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NAME: RENÉ NIÑO GONZÁLEZ

ADDRESS: CARRERA 20 #69-43 INT. 2


BOGOTÀ - COLOMBIA
MOBILE: +57 3124491935
E mail: renigon@gmail.com

AIF-SUB-FEE BENEFICIARY (LEVEL "1") INFORMATION FORM

SELLER INFORMATION: JOSÉ RENEE URREGO ZORRILLA)


CLIENT TRANSACTION CODE: 20160807/RENEE/152,000BI-NEW/GO&D
Index Number: 20170923-1

In accordance with Articles 2 through 5 of the Due Diligence Convention and the Federal Banking
Commission Circular of December 1998, and under the US Patriot Act of 2002, as amended in
February 2003 concerning the prevention of money laundering and 305 of the Swiss Criminal
Code, the following information may be supplied to banks and/or other financial institutions for
purposes of verification of identity and activities of the Client described below, and the nature and
origin of the funds which are to be utilized. The foregoing is subject to agreement by all parties to
whom this information is provided that they are obligated to respect the privacy rights of the Client
and all individuals described herein, as well as the generally accepted professional standards
relating to the maintenance of confidential information, and to take all appropriate precautions to
protect the confidentiality of the information contained herein, This legal obligation shall remain in
full force indefinitely without restriction.
Corporate

Full Name of Institution :


Registration Number :
Date of Registration :
Postal Address :
Registration Address :
Physical Address :
Business Telephone Number :
Business Facsimile Number :

Details of Signatory (Sub-Fee Beneficiary) –Individual

First Name : René


Last Name : Niño
Nationality : Colombian
Passport Number : AU321633
Date of Issue of the Passport : 23 NOVIEMBRE 2017
Expiry Date of the Passport : 23 NOVIEMBRE 2027
Mobile Phone Number : +57 3124491935
Home Address : CARRERA 20 #69-43 INT. 2
Home Telephone Number : N/A
E-mail Address : renigon@gmail.com
Do you speak English? : YES

Initials: RNG Page 1 of 3


NAME: RENÉ NIÑO GONZÁLEZ
ADDRESS: CARRERA 20 #69-43 INT. 2
BOGOTÀ - COLOMBIA
MOBILE: +57 3124491935
E mail: renigon@gmail.com

Details of the PAYMASTER's Bank Account – Where Funds to be sent


Complete the box below by inserting banking coordinates and personal information as requested.
Delete the statement below (in red) if you do not need help setting up a bank account.

If applicable, leave the following statement in place (i.e., do not delete as instructed above) and
complete the requested information in the box corresponding to BENEFICIARY GROUP: “I
need help in setting up a bank account that would be suitable for the receipt of the funds to be
received pursuant to the funding of this transaction.”

PAYMASTER
Name/ TO BE ADVISED by the Buyer's / Redeemer Group

AMOUNT TO BE PAID TO BE ADVISED BY BENEFICIARY


Represented By TBA
Title TBA
Passport Number TBA
Issue Date TBA
Expiry Date TBA
Nationality TBA
Bank Name TBA
Bank Address TBA
Account No. TBA
Account Name TBA
SWIFT Instruction re USD TBA
SWIFT Instruction re EUR TBA
Bank Officer TBA
BENEFICIARY GROUP Mr. René Niño G.
Bank Telephone /Fax TBA
PREADVICE MUST BE SENT VIA SWIFT PRIOR TO WIRE TRANSFER &
EMAIL a notification immediately upon each transfer payment together with the
SPECIAL WIRE transactions code/s to: e-mail to Paymaster: TBA and to Beneficiary:
INSTRUCTIONS juancbotero@gmail.com

ALL TRANSFER INSTRUCTIONS SHALL STATE: “FUNDS ARE CLEAN AND


Required Message CLEAR, OF NON-CRIMINAL ORIGIN AND ARE PAYABLE IN CASH
IMMEDIATELY UPON RECEIPT BY BENEFICIARY’S BANK.”

Initials: RNG Page 2 of 3


NAME: RENÉ NIÑO GONZÁLEZ
ADDRESS: CARRERA 20 #69-43 INT. 2
BOGOTÀ - COLOMBIA
MOBILE: +57 3124491935
E mail: renigon@gmail.com

COLOR COPY OF PASSPORT (EVEN IF EXPIRED)

I, René Niño G., hereby declare with full personal and corporate responsibility under penalty of perjury that the
information given above is accurate and true.

By: RENÉ NIÑO G.

_________________________________
Mr. RENÉ NIÑO G.
Passport Number : AU321633
Signed this Date: December 1, 2018

Initials: RNG Page 3 of 3

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