12.3 PLEASE SPECIFY BENEFICIAL OWNERS1 OF THE CLIENT AND SUBMIT A STATEMENT OF THE CLIENT’S INCOME STRUCTURE3 Name and last name Personal code (for foreigners date of – Country of tax residency2 Country of birth Adress Filled by Lithuanian tax payers only: Citizenship Tax identification number (TIN) Percentage of ownership / share / voting rights Name and last name Personal code (for foreigners date of – Country of tax residency2 Country of birth Filled by Adress tax payers only: Citizenship Tax identification number (TIN) Percentage of ownership / share / voting rights Name and last name Personal code (for foreigners date of – Country of tax residency2 Country of birth Filled by Adress tax payers only: Citizenship Tax identification number (TIN) Percentage of ownership / share / voting rights Name and last name Personal code (for foreigners date of birth) – Country of tax residency2 Country of birth Adress Filled by tax payers only: Citizenship Tax identification number (TIN) Percentage of ownership / share / voting rights consult with the Client’s manager as to the necessity to fill in the statement 3Please are no such persons - owners or shareholders who own or own more than 25% of the legal entity‘s shares or voting rights (please explain):
12.3 PLEASE SPECIFY BENEFICIAL OWNERS1 OF THE CLIENT AND SUBMIT A STATEMENT OF THE CLIENT’S INCOME STRUCTURE3 Name and last name Personal code (for foreigners – date of Country of tax residency2 Filled by tax payers only: Country of birth Adress Citizenship Tax identification number (TIN) Percentage of ownership / share / voting rights Name and last name Personal code (for foreigners – date of Country of tax residency2 Filled by tax payers only: Country of birth Adress Citizenship Tax identification number (TIN) Percentage of ownership / share / voting rights Name and last name Personal code (for foreigners – date of Country of tax residency2 Filled by tax payers only: Country of birth Adress Citizenship Tax identification number (TIN) Percentage of ownership / share / voting rights Name and last name Personal code (for foreigners – date of birth) Country of tax residency2 Filled by tax payers only: Country of birth Adress Citizenship Tax identification number (TIN) Percentage of ownership / share / voting rights 3Please consult with the Client’s manager as to the necessity to fill in the statement are no such persons - owners or shareholders who own or own more than 25% of the legal entity‘s shares or voting rights (please explain): Lithuanian
ja_anketa_prasymas_en.docx