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Source of Wealth Declaration EN

The document is a source of wealth declaration form for opening a crypto asset trading account, detailing the applicant's investment intentions, occupation, and financial background. It includes sections for the applicant to declare their source of funds, transaction experience, and wealth list. The applicant, Romy Yuhardiansyah, certifies the truthfulness of the information provided and includes their bank account details for trading purposes.

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Romy Yuhardiansyah
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68 views2 pages

Source of Wealth Declaration EN

The document is a source of wealth declaration form for opening a crypto asset trading account, detailing the applicant's investment intentions, occupation, and financial background. It includes sections for the applicant to declare their source of funds, transaction experience, and wealth list. The applicant, Romy Yuhardiansyah, certifies the truthfulness of the information provided and includes their bank account details for trading purposes.

Uploaded by

Romy Yuhardiansyah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

SOURCE OF WEALTH DECLARATION

THE PURPOSE OF OPENING ACCOUNT

Hedging Speculation Short Time Investment O Long Time Investment

Price Appreciation Others, mention _________________________

Crypto Asset Trading Transaction Experience

Yes, mention _______________________ O No


Have you been declared bankrupt by the court?

Yes, mention _______________________ O No

SOURCE OF FUNDS

Occupation Entrepreneur O Karyawan Swasta Pegawai Negeri Sipil

Professional/Consultant BUMN employee Student


House wife Others, mention: ____________
PT Prosperity Archilum
Company name ______________________________________________________________

Business fields Distributor


______________________________________________________________

Position Staff
______________________________________________________________

Length of work 4 Years


____ In the previous office _____ Years

Office Address Suri Mulia FF 2A, Surabaya


______________________________________________________________

Incomer per year O IDR 100 – 250 Million IDR 250 -500Million

IDR 500 juta – 1 Billion Above IDR 1 Milyar

Wealth list O House worth 400 Juta


________________

Savings worth _______________

Crypto Asset worth _____________

PT. Aset Digital Berkat


Prudential Centre, Jl. Casablanka Raya kav 88, Lantai 21 unit A
Menteng Dalam, Tebet, Jakarta Selatan 12870
+6221 30629429
Customer's bank account for depositing and withdrawing crypto assets trading results

Bank name Bank Central Asia


______________________________________________________
Romy Yuhardiansyah
Customer Name in bank account ______________________________________________________

Branch Surabaya
______________________________________________________

Bank account number 5075158570


______________________________________________________

Bank account type Saving O Current account Others ____________

STATEMENT OF TRUTH AND LIABILITY

By filling in the “YES” column below, I certify that all information and all documents that I
attach in the CUSTOMER PROPERTY DECLARATION FORM are true and correct, I will be
fully responsible if in the future something happens in connection with the untruth of the
data I provide

Acceptance statement O Yes No

Surabaya
____________,9/ 7/ 2024

Sign

Customer Name : Romy Yuhardiansyah

PT. Aset Digital Berkat


Prudential Centre, Jl. Casablanka Raya kav 88, Lantai 21 unit A
Menteng Dalam, Tebet, Jakarta Selatan 12870
+6221 30629429

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