Dominican Republic compliance questionnaire

In compliance with the provisions of Law n.º 155-17 on Prevention of Money Laundering and Terrorism Financing of the Dominican Republic, each current or potential client of the Firm will be required to complete the following Compliance Questionnaire.

Section I – General administrative information
Name or corporate name of the institution*
Type of company*
- Stock corporation
- Limited liability company
- Non-profit association
Website*
Principal commercial domicile*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physical presence refers to the fact that your institution maintains facilities in which commercial activities are carried out, not just an electronic address in a country where you are authorized to carry out activities.
Registered office address
- Same as principal commercial domicile
*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is your institution an agency, branch or subsidiary of one or more parent company?*
- Yes
- No
Parent company name*
Is the parent company listed on the stock exchange?*
- Yes
- No
Please list the exchange and symbols*
Indicate the affiliation*
- Agency
- Branch
- Subsidiary
Is your institution listed on the stock exchange?*
- Yes
- No
Please list the exchange and symbols*
Contact responsible for the relationship*
First Last
Phone*
Fax
Email*
Secondary contact*
First Last
Phone*
Fax
Email*
Section II – Scope of Commercial Activities

Please list the main countries in which your institution has branches, agencies and subsidiaries. Additionally, please indicate the type of operation and number of offices or locations.

Country	Type (branch, agency, subsidiary, etc.)	Number

Please list the main areas of commercial activity in which your institution participates in terms of contribution to income.

Main areas of commercial activity	Approximate income percentage

Section III– Information on property and administration

If your institution is not listed on the stock exchange, please list the names of the owners of your institution and their shareholding. (For purposes of this questionnaire, an "owner" is any natural or legal person who, either directly or indirectly, owns, controls or has voting power over twenty percent (20%) or more of any kind of securities of your institution or has any amount of securities of your institution but has executive functions in it).

Name of the person or institution	Shareholding (%)	Shareholding nature (direct/indirect)

If any of the owners mentioned above is a legal entity, please list the names of the shareholders of the entity and their shareholding in it. If the second-tier shareholders are also legal entities, the names, shareholding percentage and shareholding nature of the third-tier shareholders must also be listed. This exercise should continue until the final beneficiaries are identified. Note: If any legal entity is quoted on the stock exchange, please indicate only that it is listed on the stock exchange and the stock exchanges in which such shares are quoted.

Entity name	Shareholders	Shareholding (%)	Shareholding nature (direct/indirect)

Please indicate the names of the main executives and directors of your institution, their respective positions and the years they have served as employees of the institution.

Name	Position	Years of service

Are there Politically Exposed Persons in the share structure of your institution and executive management?*
- Yes
- No
Politically Exposed Persons (PEPs) are individuals who are or have been commissioned with prominent public functions, for example, Head of State or Government, senior political officials, senior government officials, judicial or military officials, senior executives of state corporations, senior executives of political parties, their relatives or close associates.
The undersigned certifies and attests that the foregoing questions were answered truthfully and that they are an accurate representation of the existing state of the relevant facts of the institution as described above.
Filled out by:*
First Last
Position*
Date*
Institution name*
Institution address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*

Dominican Republic compliance questionnaire

Section I – General administrative information

Section II – Scope of Commercial Activities

Section III– Information on property and administration

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