FOGOT AS
reg. nr. 10225817

 FOGOT AS, Narva mnt 38, Tallinn, Estonia, 10150
fax 6 321 681 (+372 6321681)

D E C L A R A T I O N
on origin of funds

DETAILS OF PERSON WHO MAKES CASH PAYMENT:
name and surname
 
 personal code date of birth
residential or registered address
 
telephone
 
 e-mail citizenship

PERSON MAKING CASH PAYMENT ACTS:
on his own behalf and for his own account
on behalf of individual name and surname
 
 personal code / date of birth
 
on behalf of business entity name
 
 registry's code
 

TERRITORY AND FIELD OF ACTIVITY:
state
 
 field of activity
 
monthly income (sum, currency)
 

TRANSACTION:
EXCHANGE OF CASH INTO WEBMONEY
 sum and currency
 

EXPLANATIONS ON ORIGIN OF FUNDS:
  sale and purchase   dividends   loan   gift   other
other explanation on origin of funds:
 

signature
 

 date