Politically
Exposed PersonDeclaration
1. Please fill in the details below:
Svitlana Bondarenko
First and Last Name: …………………………………. Ukraine
Citizenship country: ………………………………….
ID number: ………………………………….
FZ031456
Country of Residence: Ukraine
………………………………….
(the ID you registered with Rewire)
2. Please tick the box below that applies (a, b or c):
(a) Do you qualify as a politically exposed person (“PEP”)? Please select your occupation, either currently held or held
within the last 18 months, from below list:
Head of State or government, ministers and deputy Ambassador, chargé d’affaires or highranking
or assistant ministers officer in armed forces
Member of governing body of a political party Member of supreme court, constitutional court or
other highlevel judicial body1
Member of courts of auditors or boards of central banks Member of parliament or similar legislative body
Member of administrative, management or Director, deputy director, board member or
supervisory body of stateowned enterprises equivalent function in an international organization
(b) I am an immediate family member or close associate to a person that qualifies as a PEP, either currently or within the
last 18 months, as per above list and am/have:
A spouse or equivalent of a PEP
A child or spouse (or equivalent) to a child of a PEP
A parent of a PEP
Joint beneficial ownership of legal entities or legal arrangements or other close business relations with a PEP
Sole beneficial ownership of legal entities or legal arrangements to have been setup for the de facto benefit of a PEP
If you have ticked any box under (a) or (b), please answer the following questions regarding your (or this person’s)
position:
Name (if point 2) ……………………………………………………………………………………………...
PEP function ……………………………………………………………………………………………...
Country ……………………………………………………………………………………………...
Role/responsibilities ……………………………………………………………………………………………...
Start date function ……………………………………………………………………………………………...
End date if applicable ……………………………………………………………………………………………...
The funds I intend to use for my Rewire account and my net worth are generated from the following economic
activities2:……………………………………………………………………………………………...…………………………………………………………………
…………………………...……………………………………………………………………………………………...……………………………………………………
If none of the above under points (a) or (b) applies, please tick only the below box (c):
(c) I am neither considered to be a PEP nor am I an immediate family member or close associate to a PEP.
Further to the above, I, the undersigned, also bind myself to notify Rewire immediately of any change to any declaration made
or information provided in accordance with the above.
04 / 25 / 2021
Date................................ Signature.................................
1 The decisions of which are not subject to further appeal, except in exceptional circumstances.
2 The activity, event, business, occupation or employment from which the funds used in operating the account are generated. We may ask
you to provide further documentation in relation thereto.
Nieuwezijds Voorburgwal 162, 1012 SJ Amsterdam, Netherlands | hello@[Link] [Link]
Doc ID: 41e97a8138472a592dce03069445991f766da777
Audit Trail
Title
PEP Form
File Name
PEP Declaration EU 2020 [Link]
Document ID
41e97a8138472a592dce03069445991f766da777
Audit Trail Date Format
MM / DD / YYYY
Status Completed
04 / 25 / 2021 Sent for signature to Svitlana Bondarenko
11:55:05 UTC (kata12427@[Link]) from support@[Link]
IP: [Link]
04 / 25 / 2021 Viewed by Svitlana Bondarenko (kata12427@[Link])
13:46:27 UTC IP: [Link]
04 / 25 / 2021 Signed by Svitlana Bondarenko (kata12427@[Link])
16:41:42 UTC IP: [Link]
04 / 25 / 2021 The document has been completed.
16:41:42 UTC
