CLIENT INFORMATION SUMMARY

In accordance with Articles two (2) through five (5) of the Due Diligence Convention and the Federal Banking
Commission Circular of December 1998, concerning the prevention of money laundering, and Article 305 of the
Swiss Criminal Code, the following information may be supplied to banks and/or other financial institutions for the
purpose of verification of identity and activities of the investing Member, and the nature and origin of the funds that
are to be utilized. All parties have an obligation to respect professional secrecy and to take all appropriate
precautions to protect the confidentiality of the information each holds in respect of the others’ activities. This legal
obligation shall remain in full force and effect at all times.

Assets Available :
Kind of Funds :
Client Name (Signatory) : RINA RISWATI
Passport Number : A4358764
Country of Residence : INDONESIA
Passport Issue/(Date/Place) : 21 JAN 2013
Passport Expiry Date : 21 JAN 2018
Date and Place of Birth : 26 JUN 1975
Home Address : VILLA MUTIARA GARDE IV/3 RT.006/011 DESA
BULOROKENG KECAMATAN BIRING KANAYA KOTA
MAKASAR PROPINSI SULAWESI SELATAN
Home Fax Number : + 62.81254046362
Clients Email Address : rinariswati1975@gmail.com
Do you speak English? :
Business Name :

Business Address :
Registered Office Domicile :
Business Tax ID Number :
Years in Business :
Registration Number :
Country / State of Incorporation :
Business Telephone Number :
Business Fax Number :
Legal Adviser: (Law Firm) : AZH & PARTNERS LAW FIRM
Legal Adviser Mail Address : PONDOK PINANG CENTER BLOK A2 NOMOR 2 CIPUTAT
RAYA JAKARTA SELATAN
Address for Mail Delivery : ahmadzarkasihh@gmail.com

Bank Name : PT.Bank Mandiri (persero) TBK

Branch : Makassar Vetran Indonesia
Bank Address : Vetran Utara no : 206 B-C Makassar 90145
Bank Officer / Title : -ERNOLD, RS.Papalangi
Telephone Number : (62-0411) 3632367
Facsimile Number : (62-0411) 3632354
Account Number : 152.00110.56880
SWIFT Code : BMRIIDJA
Account Name / Signatory : RINA RISWATI
BANK ADDRESS ACCOUNT NAME : VILLA MUTIARA GARDEN 10/3 RT.006/001 BULUROKENG
KECAMATAN BIRINGKANAYA KOTA MAKASSAR PROPINSI
SULAWESI SELATAN
 Page 1 of 2 Client Summary

How were funds/assets earned?

The funds were lawfully earned through commercial enterprise of non-criminal origin, being free and clear of any
and all liens and encumbrances and I am authorized to offer it for use as collateral. I also affirm, attest, and certify
that the proceeds derived from any use of the Funds shall be utilized in a legal manner for either commercial or
charitable purposes at my election.

Origin of the funds/assets?

I, …………………………., hereby declare under penalty of perjury and with full personal and legal
responsibility under the Swiss court of law that I legally hold the sum of US$ OR EURO …………………… and
it is deposited in account number ………………

Are funds/assets free and clear? Yes

I further declare that 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 funds.

Brief Overview of corporate Activity:

Declaration: I swear under penalty of perjury, the information given above is both true and accurate. I am the
signatory on the aforementioned bank account. All monies/assets engaged in this transaction are derived from non-
criminal origin: and are good cleared. The origin of funds/assets is in compliance with Anti-Money-Laundering
Policies as set forth by the Financial Action Task Force (FATF) 6/01.

Dated this

_____________________________
Name : RINA RISWATI
Passport :
Date of Issue :
Date of Expiration :
Country of Issue :
Page 2 of 2 Client Summary