Source of Wealth Declaration Form Template: Asset and Fund Origin

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:

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]