Bank of Cyprus Public Company Ltd.

International Banking, Wealth & Markets

New Account Questionnaire – Personal Account

The purpose of this questionnaire is to provide all necessary information that will enable the Bank to evaluate and approve your request.

1A. APPLICANT’S GENERAL INFORMATION

Personal Account Joint Personal Account (If Joint Personal Account, please complete a separate form for each Individual)

Title: Mr Mrs Ms Dr

Full Name: Maksim Lebedev

(as it appears on the passport or identification card)

Father’s name: Alex

Mother’s name: Natalia

Date of birth: 15.01.1999 Nationality: Russian

City & country of birth: Moscow Russia

Family status: Single Married Widow Divorced

Is Applicant a Trustee? YES NO

Name of Trust: Trust Registration Country:

CY Trust Registration Number: CY Trust Registration Date:

Identification details

Passport

Number: 751350288 Expiry date (dd/mm/yy):
07.05.2025 Country of issue: Russia

Number: Expiry date (dd/mm/yy): Country of issue:

Identity Card

Number: ARC 0581914669 Expiry date (dd/mm/yy): Country of issue: Cyprus

Number: Expiry date (dd/mm/yy): Country of issue:

Residential Address

Number & street: Demetriou Tsamkirani 21D, Engomi, Nicosia

Postal code: 2416 Town:

Nicosia Country: Cyprus

Correspondence Address

Residential address Other (please specify and complete below)

Number & street:

Postal code: Town: Country:

Contact Details

Home telephone no.: Work telephone no.:

97898928
Mobile telephone no.: Fax no.:

[email protected]
Email address: Skype id:
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Bank of Cyprus Public Company Ltd. International Banking, Wealth & Markets

1B. SELF - CERTIFICATION

Pursuant to the Agreements for the automatic exchange of information which were concluded and/or will be concluded between the
Republic of Cyprus and other countries for tax matters and the relevant legislation (including those relating to the Foreign Account
Tax Compliance Act - FATCA and the Common Reporting Standard - CRS), Bank of Cyprus (‘the Bank’) is required to identify account
holders that are tax residents in foreign jurisdictions (for purposes of CRS) and are US Persons (that is US citizens or tax residents)
(for purposes of FATCA) and report all related information to the Tax Department in Cyprus which in turn will report this information
to Tax Departments of the foreign jurisdictions and/or to the IRS of the United States. As a Bank, we therefore request you to com-
plete this Self-Certification Form. Further information on FATCA and CRS may be found on the websites of the Bank of Cyprus at
www.bankofcyprus.com, the Association of Cyprus Banks at www.acb.com.cy the U.S. IRS at www.irs.gov/fatca and the OECD at
http://www.oecd.org/tax/automatic-exchange

Are you a US Citizen / Resident for tax purposes? YES NO

Please report all countries in which you are tax resident

Country of Tax Residence Taxpayer Identification Number (TIN) or Functional Equivalent * If no TIN available enter
Reason A, B or C **
Type of Document Number

* A high integrity number with an equivalent level of identification as a TIN. E.g. Social Security Number, personal ID number.
** Complete only for CRS countries - If a TIN is not availabale, please provide the appropriate reason A, B or C.
Reason A - The Country where the Account Holder is a tax resident does not issue TINs to its residents.
Reason B - The Account Holder is otherwise unable to obtain a TIN (please explain):

B. I was just relocated to Cyprus, have not received my Cyprus TIN yet
Reason C - No TIN is required (Note: Please select this reason only where the domestic law of the relevant authorities of the country of tax residence
entered above, does not require the collection of the TIN issued by such country of tax residence to be disclosed).

2. FINANCIAL INFORMATION
Occupation: Financial

Employer’s name: Renaissance Securities (Cyprus) Limited

Employer’s Address

Number & street: Capital Center 9th Floor 2-4 Arch. Makarios 3 Ave

Postal code: 1065 Town:

Nicosia Country: Cyprus

Value of Assets:

Expected Annual Dr turnover on account (equivalent in €):

Current Year Amount in €

2022 7000
Expected Annual Cr turnover on account (equivalent in €):

Current Year Amount in €

2023 40 000

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Bank of Cyprus Public Company Ltd. International Banking, Wealth & Markets

Source / Value of Income:

Type Description Amount

Salary 40 000
Pension / Allowance

Rent

Interest

Dividents

Minor Savings

Student Allowance

Source / Value of Wealth:

Type Description Amount

Immovable Property

Movable Property

Shares

Bonds

Deposits

Other

Purpose/reason of application for opening the account: i.e deposits/savings, commercial payments, card facilities, credit facilities, other
(please specify)

Deposits, savings

Nature of the transactions to be performed: i.e transfers, inward payments, outward payments, cheque deposits, cash deposits, use of
cards, proceeds of credit facilities, letters of credit, other (please specify)

use of cards

Expected origin of incoming funds:

Name of orderor Address Website of orderor Country of Business activities

orderor’s bank of orderor

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Bank of Cyprus Public Company Ltd. International Banking, Wealth & Markets

Expected destination of outgoing payments:

Name of beneficiary Address Website of beneficiary Country of Business activities

beneficiary’s bank of beneficiary

3. OTHER INFORMATION
Indication for Politically Exposed Person (PEP):

Please specify whether the applicant (yourself) /any immediate family member / associate hold/held a prominent public function the last
12 months:

None Applicant Close Relative Close Associate

Name of the person that holds / held the prominent public function:

Position: Country of the position held:

Period in which this individual holds / held political / public function:

From: To:

4. REQUESTED BANKING SERVICES

Sight / current account EUR

Currency Trading Account Currency

Fixed Deposit account Currency Debit card EUR

Currency

Internet banking

Treasury Sales Products - Dealing Room Services

Other

5. WEALTH MANAGEMENT SERVICES

For your information, the Bank offers Wealth Management and Global Brokerage services. If you are interested in these services, please
let us know if you would iike a qualified person from our team to contact you and provide further information.

Please tick here if you are interested

Please make sure that you enclose the following documents and information and tick the boxes accordingly:
Legible certified true copy of passport(s) (Inclusive of photograph, signature and expiry date)

Bank reference (not older than 6 months)

Proof of residential address, e.g. utility bill (not older than 6 months)

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