1 / 2
Published: 06/2020
WN450/Namibia PEP questionnaire
Wealth Namibia
PEP questionnaire
For us to do business with you, the Financial Intelligence Act (FIA), 13 of 2012, requires that we identify and verify all related parties to an investment.
We also have to comply with the provisions of the Prevention and Combating of Terrorist and Proliferation Activities Act, 4 of 2014. Under the FIA
nancial institutions have to implement a customer acceptance policy (“The Policy”). This includes identifying whether an investor is a politically
exposed person (PEP). A PEP is:
• an individual, whether domestic or foreign, who is or have been entrusted with prominent public functions, including heads of state or of
government, senior politicians, senior government, judicial or military ofcials, senior executives of publicly owned corporations and important
political party ofcials.
For these reasons, and to protect your investment, please answer the following questions:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
1. Are you in your domicile state/state of permanent residence holding a senior public position (eg state president,
prime minister, minister, deputy minister (or equivalent)?
2. Are you a member of parliament/member of a legislature?
3. Are you a member of the Supreme Court or another high court that passes non-appealable verdicts (allowing for
exceptional cases)?
4. Are you a judge of a financial court or member of the council of the central bank?
5. Are you an ambassador, consul or a high ranked military officer?
6. Are you a member of the managing or supervisory board of (majority) state-owned legal entities?
7. Are you an immediate family member of the person stated under 1-6 above:
7.1. spouse (including common-law partner), child (including adopted child)
7.2.
parent, brother, or sister
7.3. child (including adopted child) of the spouse in 7.1 above
7.4. the spouse (including common law partner) of the child in 7.1 above
8. Are you a personal or professional associate of the mentioned person(s) who commonly benefit from the assets
or from an established business relationship or from another form of close business contact with the person(s)
mentioned above?
9. If you are a politically exposed person, please state the source of the assets or funds that are or will be the subject of the business relationship or
transaction.
By signing this questionnaire, I co
nrm that the information I have given is true and correct.
First and last name of person
completing the form
Fulfilled by an MM Namibia employee
I agree that a business relationship is established with the person:
Place
Signature
Date
D D M M Y Y Y Y
Investment number P P
