Application Form - IOMA - Isle of Man Assurance complete wealth ...

Application Form
iomagroup

Application Form
Separate application forms must be fully completed by each trust settlor / company
beneficial owner. Any trust protector or third party authorized signatory must also
complete Sections A, B and L on a separate application form and provide the
documentary evidence specified in Section I.
A. Personal details
Full name
Any other names used and
reason for use
Current residential address
Correspondence address
(if different from the above)
Any previous residential addresses
during the last seven years
Telephone
Facsimile
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E mail
Date of birth
Passport number and issuer
Nationality
Country of birth
Country of residence
Occupation/profession
Nature and location of business
activities
Names of business partners
Do you or any member of your immediate family or any close associate
(currently or in the past):
• hold a political or high profile public position?
• have involvement in government or public contracts?
B. Your background
Membership of professional bodies:
Name of bodies corporate and jurisdictions of which you are:
(a) An officer
(b) A beneficial owner
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Have you at any time been convicted of any offence? If so, give full particulars
of the court by which you were convicted, the offence, penalty imposed and the
date of conviction.
Have you ever been disciplined by any court or professional body or
association to which you have belonged or do belong or been the subject of a
regulatory order or been refused or had revoked a license to practice law,
accounting or other profession or deal in securities? If so explain the
circumstances thereof.
Have you ever been adjudicated bankrupt by a court?
Have you failed to satisfy any debt adjudged due and payable by you as a
judgement debtor under an order of court?
Have you in connection with the formation or management of any body
corporate partnership or un-incorporated institution been adjudged by a court
civilly liable for any fraud misfeasance or other misconduct by you towards
such a body or company or towards any members thereof? If so, give full
particular.
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Has any body corporate, partnership or un-incorporated institution with which
you have been associated been compulsorily wound up or made an
arrangement with its creditors or ceased trading in circumstances where its
creditors did not receive or have not received full settlement of their claims,
either while you were associated with it or within one year thereof? If so, give
full particulars.
C. Professional advice and advisor
Where you have taken advice from a professional advisor, please provide a
copy of the advice received and details of the advisor.
Name
Institution
Address
Telephone
Facsimile
Email
D. Assets to be introduced
Please advise the nature of assets to be introduced (e.g. cash, securities,
property).
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Please advise the source of assets to be introduced (e.g. bank name and address
regarding cash transfers, or broker name and address regarding investments).
Please provide detailed information on the source of wealth, i.e. the manner in
which these assets were accumulated (e.g. through savings, inheritance, family
wealth or investment trading).
Documentary evidence may be requested to support the source of wealth and
souce of funds.
E. Initial details on formation of a trust
Proposed trust name
Purpose of forming trust
Detailed description of proposed activities
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Initial settled assets
Settlor name
Address
Protector name
(if required)
Address
Beneficiary name
Address
Date and place of birth
Relationship to settlor
Beneficiary name
Address
Date and place of birth
Relationship to settlor
If more than two beneficiaries, please provide details on a separate sheet.
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F. Initial details on formation of a company
Jurisdiction of incorporation
Proposed company name
Purpose of forming company
Detailed description of proposed activities
Geographical location of activities
Estimated annual turnover
Estimated annual volume of
transactions
Anticipated geographical origin of
receipts
Anticipated geographical destination
of payments
Your relevant experience of the proposed business to be carried out
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Investment
If the proposed activities includes investment holding please advise your
preference regarding the:
Initial investment policy
(eg capital growth, income, balance
of both or other)
Initial investment profile
(eg type of investments and
geographical spread)
Investment adviser
Level of risk
(eg high/moderate/low)
Tax
Do you wish the company to register:
(a) As resident in the Isle of Man, or
(b) As tax exempt
(c) For Value Added Tax
YES/NO
YES/NO
YES/NO
Ownership
Nominee Declarations will be issued to the person named at A. above. If there
is more than one beneficial owner please state:
Name
% of ownership
Should we accept joint or individual instructions?
G. Facsimile and email authority & indemnity
Please complete the Facsimile and Email Authority & Indemnity at Appendix 1
in order that we can communicate with you by facsimile and email.
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H. Third party authorized signatory
Should you require that we act on instructions from a third party, please
provide the following details of the person so authorized by you to deal with
the affairs of your entity. Unless otherwise instructed, this general authority
will relate to ALL aspects of management and administration.
(See I below regarding documentary evidence required.)
Name
Address
Telephone
Facsimile
Email
I. Documentary evidence
If any of the parties to this application are corporate entities or trusts, please
refer to Isle of Man Financial Trust for documentary evidence requirements.
All parties to the application (e.g. trust settlor/trust protector/trust beneficiary
over 18 years/company beneficial owner/third party authorized signatory)
must provide:
(i)
(ii)
(iii)
Two certified copies of current valid ‘full’ passport, driving
licence or government issued national identity card which
display both the photograph and signature
Two original recent utility invoices or bank statements
confirming the residential address given
Two professional references. A referee may also give
confirmation of the residential address in place of the documents
stated in (ii) above.
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Note on certification
The certification must be carried out by either a lawyer, regulated accountant,
director/manager of an authorized credit or financial institution, notary public,
or a Consular Official at a British Embassy or Consulate. The certifier must:
• state that it is “a true copy of the original”
• sign and date the copy document
• clearly print the name, organization, organization’s address and their
position/capacity within the organization on the copy document
Ideally, the certification should be written and signed on the actual copy
documents and not on a separate sheet.
Note on address confirmation
Mobile telephone invoices are not acceptable to the Isle of Man authorities.
The utility invoice or bank statement must not be more than 3 months old.
Note on references
One reference must be from a recognized bank and the other from a
professional firm or individual. The referees should be familiar with your
affairs.
References to be requested by you - all references must be addressed to Isle of
Man Financial Trust Limited, be on professional headed paper and the
position/capacity of the referee must be stated. The referee should advise how
long they have known you and give their opinion as to your professional
standing and integrity.
References to be requested by Isle of Man Financial Trust – please complete the
following:
Name
Institution
Position
Address
Telephone
Facsimile
Email
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J. In the event of my death
We appreciate the sensitivity of this section, but wish to offer clients the
opportunity to consider this important issue. We recommend that your will is
reviewed regularly and that it covers worldwide assets.
In the event of my death I wish you to contact the following person for
guidance as to how to deal with my interests managed by IOMA Group.
Name
Address
Telephone
Facsimile
Email
K. Accounting and taxation
Isle of Man Financial Trust will provide full accounting and taxation services as
necessary unless otherwise instructed. If you wish external accounting or
taxation agents to be appointed, please provided details below:
Name
Address
Telephone
Facsimile
Email
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Annual accounts will be prepared for all trusts and companies unless otherwise
agreed. Please advise whether interim management accounts are required
either monthly, quarterly or half yearly:
L. Instruction to proceed
I confirm that (a) the information contained in this application form is true,
complete and accurate, (b) I have disclosed all material facts relating to this
application, (c) I am not acting for any other party, (d) I authorize Isle of Man
Financial Trust Limited to take up references on me and my affairs from the list
of referees I have supplied on this application form and (e) I have taken
competent advice on the suitability of the proposed structure and its effect on
my particular circumstances. I also consent that any personal information
obtained by the members of the IOMA Group may be held, used or disclosed
by the IOMA Group to enable it to process this application or any subsequent
transactions and to communicate with me or my advisors for any purpose.
Signature
Date
Please delete as appropriate trust settlor/trust protector/company beneficial
owner/third party authorized signatory.
M. Checklist
Original application form(s) fully completed and signed
Two certified copies of current passport
Two address confirmations
Two professional references or authority to obtain references
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APPENDIX 1
Page 1 of 2
FACSIMILE AND EMAIL AUTHORITY & INDEMNITY
Re:
Limited / Trust
I/we authorise Isle of Man Financial Trust Limited to act in accordance with facsimile
instructions which bear [please delete as appropriate]
Either: any one of the following authorised signature/signatures
Or: any [two/ three / four] of the following authorised signatures:-
1 Name:__________________________________________ Signature: __________________________________________
2 Name:__________________________________________ Signature: __________________________________________
3 Name:__________________________________________ Signature: __________________________________________
4 Name:__________________________________________ Signature: __________________________________________
and/or email instructions which are received from any of the following email
addresses:-
1 __________________________________________
2 __________________________________________
3 __________________________________________
4 __________________________________________
Isle of Man Financial Trust Limited shall be the sole arbiter as to the authenticity and
interpretation of any facsimile/email instruction received and shall exercise its sole
discretion whether or not to act upon such instruction.
INDEMNITY
I / We hereby undertake to hold harmless Isle of Man Financial Trust Limited its
officers and employees in respect of any act done in accordance with a
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APPENDIX 1
Page 2 of 2
facsimile/email instruction received or which is reasonably believed to have been
received from me/us.
I /We hereby undertake to hold harmless Isle of Man Financial Trust Limited its
officers and employees in respect of any failure to act as a result of Isle of Man
Financial Trust Limited exercising its reasonable discretion or for any error or
ambiguity in acting in accordance with a facsimile/email instruction received from
me/us if such error or ambiguity resulted from the reasonable interpretation of such
instruction.
I / We hereby undertake to indemnify Isle of Man Financial Trust Limited its officers
and employees against all proceedings claims expenses and liabilities which may be
taken made against or incurred by Isle of Man Financial Trust Limited its officers or
employees by reason of acting in accordance with such facsimile and email
instructions.
This Indemnity shall be governed by and construed in all respects in accordance with
Isle of Man law.
IN WITNESS WHEREOF this Indemnity has been entered into on the __________
day of __________________ in the year 20______
SIGNATURE: _____________________ SIGNATURE: _____________________
PRINT NAME: _____________________
PRINT NAME: _____________________
WITNESS:
WITNESS:
SIGNATURE: _____________________ SIGNATURE: _____________________
PRINT NAME: _____________________
PRINT NAME: _____________________
ADDRESS: _____________________ ADDRESS: _____________________
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
OCCUPATION: _____________________ OCCUPATION: _____________________
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iomagroup
Isle of Man
Financial Trust
Limited
IOMA House
Hope Street
Douglas
Isle of Man
IM1 1AP
British Isles
Telephone +44 (0)1624 681250
Facsimile +44 (0)1624 681392
Email iomft@ioma.co.im
www.ioma.co.im
Licensed by the Isle of Man Financial Supervision Commission as a Corporate Service Provider.