CLAIMANT VERIFICATION
First Name: _____________________________________________
Last Name: _____________________________________________
Current Address: _______________________________________ _
Country________________________________ Postal Code _____
Telephone (____) _____-_______________ Mobile Number:____
Signature________________________________________________
Email Address ___________________________________________
Additional Email Address (If Any) ________________________
AFFIDAVIT OF CLAIMANT
State of _________________}
County of _______________}
I declare that I have examined the information on this form and to
the best of my knowledge and belief it is true, correct and complete.
I understand that presenting a false or fraudulent claim, in whole or in part,
to the MC Capital Markets LLC may subject me to criminal and/or civil penalties
as provided for in 18 U.S.C. §287 and 31 U.S.C. §3729, respectively.
____________________________
Affiant (Signature)
Signed and sworn to (affirmed) before me
_________________________, this_________ day of _____________, 201_, by
(Notary Public)
________________________________.
(Affiant Name)
__________________________________My commission expires _______________