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DOMESTIC MONEY LAUNDERING DECLARATION

(FS{ML}2003/Dex35-B)
This form is to be completed prior to any S.W.I.F.T transfer for sums greater than £2,000 between any indirect
counterparties between whom no prior relationship exists. This document is pursuant to the Financial Services (Money
Laundering) Regulations 2003, Part II, Section5. The deliberate giving of false information is a criminal offence which may
result in a fine not exceeding £20,000, 3 years imprisonment or both.

Recipient Name
Address

City
County
Postcode

Bank
Sort Code Account Number

How long have you had this


bank account? (years) (months)

FOR COMMERCIAL ACCOUNTS


Business Name
Business Address

City
County
Postcode
Telephone Fax
Type of business
How long has the business
existed (years) (months)
Annual Turnover (£)
Incorporation No.

Have you ever been: Arrested, convicted or charged with any criminal offence? Yes No
Arrested, convicted or charged in respect of fraud/financial malfeasance? Yes No
Arrested or convicted for any terrorist offences? Yes No
Arrested or convicted for any drugs offences? Yes No
A member of any terrorist or illegal group? Yes No
A member of any outlawed political party? Yes No
Convicted or incited on any war crimes offence? Yes No
Wanted for any offences by a foreign country? Yes No

I warrant that the information I


have given in this declaration is
true To the best of my
knowledge and belief (Signed) (date [dd/mm/yy])

FOR OFFICIAL USE ONLY Xe N Y N1


Account verification check conducted
Police record check conducted
Customs and excise check conducted
HAMSTER system cleared

© Bank of England Monetary Oversight Committee 2007 Form DEX-35-B Print and Design by DeLaRue Financial Printers, Cardiff, Wales.