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Self Risk Assessment
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Questionnaire
First Name
Middle Name
Last Name
Date of birth
Nationality
Place of birth
Any other nationality
Yes
No
Other nationality
Permanent address
Phone Number
Address mail
Contact address (if different)
Fiscal address
US person (yes/no)
YES
NO
TIN Number
Are you married
YES
NO
First Name (Spouse)
Middle Name (Spouse)
Last Name (Spouse)
Date of birth (Spouse)
Nationality (Spouse)
Place of birth (Spouse)
Any other nationality (Spouse)
YES
NO
Other nationality (Spouse)
Do you have children
YES
NO
First Name (Child 1)
Middle Name (Child 1)
Last Name (Child 1)
Date of birth (Child 1)
Nationality (Child 1)
Place of birth (Child 1)
Any other nationality (Child 1)
YES
NO
Other nationality (Child 1)
Do you have other children
YES
No
Are You PEP ?
YES
NO
are you Link to country/ies under sanction ?
YES
NO
Which Country ?
Have you judicial Procedure?
YES
NO
Are you under criminal investigation ?
YES
NO
How are you PEP ?
Which activity ?
What link ?
What activity has the link ?
Which type of procedure?
What are you ?
when did it happen?
What was the decision
was it old?
When was it closed ?
Which type of criminal investigation ?
when did it happen?
What was the decision
was it old?
When was it closed ?
Do you have a professional activity ?
YES
NO
Sector of activity
Occupied position
Start date
Name of the company
Location of the company
Last Diploma
Date of the last diploma
Sector of study
School / University
Amount of total Wealth
Denomination currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Type of wealth
Deposit in bank transferable securities
Denomination Currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Indicative amount
Indicate name of establishment
Country of the establishment
Industrial assets
Denomination Currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Indicative amount
Indicate name of the company
Country of the company
Real estate assets
Denomination currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Indicative amount
Indicate type of RE asset
Country of the RE
Other
Denomination Currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Indicative amount
Describe the type of wealth
Denomination Currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Indicative amount
Type of revenue
Savings from salary
Denomination Currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Indicative amount
What is the activity
Start Date
End Date
Postion
Financial Analysis
Name of the company
Salary amount
Business activity
Denomination Currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Indicative amount
Date of establishment
Name of the company
Activity of the company
Background of the company
Turnover
Profit
Number of employees
Position (if applicable)
% of shares
Other shareholders >10%
Name of the shareholder
Nationality
Inheritance/Donation
Denomination Currency
CHF (Swiss Francs)
USD
EUR
GBP
JPY
Indicative amount
Date of inheritance / Donation
Name of the donator
Source of wealth
Financial investment
Denomination Currency
CHF (Swiss Francs)
Indicative amount
Date of investment
Amount invested
Plus-value
Description
Real estate investment
Denomination Currency
CHF (Swiss Francs)
Indicative amount
Date of acquisition
Price of acquisition
Date of sale
Price of sale
Type of real estate
Location
Other
denomination currency
CHF (Swiss Francs)
USD
Option EUR
GBP
JPY
Indicative amount
Information
Description
Submit the questionnaire
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