCUMENT NUMBER

SURNAMES

DOCUMENT TYPE

• IDENTIFICATION CARD
• PASSPORT
• ID
• OTHER

POLITICALLY EXPOSED PERSON (PEP)

In accordance with the provisions of numeral 19 of article 2 of Law 155/17, politically exposed persons (PEP) are those officials obliged to present their sworn declaration of assets in accordance with article 2 of Law 311-14 on sworn declaration of heritage, and when they identify themselves as high-risk people, their spouses, partners and other people with whom a PEP is related by consanguinity or affinity up to the second degree.

Are you or were you a government employee? *

• YES
• NO

Does he exercise any degree of political power? *

• YES
• NO

Do you enjoy public recognition? *

• YES
• NO

Is there any family link with a PEP? *

• YES
• NO

Are you a PEP? *

• YES
• NO

ACTUAL CHARGE

PREVIOUS POSITION

DATE

DATES

I *

ID NUMBER *

acting voluntarily in my own name, I certify that everything stated is true, I declare that both my activities and my profession and/or trade are lawful, I exercise them within a legal framework and the resources I have do not come from illegal activities, nor are they destined to finance terrorism, nor do they violate those established by the penal code or the Laws of the Dominican Republic. I know, declare and accept that the DREAMHOME REAL ESTATE offices and their Agents are under the legal obligation to request the clarifications they deem appropriate, and that, in the event that circumstances arise based on which the Financial Analysis Unit (UAF) ), I may have reasonable doubts about my operations, as well as the origin of my assets, I will provide the clarifications of place. The origin of the funds for this operation is: *

I authorize the UAF and the entity in charge of the Supervision of Non-Financial Reporting Entities to corroborate the information provided here and to obtain and request any additional information. *

MY SIGNATURE

EMAIL *

Website

SEND

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