(Archived Content)
6. Respondent Bank understands that each financial institution in the United States at which it maintains a Correspondent Account may provide a copy of this Certification to the Secretary of the Treasury and the Attorney General of the United States.
I, _______________________________ (name), certify that I have read and understand this Certification and the Annexes hereto and that the statements made in this Certification and the Annexes hereto are true and correct.
This Certification is made on behalf of ________________________________ (name of Respondent Bank), a banking institution organized under the laws of _________________________________________________________ (specify country).
I understand that the statements contained in this Certification and the Annexes hereto may be transmitted to one or more departments or agencies of the United States of America for purpose of fulfilling such departments= and agencies= governmental functions.
_____________________________
[Signature]
_____________________________
[Title]
Executed on this _______ day of __________, 200__.
Received, reviewed and accepted by:
Name: ________________________________
Title: ________________________________
For:
______________________________________
[Name of Covered Financial Institution]
________________
Date
Annex I
1. To be completed if Respondent Bank checked paragraph 1(a) of the
Certification:
(A) Respondent Bank maintains a place of business at
_______________________________________________________
[Street Address]
in __________________________________ .
[Country]
(B) The banking authority that has the right to inspect the place of business
referred to in (A) is
___________________________________ .
[Name of Banking Authority]
2. To be completed if Respondent Bank checked paragraph 1(b) of the
Certification:
(A) Respondent Bank=s affiliate that is regulated is
_________________________________, which maintains a physical presence at
[Name of Affiliate]
________________________________________________________
[Street Address]
in ____________________________________ .
[Country]
(B) The banking authority that supervises both the Respondent Bank and its affiliate is
_____________________________________ .
[Name of Banking Authority]
Annex II
Name and Address
of Owner(s)
Name |
Address (No Post Office Boxes) |
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Attach Additional Sheets if Necessary
Annex III
Name and Address
of Agent Designated to Accept Service of Legal Process
Name |
Address (No Post Office Boxes) | Phone No. |
Fax No. |
E-mail Address |
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