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COMPANY NAME ADDRESS AND LOGO
DOCUMENTATION ENCLOSED
D
DATE: 24 August 2020
TO:
JPM TRADE GROUP
RE: Participation in Structured Privat e Financial Opportunity
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AFFIDAVIT REQUESTING INFORMATION
CLIENT INFORMATION SHEET
CORPORATE RESOLUTION
LETTER OF INTENT
LETTER OF CEASE & DESIST CONFIRMATIO N
SOURCE OF FUNDS AFFIDAVIT
LETTER OF NON-SOLICITATION & REQUEST
AUTHORIZATION TO VERIFY FUNDS
CONFIRMATION OF BANK OFFICER
PASSPORT
PROOF OF FUNDS
PROOF OF LIFE
STRICTLY CONFIDENTIAL
The information contained in this document is provided solely
and exclusively for informational purposes only, and for personal
use, upon a specific request made by the applicant enclosed.
Photocopies of documents or agreements pertaining to this subject
are declared and regarded as valid and equal to the original, provided
they are represented by proper signatories. Originals may be
obtained upon request.
Page 2 of 16
COMPANY NAME ADDRESS AND LOGO
AFFIDAVIT REQUESTING INFORMATI ON
DATE: 24 August 2020
TO:
JPM TRADE GROUP
RE: Participation in Structured Private Financial Opportunity
INVESTORTRANSACTION CODE: TBA
Dear Sir,
I, *****************, the undersigned, on my own behalf, do hereby affirm that I have requested
specific information about Private Placement Opportunities and or the Participation in
Investment Programs. The confidential information presented, received, and learn ed is not for
the solicitation of funds, nor is it an offering of any kind, but is for my general knowledge. I confirm
that I have requested the information of my own free will and choice, and further confirm that
no party has solicited me in any way. I hereby agree to keep all information received from you
strictly confidential, private, and proprietary, and that I will not disclose it to any other third party.
I, ****************, further affirm that any funds or assets I decide to place are done so at my own
specific initiative, risk, and authorization with full consideration and without duress. I further affirm
that the information received is int ended solely for my PRIVATE & CONFIDENTI ALUSE ONLY. I am
a sophisticated investor by all definitions of that classification known to me; I make my own
investment decisions and have legally acquired assets available. I, hereby reaffirm, under penalty
of perjury that I have requested information from you and your organization and that you have not
solicited me in any manner.
I, ****************, understand that the contemplated transaction is strictly one of Private
Placement and is in no way relying upon existing regulations in relation to the United States
Securities Act of 1933 as amended, or related regulations, and does not involve the buy and sell
of securities. I further declare that I am not a licensed securities broker or government employee
and understand that neither are you or your organization. I mutually agree that this Private
Placement Transaction is exempt from the securities act.
I, *****************, understand and agree that the ICC NON-DISCLOSURE and NON CIRCUM
VENTION rules apply to this affidavit and business relationship, and hereby agree to the
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COMPANY NAME ADDRESS AND LOGO
current ap plication standards of the International Chamber of Commerce, Paris, France which
rules are made a part hereof by this reference.
I, ***************, under penalty of perjury, with full corporate and individual responsibility, hereby
irrevocably, confirm that neither myself, nor anyone else associated w it h my organization, my
corporation, or the individual investor are working for any Agencies of any Government . I further
state under penalty of perjury that I am not involved in any Government entrapment operation.
I, *****************, under penalty of perjury, with full corporate and individual responsibility, hereby
irrevocably, confirm that neither myself, nor anyone else associated with my organization or
corporation have been convicted of a felony, either within the United States or anywhere in the
world where that crime would be considered equal to a US felony. To the best of my knowledge I
am not nor are any of my associates within my organization or corporation considered to be
terrorists or on any watch list with the United States Department of Homeland Security.
I, ******************, agree that all email and facsimile transmitted documents shall be treated as
original documents. I further agree that in all cases where plural might apply where sin gular tense
is used it is so appl ed.
I, ******************, hereby swear under penalty of perjury, that the information provided herein is
accurate and true as of this date: 24 August 2020
For and on behalf of *************************
****************
President & CEO
SEAL OF COMPANY
Name/ Title:
Company:
Passport Number:
Date of Issue:
Date of Expiry:
Country of Issuance:
Page 3 of 16
COMPANY NAME ADDRESS AND LOGO
CLIENT INFORMATION SHEET
Corporate Information (if applicable)
Full Name of Corporation:
Date of Incorporation:
Incorporated in (City/Country):
Registration Number:
Board of Directors (Name & Title):
Shareholders:
Person al Information of Principal Signatory
First Name:
Middle Name:
Last Name:
Gender:
Date of Birth:
Country of Citizenship:
Languages:
Passport Number:
Date of Issue:
Date of Expiration:
Issuing Authority:
Registered Address (for Corporation only)
Street Address:
City:
State:
Country:
Postal Code:
Location of Address: Mailing Address
Street Address:
City:
State:
Country:
Postal Code:
Page 4 of 16
COMPANY NAME ADDRESS AND LOGO
Contact Information
Telephone Number:
C/0 Email Address:
Bank Information
Name (where funds/Asset are currently on deposit): ASSET DEPOSITED AT CORPORATE HQ
Stre et Address:
City:
State:
Country:
Posta l Cod e:
Client Account where Profits to be paid: TO BE ADVISED (TBA)
Investment
Funds available for this transaction:
Type of currency: USD
Origin of funds:
Are these funds free and clear of all liens, encumbrances and third-party interests: YES
I, ******************, hereby swear under penalty of perjury, that the information provided herein is
accurate and true as of this date: 24 August 2020
For and on behalf of *************************
****************
President & CEO
SIGNATURE:
Name / Tit le:
Company:
Passport Number:
Date of Issue:
Date of Expiration:
SEAL OF COMPANY
Page 5 of 16
COMPANY NAME ADDRESS AND LOGO
CORPORATE RESOLUTION
INVESTOR TRANSACTION CODE: TBA
All of the directors of *********************************** be l ow list ed were in attendance, in person or by
telephone conference. General discussion was then held concerning the issue, and all aspects of the
same, were fully explained in detail to the satisfaction of the board members.
DIRECTOR Name/ Title:
Passport No.:
The Board of Director of ***********************, a Company incorporated on (DATE) in *********** in
(COUNTRY), with Registered Offices at (ADDRESS), in a meet in g held on this the (DATE), adopted
the following resolutions.
RESOLUTION 1:
It is resolved that the Board of Director of ************************************** hereby authorizes:
******************** holder of Passport Number************* issued on (DATE);
As our Transactional Managing Member, who currently hold s the office of President with assigned
author it y, on our behalf stay and name, to instruct, negotiate, arrange, monitor , execute, manage
and sign any and all agreements and/or necessary contracts with third parties pertinent to all
financial transactions with bank instruments (securities/ derivatives)
RESOLUTION 2:
It is resolved that at this meeting of the Board of Directors that our Transaction al Managing Member and
in fact ***************** acts for **************************** with regards to the afore said financial
investment .
RESOLUTION 3:
It is resolved that ******************* is hereby authorized to act as our Financial Director for the
aforesaid purpose.
RESOLUTION 4:
It is resolved the Board of Directors of ******************************** hereby authorized *************** to
assume all authority, powers, duties, signatory rights and responsibilities on our behalf.
Page 6 of 16
COMPANY NAME ADDRESS AND LOGO
,
DATE: September 19th, 2020
TO:
JPM TRADE GROU P
RE:
Participation in Structured Private Financial Opportunity
INVESTOR TRANSACTION CODE: TBA
Dear Sir,
I, ***************, the undersigned, hereby confirm under penalty of perjury, my full commitment and
agreement to participate in an investment opportunity , subject to my acceptance of the terms,
conditions and procedures that shall be outlined in the Private Placement Program.
Furthermore, I hereby warrant and represent that I have available for placement into the proposed
investment, an asset in the form of an International Bill of Exchange of value, the sum of Five
Billion United States Dollars ($1,080,000,000 .00 USO) of clean, clear funds, free of any levy, liens or
encumbrances and of non-criminal origin, and here with attached documentary evidence of same. I
hereby warrant and represent that the Rule of Full disclosure has established these funds were legally
obtained from non-criminal business or actions. I further confirm that I am the beneficial owner of
these cash funds, that I have full signatory authority and control thereof, and that such funds are
available for immediate placement at my sole discretion.
I confirm and acknowledge, with full responsibility, that neither your company nor anyone
working on your behalf has soli cited me; that the documents that I shall receive shall not be deemed
to be a solicitation of funds in connection with an investment program; and, that I am approaching you
voluntarily for the purpose of securing participation in a bona fide Secure Private Placement Program.
I am prepared to instruct my bank to act upon the funds as required pursuant to the specifics of
this program. In the case of Blocked Funds, it is my understanding the funds will be blocked and
or reserved) in the account and they will remain, at all times, non-calla ble.
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COMPANY NAME ADDRESS AND LOGO
I hereby request information from you covering the terms, condition and procedures of a secured
investment and look forward to commencing the transact ion, upon my acceptance of the
agreement.
Email, facsimile copies or photo copies of documents or agreements pertaining to this subject are
declared and regard ed as valid and equal to the original, provided they are represent ed by proper
sign authorities. Originals may be obtained upon request.
I, *****************, here by swear under penalty of perjury, that the information provided here in is
accurate and true as of this date: 24 August 2020
For and on behalf of *******************************
*******************
President & CEO
Signature:
SEAL OF COMPANY
Name / Title:
Company:
Passport Number:
Date of Issue:
Date of Expiry:
Country of Issuance:
Page 8 of 16
COMPANY NAME ADDRESS AND LOGO
LETTER OF CEASE & DESI ST CONFIR M ATI ON
DATE: 24 August 2020
TO:
JPM TRADE GROUP
RE: Participation in Structured Private Financial Opportunity
INVESTOR TRANSACTION CODE: TBA
Dear Sir,
I, *******************, bearing COUNTRY Passport No. **************, duly authorized and full legally
representative director for and on behalf of ***************, give notice to have Cease and Desist and
any/other group previous group approached in the past regarding our/my files
I, ********************, make a clear statement and confirm under risk and penalty of perjury not to
have any other entities, associations, financial institutions, affiliates, intermediaries, groups or
others with my /our permission nor any specific authorization to handle nor process any one of my
/our documents as from 24 August 2020
And that; All previous entities, associations, financial institutions, affiliates, intermediaries,
groups or others have been notified of such by the correspondent official Cease and Desist Letter
communication. This exclusive authority and engagement shall continue fully effective until
cancelled in writing by me.
I, *****************, hereby swear under pena lty of perjury, that the infor mation provided herein is
accurate and true as of this date : 24 August 2020
For and on behalf of ******************************
*******************
President & CEO
Signature:
SEAL OF COMPANY
Name / Title:
Company:
Passport Number:
Date of Issue:
Date of Expiration:
Country of Issuance:
Page 9 of 16
COMPANY NAME ADDRESS AND LOGO
SOURCE OF FUNDS AFFIDAVIT
DATE: 24 August 2020 TO:
JPM TRADE GROUP
RE:
Participation in Structured Private Financial Opportunity
INVESTOR TRANSACTION CODE: TBA
Dear Sir,
I, *******************, bearing COUNTRY Passport No. ****************, du ly authorized and full legally
representative director for and on behalf of xxxxx, do solemnly swear/attest the following statements
to be true.
I, **************, declare under penalty of perjury and with full personal and legal responsibility under
the International Court of Law that I legally hold the sum of FIVE BILLION, United States Dollars
$5,000,000,000.00 USD in value on an (TYPE OF INSTRUMENT) and that the original
certificate is in my possession at my office Headquarters, in Ontario, Canada.
I further declare these funds are current and valid currency lawfully obtained and constitute clean,
cleared funds of legitimate, non-criminal, commercial origin. There are no liens, contractual
obligations, or encumbrances of any kind against these fun ds.
I have full and complete, legal ownership of, and the unrestricted right and authority to pledge or
otherwise utilize these funds. The funds are ready for transfer or release upon my instruction.
These funds are authentic and verifiable. I am not aware of any matter which could or might
cause the non-validation of these funds and I hereby indemnify the Program Manager and/or
assignees, intermediaries, or other parties involved, against any claims, demands, civil and/or
criminal in nature, and liabilities, damages, or expenses including without limitation any
attorney's fees which may arise, whether in whole or in part, caused by reason of reliance upon
this sworn declaration.
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COMPANY NAME ADDRESS AND LOGO
E-mail, facsimile copies or photocopies of documents or agreements pertaining to this sub je ct are
declared and regarded as valid and equal to the original, provided they are represented by proper
signatories. Origina ls may be obtained upon request.
Details of how cash funds were earned or how funds were earned to purchase a bank instrument:
I, XXXX, hereby swear under penalty of perjury, that the information provided herein is accurate
and true as of this date: 24 August 2020
I, *****************, hereby swear under pena lty of perjury, that the infor mation provided herein is
accurate and true as of this date : 24 August 2020
For and on behalf of ******************************
*******************
President & CEO
Name/Title:
Company:
Passport Number:
Date of Issue:
Date of Expiration:
Country of Issue:
Page 12 of 16
COMPANY NAME ADDRESS AND LOGO
LETTER OF NON-SOLI CITATI ON & REQUEST
DATE: 24 August 2020
TO: JPM TRADE GROUP
RE: Participation in Structured Private Financial Opportunity
INVESTOR TRANSACTION CODE: TBA
Dear Sir,
I, XXXX, the undersigned, hereby confirm that I have requested of you and your organization
specific confidential information and documentation on behalf of ourselves. I hereby declare that I
am fully aware of the information received from you is in direct response to my request, and is not
in any way considered or intended to be a solicitation of funds of any sort, or any type of offering,
and is intended for our general know ledge only. I hereby affirm under penalty of perjury that you
have not solicited in any way. I understand that the contemplated transaction is strictly one of
private placement, and is in no way relying on or related to the United States Securities Act of
1933, as amended or related regulations, and does not involve the sale of securities. That affiant
makes this affidavit knowing that the recipients will rely on the contents hereof, and agrees to
indemnify and hold-harmless all recipients and all other part ies including intermediaries -- against
any and all claims result in g from any applicant misrepresentation of a material fact or any loss of
asset value or any act (legal or not) of a bank or other financial institution, governing authority or
agency, the Federal Reserve or an official or other insider of any such entity. Further, I hereby
declare we are not licensed brokers or government employees and understand that neither are you
or your organization. We mutually agree that this private placement transaction is exempt from the
Securities Act, and not intended for the general public, and all materials are for private use only.
For and on behalf of **************************
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COMPANY NAME ADDRESS AND LOGO
PASSPORT
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COMPANY NAME ADDRESS AND LOGO
PROOF OF FUNDS
COPY
OF (TYPE) ASSET
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COMPANY NAME ADDRESS AND LOGO
PROOF OF LIFE
PHOTO OF INVESTOR HOLDING PASSPORT & PROOF OF DATE
Page 16 of 16
COMPANY NAME ADDRESS AND LOGO
I, Investor (XXXX / Mr. XXX and/or assigned), as the Authorized Signatory for INVESTOR under penalty of
perjury, hereby confirm with full legal and corporate responsibility, that in the Structured Private Financial
Opportunity Agreement/Letter of Intent/Transaction Contract identified with above-written Transaction Code,
Investor’s Code, and Monitizer’s Code, with full legal and corporate authority and responsibility, under penalty
of perjury, hereby endorse this Irrevocable Profit Participation Agreement and Pay Order (IPPA/PO) for Two
percent (10) % of total value of each and every tranche, including all rolls and extensions, or any further business
between the parties, their shareholders, heirs, assigns, or trusts for the benefit of the Buy Side( 5.0%) & (5.0%)
Sell Side/ beneficiaries / consultants named herein. The Consultants / beneficiaries named herein have
performed their function by introducing the Principals for a financial transaction. Consultant fees are due and
payable if a substitute financial transaction is accomplished in lieu of the above described.
I further agree and acknowledge that this IPPA/PO constitutes an Irrevocable and Unconditional Guarantee to
share and pay profits in compliance with the terms hereof for any and all transactions or tranches that are
completed pursuant to the Purchase Agreement/Letter of Intent/Transaction Contract identified by the above
Transaction, Monitizer, and Investor Codes.
PAYMENT ORDER VALUE:
TWO PERCENT (5%) of the full face value of the financial instrument on the above -referenced transaction,
payable to the Beneficiary Paymasters or assigns named or represented herein, 5.00% to Consultant Rep Group
1 & 5.00% to Consultant Rep 2. Such payment shall be made by Investor via SWIFT wire, without protest, delay
or deduction and free of any bank charges (except for normal bank transfer charges), local and national taxes
and liens, to the extent legally permissible only after confirmation that the structured private financial
opportunity appears onscreen in the investor’s account.
ALL WIRE TRANSFER INSTRUCTIONS SHALL STATE: “FUNDS ARE CLEAN AND CLEAR, OF NON-CRIMINAL ORIGIN
AND ARE FOR IMMEDIATE CREDIT – SAME DAY VALUE / INSTANT CASH UPON RECEIPT.”
THIS FEE PROTECTION DOCUMENT SHALL BE LODGED WITH THE PAYMENT BANK TOGETHER WITH THE FIRST
RECEIVED CORPORATE INVOICE. THE Monetizer SHALL SEND A COPY OF THE COMPLETED DOCUMENT TO EACH
PAYMASTER.
( * * * * * THE REST OF THIS PAGE IS INTENTIONALLY LEFT BLANK * * * * * )
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COMPANY NAME ADDRESS AND LOGO
COMMISSIONS OF 10.00% (TEN PERCENT) OF FULL FACE VALUE INCLUDING ROLLS AND EXTENSIONS
CONSULTANT REP 1 (INVESTOR SIDE): FIVE PERCENT (5.00%) (LUIS PERALTA GROUP) COMMISSION OF
5.00% OF FULL-FACE VALUE INCLUDING ROLLS AND EXTENSIONS, SHALL BE PAID BY MONITIZER TO:
CLOSED
Paymaster Name:
Michael J. Rubin, Esq. Attorney
Paymaster Address:
5 Nathan Pratt Drive, Unit 104, Concord, MA 01742-4641
Paymaster Email:
rubinmj@gmail.com
Paymaster Telephone Number:
617‐417‐1749
Bank Name:
JP Morgan Chase Bank, N.A
Bank Address:
184 Main Street, Westport, CT 06880
Account Name:
Michael J. Rubin, Esq. Attorney Trust Account IOLTA
Account Holder
Michael J. Rubin
Account Number:
410 547 009
Routing ABA Number:
021 000 021
SWIFT Code:
CHASUS33
Bank Officer:
TBD
Bank Officer Telephone Number:
TBD
Beneficiary:
LUIS PERALTA
Special Wire Instructions:
PREADVICE MUST BE SENT VIA SWIFT RIOR TO WIRE
TRANSFER & EMAIL A NOTIFICATION IMMEDIATELY UPON
EACH TRANSFER PAYMENT TOGETHER WITH THE
TRANSACTION CODE/S TO: rubinmj@gmail.com &
Luis@ParkWestCapital.Com
Required Message:
ALL TRANSFER INSTRUCTIONS SHALL STATE: ‘FUND ARE
CLEAN AND CLEAR, OF NON‐CRIMINAL ORIGIN AND ARE
PAYABLE IN CASH IMMEDIATELY UPON RECEIPT BY
BENEFICIARY’S BANK –SAME DAY CREDIT.”
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COMPANY NAME ADDRESS AND LOGO
CONSULTANT REP 2 (TRADE SIDE): 5.00% (SMITH GROUP) COMMISSION OF 5.00% OF FULL FACE VALUE
INCLUDING ROLLS AND EXTENSIONS, SHALL BE PAID BY MONITIZER TO: CLOSED
Paymaster Name:
Michael J. Rubin, Esq. Attorney
Paymaster Address:
5 Nathan Pratt Drive, Unit 104, Concord, MA 01742-4641
Paymaster Email:
rubinmj@gmail.com
Paymaster Telephone Number:
617‐417‐1749
Bank Name:
JP Morgan Chase Bank, N.A
Bank Address:
184 Main Street, Westport, CT 06880
Account Name:
Michael J. Rubin, Esq. Attorney Trust Account IOLTA
Account Holder
Michael J. Rubin
Account Number:
410 547 009
Routing ABA Number:
021 000 021
SWIFT Code:
CHASUS33
Bank Officer:
TBD
Bank Officer Telephone Number:
TBD
Beneficiary:
LEVINE GROUP & ASSIGNS
Special Wire Instructions:
PREADVICE MUST BE SENT VIA SWIFT RIOR TO WIRE TRANSFER
& EMAIL A NOTIFICATION IMMEDIATELY UPON EACH TRANSFER
PAYMENT TOGETHER WITH THE TRANSACTION CODE/S TO:
rubinmj@gmail.com
Required Message:
ALL TRANSFER INSTRUCTIONS SHALL STATE: ‘FUND ARE
CLEAN AND CLEAR, OF NON‐CRIMINAL ORIGIN AND ARE
PAYABLE IN CASH IMMEDIATELY UPON RECEIPT BY
BENEFICIARY’S BANK –SAME DAY CREDIT.”
Paymasters may change their receiving banks by serving prior notice in writing to Investor / Payer within 8
banking hours thereof. Paymasters shall issue their own respective Payment Orders for all
Beneficiaries/Consultants identified within their own groups per Addendum A for profits received specific to this
Agreement and said Payment Orders shall be lodged with their bank officers as herein written for
implementation.
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COMPANY NAME ADDRESS AND LOGO
This Irrevocable Profit Participation Agreement becomes unconditional, assignable, and divisible upon the
successful initiation of the transaction referenced above.
All profit transfers specific to this Agreement are to be made by wire or internal bank transfers and transferred
immediately upon closing of each transaction or tranche or as soon thereafter as banking processes allow
without liens or delays of any kind whatsoever.
This Agreement becomes effective with the execution of the Purchase Agreement/Letter of Intent/Transaction
Contract referenced by the Transaction Code, Monetizer’s Code, and Investor’s Code set forth above and shall
remain valid and enforceable for the full term of the contract.
The applicable Non-Circumvention/Non-Disclosure conditions of the ICC rules and regulations (latest edition) are
binding upon all parties to this agreement or any other pending or future transactions. All signed copies of this
agreement including fax transmissions thereof, shall be considered legally binding documents. This agreement
and the rights and obligations hereof are binding and inure to the respective heirs, legal representatives,
assignees and/or successors of the parties hereof.
This Agreement/Irrevocable Corporate Payment Order and the payment of commissions herein are subject to
the International Chamber of Commerce “ICC” and the ICC Arbitration Act as adopted by the ICC office in
Geneva, Switzerland, by three arbitrary appointees in accordance with ICC rules.
A signed Fax or electronically transmitted copy of this document shall be deemed binding on the “Parties” with
the force as the signed original. The Agreement and Irrevocable Corporate Payment Order is valid when
commencement of the above-referenced transaction takes place and shall remain valid and enforceable for the
full terms of the transaction, including any new agreement between the Investor and Monitizer and/or their
assigns.
The Investor’s bank shall provide the beneficiaries, by e-mails or by tele/fax with copies of the swift related to all
payment instructions upon the closing of each and every transaction of the above transaction.
THE INVESTOR’S PAYING BANK
Name of Bank
: XXXX
Account name
: XXXX
Account number
: XXXX
IBAN/ROUTING NO.
: XXXX
SWIFT CODE
: XXXX
Bank Officer Name
: XXXX
It is understood that all parties herein involved are considered to be bound by international standard of noncircumvention/non-disclosure as governed by the International Chamber of Commerce, and if subject to
litigation, to the laws of the involved countries.
Parties to this agreement are independent contractors and all contemplated payments and/or distributions
hereunder are divided interests. All taxes, federal, state or other, are the independent responsibility of each of
the parties hereto. Reporting of income and the payment of any related taxes is the sole responsibility of the
parties individually.
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COMPANY NAME ADDRESS AND LOGO
This agreement will become an integral part and included within the Purchase Agreement/Letter of Intent/
Transaction Code: XXXX and Investor’s Code: XXXX as soon as the contract becomes valid and signed. If no
transaction is completed under the aforesaid Transaction, Monetizer, and Monetizer Codes collectively, then no
obligation to the Beneficiaries / Consultants and any other parties under this agreement is established.
The receipt of this document constitutes acknowledgement on the part of recipients hereof that the
transactions herein are not to be in violation of existing regulations and laws and all parties herein are bound to
obey and be in compliance with all regulations and laws as related to the transactions herein.
ISSUED BY THE MONITIZER:
For and on behalf of the Investor:
SIGNATURE OF THE LEGAL REPRESENTATIVE OF THE INVESTOR:
_________________________
Authorized Signatory:
Print Name: XXXX
Nationally: United States
Title: Principal / Managing Member
Company: XXXX
Passport No: XXXX
Date of Issue: XXXX
Date of Expiration: XXX
Issuing Country: XXXX
Date of Birth: XXX
Business: XXXX and/or Assigns
Location of Address: Home-Legal Residence | Business Address: XXXX
Country: XXX
Postal Code: XXXX
Telephone: XXXX
Email Address: XXXX
XXXXXX END OF DOCUMENT XXXXXX
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