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PRIVATE FOREIGN CURRENCY EXCHANGE AGREEMENT

US DOLLARS ($ USD) FOR EURO (€ EUR)
Bank to Bank SWIFT TO SWIFT (MT 103/23)

Date xx/xx/xx

This private foreign exchange transaction agreement and the four (4) attached Annexes are entered on
this 04th, day of February 2011 by and between:

USD PROVIDER PRINCIPAL:

COMPANY NAME :
REPRESENTED BY :
ADDRESS :
COUNTRY :
PASSPORT Nº :
PHONE :
FAX :
E-MAIL :

(Hereinafter referred to as USD Principal or USD-P)

AND

EURO PROVIDER PRINCIPAL :

COMPANY NAME :
REPRESENTED BY :
ADDRESS :
COUNTRY :
PASSPORT Nº :
PHONE Nº :+
FAX Nº :+
E-MAIL: :

(Hereinafter referred to as Euro Principal or EUR-P)

REPRESENTED BY :
ADDRESS :
COUNTRY :
PASSPORT NO :
PHONE : +
E-MAIL :
(Hereinafter referred to as Euro Mandate)

WHEREAS, in consideration of the promises and the mutual covenants, warranties, terms and conditions
herein contained and for other good and valuable consideration, the receipt and sufficiency of which are
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hereby acknowledged, the undersigned parties agree and state that they wish to enter into this agreement
for the exchange of United States Dollars (USD) for Euros (EUR) under the following terms and conditions:
This currency exchange transaction is a bank to bank transaction, to be executed via SWIFT transmittal
transfer mode upon banks agreement, according to the following terms, conditions and agreed Bank to Bank
procedure.

BY THE EURO PRINCIPAL / AUTHORIZED SIGNATORY:

I HEREBY SWEAR UNDER THE INTERNATIONAL LAWS OF PERJURY AND FRAUD THAT THE INFORMATION
PROVIDED BY ME HEREIN IS ACCURATE AND TRUE AND THAT I HAVE READ AND UNDERSTOOD THE FULL
CONTRACT. SIGNED AND SEALED ON THE DATE INDICATED BELOW BY SIGNATURE:

SIGNATURE: __________________________
NAME :
PASSPORT Nº :
DATE OF EXPIRY :
COUNTRY OF ISSUE :
TITLE :

BY THE USD PRINCIPAL / AUTHORIZED SIGNATORY:

I HEREBY SWEAR UNDER THE INTERNATIONAL LAWS OF PERJURY AND FRAUD THAT THE INFORMATION
PROVIDED BY ME HEREIN IS ACCURATE AND TRUE AND THAT I HAVE READ AND UNDERSTOOD THE FULL
CONTRACT. SIGNED AND SEALED ON THE DATE INDICATED BELOW BY SIGNATURE:

SIGNATURE: ___________________________
NAME :
PASSPORT Nº :
DATE OF EXPIRY :
COUNTRY OF ISSUE :
TITLE :

INTENTIONALLY LEFT BLANK

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ANNEX “D”
The USD Provider and the EURO P presents the legal tender United States Dollars (USD) and
EUROS available in a bank and warrants under penalty of perjury laws of jurisdiction as it applies,
that the US DOLLAR and EURO funds are totally derived from legal sources and not from any
illegal drug traffic or money laundering activities, terrorist group or association and neither from any
other criminal activity, and confirms that the funds are good, clean, clear, of non-criminal origin,
free from any liens and taxes, freely transferable to be exchanged for Euros (EURO) and USD

The parties must follow the guidelines provided by the rules of the banks on the Anti-Terrorism Act
and the U.S.A. Patriot Act I and II. The USD-PR and EURO-PR will not be held responsible for any
harmful money laundering.

Each Party, individually and separately, accepts liabilities on taxes, import, levies, duties or
charges that may be applicable while in the execution of their institutional role.

USD PROVIDER EURO PROVIDER

SIGNATURE:_________________ SIGNATURE:__
_________________
NAME: NAME:
PASSPORT Nº: PASSPORT Nº:

EURO Mandate

SIGNATURE:___________________
NAME:
Passport No:

INTENTIONALLY LEFT BLANK

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EURO PROVIDER PASSPORT COLOR COPY

EURO MANDATE PASSPORT COLOR COPY

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USD PROVIDER PASSPORT COLOR COPY

<<<<<<<< END OF DOCUMENT >>>>>>>>>

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