Special authorization form and Client / User file FOR NATURAL PEOPLE ABROAD

I' YY MM DD
NAME SURNAMES BIRTHDATE

IDENTIFICATION TYPE ( RC, CC, TI, CE, PA, CM, CA, OT) No. IDENTIFICATION

RESIDENCE ADDRESS TELEPHONE MOBILE

RESIDENCE CITY COUNTRY OF RESIDENCE OFFICE OR PROFESSION OCCUPATION

ACTIVITY DESCRIPTION

INDEPENDENT OR DEPENDENT WORKER MAIN ECONOMIC ACTIVITY

NAME OF THE COMPANY WHERE IT WORKS OFFICE ADDRESS TELEPHONE FROM WHERE IT WORKS

FINANCIAL DATA:

ASSETS - PROPERTY OF YOUR PROPERTY LIABILITIES - OBLIGATIONS WITH THIRD PARTIES INCOME - SALES - MONTHLY EARNINGS

EXPENSES - EXPENSES - MONTHLY DEDUCTIONS IF YOU HAVE OTHER INCOME DETAIL OF WHAT OPERATION, TRANSACTION OR BUSINESS COMES FROM

CURRENCY USED IN FINANCIAL DATA: USD () EUROS () POUNDS () COLOMBIAN PESOS () OTHER (WHICH) __________________

SPACE TO KNOW IF THE BENEFICIARY / SENDER CARRIES OUT ACTIVITIES IN FOREIGN CURRENCY (OTHER THAN THE COLOMBIAN WEIGHT)

CARRY OUT ACTIVITIES IN FOREIGN CURRENCY IN CURRENCIES OR ANOTHER CURRENCY OTHER THAN THE YES NO
COLOMBIAN PESO:

WHAT ARE THE TYPES OF FOREIGN CURRENCY TRANSACTIONS OTHER THAN INTERNACIOAN PAYMENTS THAT YOU HAVE
PLEASE DILIGENCE THIS PICTURE:
TYPE OF PRODUCT No. PRODUCT TYPE OF MONEY PRODUCT COUNTRY VALUE ENTITY

(1) In accordance with Articles 1505, 2144 and following of the Civil Code, in accordance with numerals 1 and 1.1 of the External Circular DCIN-83 of December 16, 2004 of the Bank of the Republic where it states that "It may be grant mandate to the
Intermediaries of the Exchange Market for the presentation of the Declarations of Change, "I confer ample and sufficient SPECIAL POWER in favor of Financiera Pagos Internacionales S.A. C. F., so that in my name and representation diligencie,
subscribe, sign and present the corresponding Declaration of Change, referred to in Article No. 1 of External Resolution No. 8 of 2000 of the Board of Directors of the Bank of the Republic and numerals 1 and 1.1 of the Regulatory Circular External
DCIN - 83 of the Bank of the Republic and its modifications, for each one of the remittances that in the future it receives from the outside Financial International Payments S.A. C. F. to be paid in my name, as well as for to complete and sign all the
documents required to legalize them.

(2) Through this document and as a beneficiary of international remittances, I also AUTHORIZE Financiera Pagos Internacionales S.A. C. F. for (A) That he cancels in my favor all the money that he receives in my future in my name; (B) So that in the
case that Financiera Pagos International S.A. C. F. receive money orders for account in my name, order the transfer of the value of each of the money orders, in Colombian pesos, only and exclusively in the bank account mentioned below or to
constitute in the International Payment International S.A. C. F. financial products; (C) to carry out the procedures of endorsement, lifting of stamps and other necessary to make the payment of any money order, CDT`s or savings accounts in which I
am a beneficiary.

Likewise, I authorize Financiera Pagos Internacionales S.A. C. F. to delegate this special mandate and / or also grant a special mandate on behalf of the official
of Financiera Pagos Internacionales S.A. C. to whom said institution delegates the mandate conferred upon it, who (is) for the present event is (are)

The agents appointed here, may act independently of each other, for the purpose of carrying out the assignment conferred here
Account type
NAME OF THE FIRST AND ONLY ACCOUNT HOLDER
CURRENT SAVINGS

NAME OF THE BANK CITY OF ACCOUNT CREATION ACCOUNT NUMBER

MOTIVE FOR SENDING

(3) Under the severity of the oath and acting on its own behalf, voluntarily and giving certainty that everything herein is true, I make the following statement of origin of funds to Financiera Pagos Internacionales S.A. C. F., with the purpose that you can
give compliance with the provisions of the current regulations for the control and prevention of money laundering: A. The monies received by the Financiera Pagos Internacionales S.A. C. F., through these drafts and other operations, including
deposits, come from object and cause lawful;

THE RESOURCES I RECEIVE THROUGH FINANCIAL INTERNATIONAL PAYMENTS S.A. COME FROM THE FOLLOWING SOURCE:

(payment obligations / savings // fees or salaries // business // family support)

I irrevocably authorize Financiera Pagos Internacionales S.A. C. F. and in guardian of the commercial moral, to report, and to consult in the power stations of risk of a public or private nature, my name, identity document number, and the other
pertinent data included in this form and to my financial, credit and commercial operations. In record of the above:

DILIGENCE DATE SIGNATURE

Fingerprint

FOR EXCLUSIVE USE OF FINANCIERA PAGOS INTERNACIONALES S.A. CF

I, _________________________________________________________________________________________________________________
IDENTIFIED WITH THE NUMBER

IN REPRESENTATION OF FINANCIAL INTERNATIONAL PAYMENTS S.A. CF IN SIGN OF ACCEPTANCE OF POWER AND PREVIOUS AUTHORIZATION

I SIGN TO ____________ DAYS OF THE MONTH OF ______________ OF THE YEAR _______________

SIGNATURE Fingerprint

*1 - Tipo y No. de Identificación ( NT, RC, CC, TI, CE, PA, CM) :Personas Nacionales: Número de identificación: NT= NIT, RC= registro civil de nacimiento, CC=cédula de ciudadanía y TI= tarjeta de identidad. Personas Extranjeras: Número de
identificación: CE= Cédula de extranjería, PA= pasaporte vigente para titulares de visa de turista o visitante u otra clase de visa con vigencia inferior a tres (3) meses, o CM= carné expedido por la Dirección de Protocolo del Ministerio de Relaciones
Exteriores para titulares de Visas Preferenciales (diplomático, consular, de servicio, de organismos internacionales o administrativo, según el caso, y de acuerdo con las normas migratorias vigentes). Nacionales turistas de los países miembros de la
Comunidad Andina de Naciones. Número de identificación: CA= Documento de identificación válido y vigente en el país emisor con el cual ingresó a Colombia. OT: Otro documento distinto de los anteriores y que se utilice en el país de origen de la
orden del giro.