Statement of Individual Ultimate Beneficial Owner(s)
To: PT Bank CIMB Niaga Tbk.
I, _______________________________ (Full Name), as a _____________________ (Occupation) of the above mentioned company, hereby declare that at the time this document was signed, the following names are individuals who have a share in the company for at least 25% or more, either directly, or indirectly.
Full Name of
Individual Beneficial Owner(s) Alias (If any)
Full Address Nationality Birth Place & Date of Birth
Percentage Interest (%)
NB: Extra lines for name should be added
I, on behalf of the company stated that will immediately inform the PT Bank CIMB Niaga Tbk if there is a change in ownership information related to the data mentioned above.
Company Name
Address
Signature: Full Name:
