Source of Wealth Declaration Form Template

Full Name: [Full Name]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Email Address: [Email Address]
Phone Number: [Phone Number]

Date: [Date]
Reference Number: [Reference Number, if applicable]

1. Declarant Information

Full Name: [Full Name]
Date of Birth: [Date of Birth]
Nationality: [Country]
Residential Address: [Address]
Occupation: [Occupation]
Employer or Business Name: [Name, if applicable]

2. Purpose of Declaration

This Source of Wealth Declaration is provided for the following purpose:

☐ bank onboarding
☐ investment or financial review
☐ compliance or due diligence
☐ property or business transaction
☐ account review
☐ other: [Describe]

Name of requesting institution or organization:

[Institution or Organization Name]

3. Summary of Source of Wealth

My wealth has been derived from the following lawful sources:

☐ salary or employment income
☐ business ownership or profits
☐ investments or dividends
☐ sale of property or other assets
☐ inheritance
☐ gifts
☐ trust distributions
☐ retirement or pension income
☐ other: [Describe]

4. Detailed Explanation

Please describe how your wealth was accumulated:

[Insert explanation of employment history, business activity, investments, inheritance, asset sales, or other relevant background]

Estimated period during which wealth was accumulated:

[Insert years or date range]

5. Major Assets or Wealth Components

The main assets or holdings connected to my wealth include:

[Real estate]
[Business interests]
[Investment accounts]
[Savings or deposits]
[Other major assets]

Additional notes:

[Insert details]

6. Supporting Documents

The following documents are attached or available to support this declaration:

☐ pay slips or salary statements
☐ tax returns
☐ bank statements
☐ business financial records
☐ sale agreements or closing statements
☐ inheritance or probate documents
☐ trust documents
☐ investment statements
☐ other: [Describe]

7. Additional Information

Additional explanation relevant to the origin of my wealth:

[Insert details]

8. Declaration

I declare that the information provided in this Source of Wealth Declaration Form is true, complete, and accurate to the best of my knowledge.

I understand that this declaration may be relied upon for compliance, due diligence, onboarding, or other lawful review purposes.

9. Signature

Signature: __________________________
Name: [Full Name]
Date: [Date]

10. Internal Review, if Applicable

Reviewed By: [Name]
Title: [Title]
Review Date: [Date]
Comments: [Notes]