1. Client Identification & Contact Details

Name:

First

Last

CLIENT IDENTIFICATION & CONTACT DETAILS

Other names (or aliases) known by or used:

City:

Address:

Marital Status:

Zip Code:

Previous addresses (for the last 3 years):

Passport details:

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Country of issue:

Expiry Date

Social Security number:

Home Telephone number:

Email address:

Passport number:

Place of Issue:

Other citizenships (if any):

Mobile number:

2. Income

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Employer name and address:

Job title:

Shareholding in employer (if applicable):

Business description:

Salary and bonuses in each of the last 3 years:

Summary of other material income:

3. Personal Asset & Liability Statement

The information collected on this form is confidential and will only be used for the purpose of assessing your viability for fine art financing. If you fail to provide complete and accurate information or if you delay in supplying any information that we require, delays may occur. If you provide fraudulent, false or misleading information that we rely upon, you may face legal action for any losses or damages suffered by us.

Attachments:

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4. High Net Worth Statement

Please provide a completed high net worth statement in the form set out in Annex I hereto. For the avoidance of doubt, Part A of Annex I must be completed by a person qualified to make a statement of high net worth under the rules made by the Financial Conduct Authority. Part B of Annex I must be completed and signed by you.

Attachments:

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5. Financing

Financing amount requested:

Financing amount: $10000

Financing details

Requested tenor of financing:

Expected use of proceeds of financing:

Details of account to which payment is to be made:

Expected source of funds for repayment:

6. Fine Art Details

Upload Images & Files related to the Artwork

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.pdf, .jpg, .png, .doc

Fine Art Details

Artist(s) name:

Dimensions:

Date of artwork (approximate if not known):

Artwork Name

Expected source of funds for repayment:

Condition of the artwork and details of any previous restoration, conservation and scientific examination of the artwork:

Details of any previous valuations (if relevant) including the basis for such valuations, e.g. insurance purposes:

Location of artwork (if different to home address) and details of who owns the property:

Details of any security systems at location (including connectivity of burglar and fire alarm system):

Ownership of artwork (personal property, co-owned with spouse, trust, etc.):

If artwork is held in trust/ partnership/ foundation/ etc., evidence of authority to sell it, including details of any restrictions on sale (e.g. agreements that sales must be through a specific auction house):

Details of any charges, liens or other security over, or interests in, the artwork:

Is, or will, the artwork be held in bond? If so please provide details:

How and when artwork was acquired and any associated family history (including any available documentations such as bills of sale, sales catalogues, invoices, contracts, wills, deeds of gift, etc.):

If the artwork was recently acquired, please provide the Bills of Sale or Invoices:

Details of any expertise or certificates regarding attribution (e.g. the artwork appears in the relevant catalogue raisonné):

Please provide any supporting documentation that substantiates provenance (e.g. auction catalogues and publications):

Please provide a recent photo of the artwork:

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Insurance details (including value for insurance purposes):

Loss record for all losses in relation to any artwork owned by you or in which you had an interest for the last 5 years which (i) were claimed; or (ii) were not claimed for any reason (e.g. because they were not insured or because the loss was below the excess under the insurance policy):

Any request for insurance (of any type) that has been declined or cancelled (for any reason):

List of countries the artwork has been located in since 1970 (please provide export licenses, import documentation for the UK, declarations, taxes paid and details of how the artwork was transported): Please provide details of any claim or potential claim by any party asserting any right, title or interest in the artwork:

7. Adviser Details

Legal adviser name and contact details:

Accountant name and contact details:

I hereby certify that the above information is true, accurate and correct to the best of my knowledge. I authorise thru this document to pass on the information, including my personal details, to other related companies, its professional advisers, insurers, brokers and other third parties, only to the extent required to consider my request for financing.

I understand and agree that Oblyon and its related companies (together “Oblyon Group”) or third parties engaged by Oblyon will verify all or part of the information I have disclosed in this questionnaire. I understand that this verification may include an inquiry into my credit history, criminal and civil records as well as other public record information. My signature below constitutes my authorisation for Oblyon or third parties engaged by Oblyon to check my background. I release and hold harmless each member of Oblyon and third parties engaged by Oblyon from all liability with respect to any such background check so far as permitted by law.

I agree the above will also apply in relation to any additional information I provide in response to queries on the information disclosed in this questionnaire.

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Print name:

Actual Date / Time

Time

Upload Your Signature

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New Financing?Register now

1. Client Identification & Contact Details

2. Income

3. Personal Asset & Liability Statement

4. High Net Worth Statement

5. Financing

6. Fine Art Details

7. Adviser Details

New Financing?
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