FM-D01 Corporate DD Declaration 2015 01 08

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Transcript of FM-D01 Corporate DD Declaration 2015 01 08

Please complete this form to the fullest extent possible. Guidance notes on how to complete the sections are attached for your reference.PART I GENERAL INFORMATION1. Full Registered Name:Gulfstream Asia Pacific Incorporated2. Trading and /Former Name(s) or any alias:N/A3.Full Registered Address including postal code:Please do not use PO Box AddressUnit B, 15th Floor, ACT Tower, H.V. de la Costa Street, Salcedo Village, Makati City 12094.Full Principal Business / Trading Address (if different from 3 above):Click here to enter text.5. Telephone number(s):632-8932344

6.Website and / or email address: [email protected]

7. Date of Incorporation (DD/MM/YYYY): 16/05/2014 8. Place of Incorporation:Philippines9. Registered Number: CS201409459

10.Business Activities:buying and holding shares of other companies as a holding companyPART II PRINCIPALS AND MANAGEMENT11.Names of all current Directors and Officers:Please state position held1. Teresa Tam-Yap 2.Terese Samantha Yap3.Terese Melissa Yap 4.Eliza Iso Martinez 5. Artemia Tolabing Sibala 6. Click here to enter text. 12.Names of all shareholders holding 25% or more of the issued share capital of the CompanyPlease state percentage holding1. Teresa Tam-Yap 99.995% 2. Click here to enter text.3. 4.

13.Regarding shares held by nominees, companies, in trust, or in bearer form please name each ultimate beneficial owner and percentage ownership: -1. 2. 3. 4. Click here to enter text.14.Is the Company capable of issuing bearer shares (please tick):Yes|_|No |_|15. Please name all individuals who have the authority to operate an account or give instructions concerning the use or transfer of assets (if not already named in the sections above):1. Teresa Tam-Yap 2.Terese Samantha Yap3. Click here to enter text. 4. Click here to enter text.PART III TAX RESIDENCY16. Country of Tax Residence: Philippines17. Organisations Taxpayer Identification Number (TIN) or Tax Reference Number:008-778-03418.If the organisation is not a US Specified Person please tick this box:|_|Please refer to guidance notes attached

PART IV REFERENCES19.Please complete the attached template letters.PART IV SUPPORTING DOCUMENTATIONPlease enclose the following documentation with this form: -

DocumentAttached (tick)1. Certificate of Incorporation or Good Standing |_|2. Latest annual accounts |_|3. Register of shareholders |_|4. Proof of ID and address in respect of all current directors, officers and authorised signatories of the company |_|5. Proof of ID and address in respect of all shareholders owning more than 25% of the issued share capital of the company |_|6. Completed W8-BENE form (entities not resident for tax purposes in the United States only) |_|7. Bearer shares declaration (companies capable of issuing bearer shares) |_|

PART V - DECLARATIONSBLENHEIM FIDUCIARY GROUP LIMITED (BFGL)CORPORATE DUE DILIGENCE DECLARATION

Blenheim Fiduciary Group Limited is licensed as a fiduciary by the Guernsey Financial Services CommissionPage 1 of 6

I/We hereby declare that the information provided herein and herewith may be held, processed and retained by BFGL and its associated, parent and subsidiary companies, and their assigns (collectively or severally Blenheim) for the purposes of complying with anti-money laundering laws and regulations. I/We further declare that the information/documentation may be disclosed or provided to financial institutions, banks, investment houses and others for the purposes of satisfying their verification and due diligence requirements.I/We hereby declare that the source of funds and other assets placed in any entity serviced, administered or managed by Blenheim results from the activities listed under Part I(10) above and that the transferors have full and unencumbered legal right and title to those funds and assets immediately prior to their transfer to any such entity.I/We hereby declare that the Company is not involved in and has not been involved in, nor do any of its assets, net worth, income nor activities relate to, any criminal act, activity or event including (but not limited to) armaments, illegal drugs or controlled substances, prostitution, bribery, corruption or money laundering.I/We hereby declare that the Company continues to be validly incorporated and is not insolvent.I/We hereby declare that neither the Company nor its directors have been nor are presently the subject of any court action, legal proceedings or dispute of any nature whatsoever, whether civil or criminal, which has been taken, is being taken or (to the best of my knowledge) is about to be taken against us.I/We hereby declare that the Company will not: a) hinder, delay or defraud any creditors; b) engage in any illegal or criminal conduct; nor c) supply, trade in or move goods or services in contravention of international sanctions or import/export controls in Guernsey or in other applicable countries. Furthermore, I/We declare that neither Blenheim nor any entities serviced, administered and/or managed by Blenheim will be sought or retained to assist, facilitate or engage in any illegal or criminal act, activities, trade or conduct nor will they be sought or retained to undertake licensed, regulated or restricted activities without proper authority or valid licence.I/We hereby declare that the Company, its directors and officers comply with applicable anti-bribery and corruption legislation including (but not limited to) the Prevention of Corruption (Bailiwick of Guernsey) Law, 2003, as amended, the UK Bribery Act, 2010, as amended and The Foreign Corrupt Practices Act, 1977, as amended. By accepting or benefiting from Blenheims services, I/We undertake not to render, procure or benefit from any improper advantage whatsoever.I/We hereby declare and undertake to advise Blenheim within 30 days of any changes to the information contained herein and agree to provide such further documentation as may be required by Blenheim as a result of said change(s). I/We hereby agree expressly, specifically and without qualification to hold harmless and indemnify Blenheim, their officers and employees, and all other entities and individuals that engage in any transaction in reliance on any fact or statement contained in this Declaration from any liability of any kind with respect to any fact or statement contained in this declaration which is false, untrue or inaccurate in any manner.

For and on behalf of:

Entity Name:

________________________________________ Date: ______________________________________Print Name:Duly Authorised Officer:

To expedite matters, in the first instance, you may wish to e-mail or fax this form and its attachments to us, but in any event, we will require that the hard copy originals be sent to us either by courier or normal post to:

Second Floor, St. Peters House, Le Bordage, St. Peter Port, Guernsey, GY1 1BRE-mail: [email protected] +44 (0)1481 724 116

Date: Click here to enter a date.Bank Name: Address:Fax Number: For the attention of:

Dear Sirs,Account Number:

I hereby authorise you to provide Blenheim Trust Company Limited, Blenheim Management Services Limited or Barrington Trust Company Limited with a reference regarding the following:

Confirming the Companys name and address,Confirming that the Company holds an account with yourselves and the length of time that we have done so,Attesting to our character and trustworthiness, andAttesting that to the best of your belief we have not been, nor are we presently the subject of any court action or legal proceedings.Yours faithfully,For and on behalf of (Company)

Signed __________________________

Print Name: Duly Authorised Officer

Date: Click here to enter a date.Accountant/Lawyer Name:

Name of Firm/Practice Address:

Fax Number

For the attention of:

Dear Sirs,I hereby authorise you to provide Blenheim Trust Company Limited, Blenheim Management Services Limited or Barrington Trust Company Limited with a reference regarding the following:Confirming the Companys name and address,Confirming the length of time that you have known the Company,Attesting to our character and trustworthiness, andAttesting that to the best of your belief we have not been, nor are we presently the subject of any court action or legal proceedings.Yours faithfully,For and on behalf of (Company)

Signed __________________________

Print Name: Duly Authorised Officer