A – Basic Information:

1. Surname, name, patronymic (if any)

2. Date of birth

3. Place of birth

4. Place of residence (stay)

5. Tel:

6. Citizenship

 ___ Russian Federation

 ___ USA

 ____ Other ____________________

7. INN (if any)

8. Account number

In regard to the account, I am:

 ____ Account holder

 ____ Authorised representative

 ____ Other ____________________

B – Declarations:

 ____ I declare that one (or both) of my parents has not lived in the USA for more than 5 years since he/she was 14 years old.

 ____ I declare that I do not have a Green Card

 ____ I declare that I have not been present in the USA for more than 31 days in the current year and more than 183 days in total during three preceding years*

* If you have not ticked this item, please tick one of the following subitems to classify yourself as:

 ____ official temporary present in the USA by reason of A and G visas;

 ____ teacher or trainer temporary present in the USA by reason of J and Q visas;

 ____ student temporary present in the USA by reason of F, J, М, Q visas;

 _____ sportsman temporary present in the USA to participate in charitable sports events;

 ____ person formally classified as resident alien who has proved their close financial connection with another state during their presence in the USA. Signs of such a close connection are: physical presence in the USA for less than 183 days during one calendar year, taxes paid (tax return filed) in another country, permanent residence, family, major property assets, business being in the foreign state;

 ____ other.

C – Confirmation of reliability of information provided and consent to transfer:

I declare that:

 ____ Information provided on this Questionnaire is true and accurate

 ____ I undertake to inform you of any changes to the information provided within 30 days

 ____ I hereby give my consent to information transfer to the Internal Revenue Service (IRS), the Bank of Russia, Rosfinmonitoring and the FTS

Signature

Date of completion