E-Merchant questionnaire

Brīvības iela 54, Rīga, LV-1011 • Tālr. +371 6 777 2 999 • [email protected] • www.lpb.lv

1. lpp. VEI:171 I Versija: 4 I Apstiprināts: 13.05.2021., Nr.25-3/20, 11.jautājums

E-Merchant questionnaire

Please read and carefully complete all fields, all fields are required. If you are not sure about information you should

provide, please contact your manager in LPB.

1. General information

1.1. Company name: ________________________________________________ 1.2. Country of incorp.: ____________________________

1.3. Registration number: ___________________________________________ 1.4. Registration date: _____________________________

1.5. Tax ID number: ________________________________

1.6. Legal address: _______________________________________________________________________________________________________

1.7. Actual address: ______________________________________________________________________________________________________

1.8. Contact information: phone: _______________________________________ email: _________________________________________

1.9. Number of employees: _____

1.10. Should the company submit financial reports in its place of registration or business activity?

No Yes (if Yes, please fill in for what period the last financial report was submitted) _____________________

specify the institution for submitting financial reports _______________________________ www._____________________________

1.11. Financial reports are publicly available No Yes(explain) __________________________________________________

1.12. Does the company have micro enterprise status? No Yes

1.13. Does the company have nonprofit status? No Yes

1.14. Is the company related to a Politically Exposed Person? No Yes

1.15. The company issues or is entitled to issue bearer shares (equity securities)? No Yes

1.16. Is the company’s economic activity linked to the Republic of Latvia? No Yes

1.17. Is the company’s representative linked to the Republic of Latvia? No Yes

1.18. Is the company a part of group of companies or association? No Yes (describe the

name of group, structure and scheme of operation) _______________________________________________________________________

___________________________________________________________________________________________________________________________

1.19. Does the company have an additional source of income / sources to increase working capital? No Yes

2. I confirm, that the Company’s Beneficial owner is: Another company Merchant

3. Information about beneficiary owner:

3.1. Name, surname: _______________________________________ 3.1.1. Personal ID nr. /Date of Birth: _________________

3.1.2. Passport/ID number: _____________________________________ 3.1.3. Issuing date: ___________________________

3.1.4. Passport/ID issuer, country of issue: __________________________________ 3.1.5. Share in the company (%) _______

3.1.6. Shareholder participation in other business areas (ownership share > 10%) No Yes (specify

the company name, industry of business, ownership share) _____________________________________________________________

3.1.7. The Beneficial Owner’s legal address: Street, house, apartment: __________________________________________________

City: _________________________________________ Country: ___________________________ Postal code: __________

3.1.8. The Beneficial Owner’s actual address: Street, house, apartment: _________________________________________________


3.1.9. Existence of a criminal record: No Yes

3.1.10. Is the Beneficial owner a Politically exposed person1?

Yes (explain) __________________________________________________________________________________________ No

Is the Beneficial owner a Family member of a politically exposed person2?

Yes (explain) __________________________________________________________________________________________ No

Is the Beneficial owner a Person closely related to a politically exposed person3?

Yes (explain) __________________________________________________________________________________________ No

Is the Beneficial owner related to the US4?

Yes (fill the form “Information for determining US tax payer status” for each Beneficial owner separately) No

3.1.11. Sources of the Beneficial owner’s funds:

Salary / honorarium/ reward The sale of the property Interest / dividends Heritage

Sale of shares / capital shares Rent / credit Other ________________________________



3.2. Name, surname: _______________________________________ 3.2.1. Personal ID nr. /Date of Birth: ____________________

3.2.2. Passport/ID number: _____________________________________ 3.2.3. Issuing date: ______________

3.2.4. Passport/ID issuer, country of issue: __________________________________ 3.2.5. Share in the company (%) ________

3.2.6. Shareholder participation in other business areas (ownership share > 10%) No Yes (specify the

company name, industry of business, ownership share) __________________________________________________________________







Yes (explain) __________________________________________________________________________________________ No


Yes (explain) __________________________________________________________________________________________ No


Yes (explain) __________________________________________________________________________________________ No





Sale of shares / capital shares Rent / credit Other ___________________________________

3.3. Name, surname: _______________________________________ 3.3.1. Personal ID nr. /Date of Birth: ____________________

3.3.2. Passport/ID number: _____________________________________ 3.3.3. Issuing date: ___________________________

3.3.4. Passport/ID issuer, country of issue: __________________________________ 3.3.5. Share in the company (%) ________

3.3.6. Shareholder participation in other business areas (ownership share > 10%) No Yes (describe company

name, industry of business, ownership share: ___________________________________________________________________________







Yes (explain) __________________________________________________________________________________________ No


Yes (explain) __________________________________________________________________________________________ No


Yes (explain) __________________________________________________________________________________________ No






3.4. Name, surname: ______________________________________ 3.4.1. Personal ID nr. /Date of Birth: ____________________

3.4.2. Passport/ID number: ____________________________________ 3.4.3. Issuing date: ________________

3.4.4. Passport/ID issuer, country of issue: __________________________________ 3.4.5. Share in the company (%) _____

3.4.6. Shareholder participation in other business areas (ownership share > 10%) No Yes (describe company

name, industry of business, ownership share): _______________________________________________________________









Yes (explain) __________________________________________________________________________________________ No


Yes (explain) __________________________________________________________________________________________ No


Yes (explain) __________________________________________________________________________________________ No






4. Company board (including person, who will sign the agreement with the bank)

4.1. Name, surname: _____________________________________ 4.1.1. Position: __________________________________

4.1.2. Personal ID nr. /Date of Birth: ____________________ 4.1.3. Passport/ID number: ________________________

4.1.4. Issuing date: _______________________ 4.1.5. Passport/ID issuer, country of issue: ____________________________________

4.1.6. Legal address: __________________________________________________________________________________________________________

4.1.7. Actual address: _________________________________________________________________________________________________________

4.1.8. Contact information: phone + ____________________________ email ___________________________________________


4.2. Name, surname: _____________________________________ 4.2.1. Position: __________________________________

4.2.2. Personal ID nr. /Date of Birth: ____________________ 4.2.3. Passport/ID number: _________________________

4.2.4. Issuing date: ____________________ 4.2.5. Passport/ID issuer, country of issue: ____________________________________

4.2.6. Legal address: __________________________________________________________________________________________________________

4.2.7. Actual address: _________________________________________________________________________________________________________

4.2.8. Contact information: phone + ____________________________ email ___________________________________________


5. Contact persons:

5.1. General contact name, surname: ________________________________________

5.1.1. Contact information: phone + ___________________________ email __________________________________________

5.2. Disputes contact person name, surname: ____________________________


5.3. Finance contact person name, surname: ________________________________________


6. Information about business activity

6.1. Please choose the industry of business activity:

Describe the specifics if necessary ___________________________________________________________________________________________

If chosen industry marked by * - fill the 6.2., 6.3., 6.5. and 7.6. points

6.1. Does the Merchant carry economic activity in the country of registration? Yes No (specify the country in which

the economic activity is being carried out) _______________________________________________________________________________

*6.2. Is the Merchant a member or participant in the organization which unites merchants of the relevant field?

Yes (specify name) ____________________________________________ Website ____________________________ No

*6.3. Describe your customers:

Individuals __________ % of the total number of customers

Legal entities __________ % of the total number of customers

LV residents __________ % of the total number of customers

LV non-residents __________ % of the total number of customers

6.4. Please specify countries of residence of your customers ____________________________________________________________________

*6.5. Please specify countries of economic/personal activity of your customers ___________________________________________________

6.6. Duration of business activities (years) ____



6.7. The turnover of the previous year reported in last financial statement (EUR) _________________________

7. Additional questions to the Merchant whose business activity requires license or registration in relevant authority

7.1. Provide legislation applied in mentioned business activities (country of incorporation/ country of business):

_______________________________________________________________________________________________________________________________7.2. Whether the company is a subject of its country of incorporation laws that are aimed to fight against money-laundering and

terrorism financing? No Yes (specify the laws, structures, internal acts, the name, surname, contact information of

responsible persons): ______________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________7.3. Does the Company perform identification, investigation, origin of funds analysis of the customers and keep records related to

the customer investigation? __________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________7.4. Please describe the methods of restrain and control, which you apply in order to follow requirements to the relevant type of

activity (incl. Notes, cautions and warnings, etc.) __________________________________________________________________________________________________________________________________________________________________________________________________________7.5. Whether the company is a subject of its supervisor regular control (exc. Revenue services)? No Yes (provide

controlling organization and date of last control)

_______________________________________________________________________________________________________________________________

*7.6. Is the Merchant a financial institution within the meaning of U.S. FATCA? Yes (specify) No

Conformity FATCA status of the financial institution

_______________________________________________________________________________________________________________________________

FATCA Global Intermediary Identification Number (GIIN)

_______________________________________________________________________________________________________________________________

The reasons for the lack of financial authorities GIIN

_______________________________________________________________________________________________________________________________

* “Financial institution” - Holder institution, a Depository institution, an Investment entity, or a Specified Insurance Company.

a) “Custodial Institution” - any entity that holds, as a substantial portion of its business, financial assets for the account of others.

b) “Depository institution” - any entity that accept deposits in the ordinary course of a banking or similar business.

c) “Investment entity” - any entity that conducts as a business (or is managed by an entity that conducts as a business) one or more of the following

activities or operations for or on behalf of a Merchant (for example an account holder):

i) Trading in money market instruments (cheques, bills, certificates of deposit, derivatives, etc.); foreign exchange; exchange, interest rate and

index instruments; transferable securities; or commodity futures trading;

ii) Individual and collective portfolio management; or

iii) Otherwise investing, administering, or managing funds or money on behalf of other persons.

This subparagraph “c” shall be interpreted in a manner consistent with similar language set forth in the definition of “Financial Institution” in the Financial

Action Task Force or FATF Recommendations.”

d) The term “Specified Insurance Company” means any entity that is an insurance company (or the holding company of an insurance company) that

issues, or is obligated to make payments with respect to, a Cash Value Insurance Contract or an Annuity Contract.

I Certify that the information in this document is complete and true.

8. Documents required by bank (in case of need upon additional request)

1Politically exposed person — a person, who is currently, or has been in the past in the Republic of Latvia or other member state or third country, in a publicly significant position, including the highest

official of a state authority, head of state administrative division (local government), head of a government, a minister (deputy of minister or deputy of minister’s deputy, if the respective country has

such a position), secretary of state or other high level official in a government or state administrative division (local government), member of a parliament or member of a similar legislative body,

member of an authoritative structure (the board) of a political party, a judge of the constitutional court, supreme court or a different level court (member of a judicial institution), member of the council

or member of the board in highest revision (audit) institution, member of the council or member of the board of a central bank, an ambassador, authorized clerk, highest officer of the armed forces,

member of the council or member of the board of a state capital company, head (director, deputy director) of an international organization and member of the board or a person, who has an

equivalent position in this organization. 2Family member of a politically exposed person — a person, who is the politically exposed person’s: a) spouse or a person comparable to a spouse. A person can be considered as comparable to a

spouse, only if the legislation of the respective country provides this kind of a status, b) a child or a child of the politically exposed person’s spouse, or child of a person comparable to a spouse, his/her

spouse or a person comparable to a spouse, c) parent, grandparent or grandchild, d) brother or sister. 3Person closely related to a politically exposed person – a person, about whom it is known, that the person has business relationship or other close relations with politically exposed person,

or he / she is a shareholder or member in the same company with politically exposed persons, as well a person, who is the sole owner of a legal establishment, about which it is known, that it has been

established in the interest of a politically exposed person.

7.1. Registration documents 7.5. Identification document (passport) of the Authorized Person

7.2. Articles of Association 7.6. License (if available)

7.3. Excerpt from the Company Register of the Company of incorporation with complete

applicable information (no older than 15 days)

7.4. Document certifying the delegate’s authority to represent the Merchant in the dealings with

7.7. Financial Statements

7.8. Contracts with partners

7.9. Recommendations / statements from banks, including the current bank acquirer

JSC “LPB Bank” (e.g. a resolution, order, regulation, etc., by the founders, members or other 7.10. Documents on the ownership / lease property

authority) 7.11. Other



4 Person related to the United States - a person who meets any of the following conditions: 1) The person has U.S. citizenship or a legal residence permit (green card); 2) Persons is the United States

taxpayer; 3) The person's place of birth is the United States; 4) The person has a phone number with a US country code; 5) The person's residence address or correspondence address is in the United

States (including the United States P.O. box); 6) The power of attorney was issued to a person who is related to the United States.

Confirmations:

I Certify that the information in this document is complete and true. I undertake to immediately inform the Bank in writing on any changes in the above information. I am informed that in accordance with General terms of service, Merchant Questionnaire

is an integral part of the Agreement and the signing of this Application means the signing of the Agreement, except the Bank Services, which can be received only by signing of Special agreement;

Merchant allows the Bank to perform processing of the Merchant’s and its other persons data (gathering, saving, registering, submitting, transferring, transmitting and

other), which the Merchant has submitted to the Bank, as well as, in the order set by applicable law, to request and receive the mentioned data and other information from third persons and

process it. Bank has the right to transfer personal data of Merchant to third persons, if the Bank considers it necessary in order to provide services or collect debts from the Merchant. The Merchant

confirms that he has the right to transfer the data of other individuals to the Bank.

By signing the present Questionnaire, the representative of the Merchant hereby confirms that: — the Merchant is not involved in providing other products and services, except the products and services indicated in the present Questionnaire;

— the Merchant undertakes to promptly inform the Bank about any changes in the range of products and services indicated in the present Questionnaire;

— all information provided above is complete and reliable, and the Merchant undertakes to promptly inform the Bank about any changes in the information provided above;

— he/she is authorized to represent the Merchant and has the right on behalf of the Merchant to submit the information indicated in the present Questionnaire, which is binding to the Merchant

and the Bank;

— he/she is informed about the responsibility, including criminal responsibility, for the provision of knowingly false or incomplete information;

— he/she is familiar with the General provisions of transactions and fees of the Bank, agrees to them and recognizes them to be binding to him/her.

Authorized person ___________________________________________________________________________________

(name, surname)

__________________________________________________ ______________________ _________________

(position) ( signature ) (date)