Personal & Pension Investors Application Form

Transcription

1 Personal & Pension Investors Application Form Secure Bond 12 NOVEMBER 2018 MMPI Limited trading as Broker Solutions is regulated by the Central Bank of Ireland.

2 Personal & Pension Investors Application Form Broker Solutions Secure Bond 12 Please note that by signing this Application Form, you are confirming that you have read and understood the material in the Brochure and the Base Prospectus and that you have received advice from your Financial Broker in relation to the suitability and appropriateness of this investment for you. If you are unclear about any of the information presented in the Brochure or the Base Prospectus or about the suitability of this investment for you, please seek further advice from your Financial Broker before completing this Application Form. In order to effect this investment, unless you are an insured pension investor, you will also need to open an Execution Only Account with Merrion Stockbrokers Limited ( Merrion ). The Merrion Execution Only Stockbroking Account Opening Form (which includes its Terms of Business and Client Asset Key Information Document) is included within this pack of documentation for your completion. Note that Merrion will only provide you with an Execution Only service. It will not provide you with any investment advice or recommendation nor will it carry out any assessment of suitability or of appropriateness relating to your proposed investment. Your Financial Broker will provide you with investment advice or a recommendation and it will carry out an assessment of suitability or appropriateness of this investment for you. Merrion shall rely on the information transmitted to it by Broker Solutions in relation to you, the client, and shall rely on the assessment carried out by your Financial Broker. 1. Investor Information Please complete Section A or B (as appropriate) and Section C in BLOCK CAPITALS and return along with your cheque made payable to Merrion Stockbrokers Limited (or the investing life company where an investment is made on behalf of a Self-Directed or Self-Invested Insured Pension Plan). Prior to any transaction being entered into, a completed Application Form must be received. I/We hereby apply for the Broker Solutions Secure Bond 12 in the name(s) of: A. Personal Investors Primary Name*: Date of Birth: Address*: Telephone Number (Home): Address: PPS Number: Mobile Number: Nationality: Occupation: Secondary Name*: Date of Birth: Address*: Telephone Number (Home): Address: PPS Number: Mobile Number: Nationality: Occupation: *Certified proof of Identity and Address required. If your investment is being made together with another person you acknowledge that the investment will be a joint investment between the persons named herein. 2

3 B. Pension/Post Retirement Investors Scheme Name: Scheme Provider Name: Pre or Post Retirement: Scheme Type: Policy/Plan/Account Number: Revenue Number: Scheme/Trust/Fund Legal Entity Identifier (LEI): Trustee Company LEI: C. All Investors Foreign Account Tax Compliance Act (FATCA): Are you a citizen of, or resident for tax purposes in the US? Primary Investor: Yes No Secondary Investor: Yes No Common Reporting Standards: Are you resident in any country or territory other than Ireland for tax purposes? Primary Investor: Yes No Secondary Investor: Yes No If Yes, please list below the countries/territories in which you are resident and provide the relevant Tax Identification Number(s) (TIN) in each case: Primary Investor: Country/Territory: TIN: Secondary Investor: Country/Territory: TIN: Source of Wealth & Source of Funds Source of Wealth: Examples: Surplus Earned Income / Investment Gain or Income / Sale of Asset(s) / Retirement Lump Sum / Maturing Investment etc. Source of Funds: Payment by: (A) Cheque (drawn on an account in the name of the investor(s) (B) EFT (C) Existing Merrion Account Note: Drafts will not be accepted. 3

4 Investor Experience/Suitability & Appropriateness I/We would describe myself/ourselves as having the following Investment Knowledge and Experience: Basic (e.g. have never made an investment decision before) Informed (e.g. have made a number of investments in the past) Advanced (e.g. make regular investments on a frequent basis) Do you have any other experience or training relevant to making investment decisions? Yes No If yes, please provide any details: Please tick box A, B or C for each of the 9 investment product categories below and indicate the number of investments made and whether you were advised by a Financial Broker in each case: Investment Type (A) Basic (B) Informed (C) Advanced (Number of Advised by a Knowledge Knowledge Knowledge Investments in Financial Broker & Experience & Experience & Experience the last 5 years (Y/N) Equities Bonds Alternatives (commodities, hedge funds, private equity etc.) Real Estate Funds (all collective investments) Tax Based Investments Derivatives Structured Products (Capital Protected) Structured Products (Capital at Risk) Do you understand the risks of the investment, including the potential that you could lose 10% in the case of Option A or 5% in the case of Option B of the amount invested? Do you understand that any return will depend on the performance of the Underlying Investment and that in the event of adverse performance from the Underlying Investment, you may not receive any growth? Do you understand that the Bond is designed to be held for the full 5 year investment term and if you encash it early, the amount you may receive would depend on the value of the Certificates at the date of sale and that this value could be less than the amount you invested? Do you understand that if BNP Paribas is unable to pay the amounts due when the investment matures, or on earlier encashment, you may lose some or all of your initial investment as well as any indicative returns which you might have otherwise expected? Are your Investment Objectives and Risk Profile consistent with the Target Market described in Section 2.2 in the Brochure? Do you understand that you will not be entitled to compensation under any Deposit Protection Scheme as a result of your investment in this Bond? Do you understand the fees and charges described in the Costs and Charges Section 2.7 of the Brochure? Yes Yes Yes Yes Yes Yes Yes No No No No No No No 4

5 2. Application Amount I/We wish to invest in the Secure Bond 12 (Option A) I/We wish to invest in the Secure Bond 12 (Option B) ( 25,000 minimum in each Option in denominations of 1,000) and if necessary, to open a Merrion Account to do so. 3. Investor Declarations (Please confirm by ticking the boxes) I/We declare that the details above are correct, and that I/We are over 18 and confirm that I/We understand the Key Features and Terms & Conditions of the Bond set out in the Brochure and the Base Prospectus. I/We confirm that the Bond is consistent with my/our Investment Objectives and Risk Profile. I/We understand that the indicative terms outlined in the brochure are subject to change and that the final terms will not be known until 28 December I/We understand that I/We can lose 10% in the case of Option A or 5% in the case of Option B of the amount invested I/We understand that the investment will not be deemed to have been made until the application has been accepted and that, if and when accepted, the investment will commence on 4 January Where applicable, I/we confirm that I/we have received a copy of the Merrion Stockbrokers Limited Terms of Business and Client Asset Key Information Document ( CAKID ) and that I/We have read and understood this document and its contents. Where applicable, I/we hereby request and authorise you to place my/our Investment Amount in a Client Asset Account in the name of Merrion Stockbrokers Limited. Where applicable, I/we hereby authorise you to transmit to Broker Solutions and for Broker Solutions to transmit to Merrion client information you hold on me/us. Primary Signature: Secondary Signature: (Trustees where applicable) Date: Date: If you invest in this Bond you can lose 10% in the case of Option A or 5% in the case of Option B of the money you invest. Warning: The value of your investment can go down as well as up. 4. The General Data Protection Regulation (GDPR) Consent: I/we authorise Broker Solutions to hold my/our personal data on file and to process it for the purposes intended. Primary Signature: Date: Secondary Signature: (Trustees where applicable) Date: 5

6 5. Financial Broker Declarations (Please confirm by ticking the boxes) We have conducted a full review of this investor s financial circumstances. This Bond (in the form of Certificates involving derivatives and therefore a complex product) is suitable and appropriate for the investor. The client understands the Key Features and the risks of the Bond. This Bond is consistent with the investor s Investment Objectives and Risk Profile. We have advised the investor that they can lose 10% in the case of Option A or 5% in the case of Option B of the amount invested. We have complied in full with the Anti Money Laundering (AML) and combating terrorist system that applies to all designated bodies. Where an investor has been identified as potentially vulnerable, we have followed our internal procedures in this regard. We confirm that we are appropriately authorised by the Central Bank of Ireland to recommend this Bond to the investor and have done so in accordance with the requirements of such authorisation and also with due regard to the suitability and appropriateness approaches as laid down by the ESMA Guidance (ESMA(2014/146). Firm Name: Advisor Name: Advisor Signature: Date: Date: 6

7 Application Checklist 1. Completed Application Form Completed by Investor and by the Financial Broker 2. Completed Merrion Stockbrokers Limited Account Opening Application Form Completed by Investor and by the Financial Broker 3. Payment Cheque, EFT or Existing Merrion Account (Drafts will not be accepted) Cheques made payable to Merrion Stockbrokers Limited Account Details for EFTs below Investments via Pension & Post Retirement Schemes transfer investment monies via Administrator/Trustee 4. Personal Investors Certified Proof of Identity: Certified copy of valid passport, driving license for each Investor Certified Proof of Address: Certified copy of valid (within last 6 months) proof of address e.g. utilitybills (not mobile phone), bank statements, correspondence from Revenue etc. 5. Self Administered Pensions Trusts Certified copy of the Trust Deed Certified copy of the Revenue Approval Letter TRUSTEE COMPANY: Proof of Identity: Certified copy of valid passport, driving license for each Trustee Authorised Signatory signing the Application Form(s) Proof of Address: Certified copy of valid (within last 6 months) proof of address e.g. utility bills (not mobile phone), bank statements, correspondence from Revenue etc. for each Trustee Authorised Signatory signing the Application Forms Legal Entity Identifier: Trust LEI & Trustee Company LEI provided on Application Form BENEFICIARY: Proof of Identity: Certified copy of valid passport, driving license Proof of Address: Certified copy of valid (within last 6 months) proof of address e.g. utility bills (not mobile phone), bank statements, correspondence from Revenue etc. 6. Self Administered ARFs/AMRFs Certified copy Management Agreement (or other relevant set up document) TRUSTEE COMPANY: Proof of Identity: Certified copy of valid passport, driving license for each Trustee Authorised Signatory signing the Application Form(s) Proof of Address: Certified copy of valid (within last 6 months) proof of address e.g. utility bills (not mobile phone), bank statements, correspondence from Revenue etc. for each Trustee Authorised Signatory signing the Application Forms Legal Entity Identifier: Trust LEI & Trustee Company LEI provided on Application Form BENEFICIARY: Proof of Identity: Certified copy of valid passport, driving license Proof of Address: Certified copy of valid (within last 6 months) proof of address e.g. utility bills (not mobile phone), bank statements, correspondence from Revenue etc. 7. Insured Pension and Insured ARF/AMRF investors All documentation and investment instructions submitted to the relevant life company Bank Account Details Please make EFTs to the following account: Merrion Stockbrokers Limited Client Asset Account Bank of Ireland BIC: BOFIIE2D IBAN: IE 38 BOFI Reference: Investor Name 7

8 4 The Concourse, Beacon Court, Sandyford, D18 X4A4 MMPI Limited trading as Broker Solutions is regulated by the Central Bank of Ireland.

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10 Client Application Form SECTION 1: GENERAL INFORMATION WARNING: Please note that Merrion (Merrion Stockbrokers Ltd Trading as Merrion Private) will only provide you with an Execution-Only service. It will not provide you with any investment advice or recommendation nor will it carry out any assessment of suitability or of appropriateness relating to your proposed investment. Your Financial Broker will provide you with investment advice or a recommendation and it will carry out an assessment of suitability or appropriateness of this investment for you. Merrion shall rely on the information transmitted to it by the Product Producer (MMPI t/a Broker Solutions). FEES & CHARGES: Merrion does not apply custody fees directly for client accounts introduced by MMPI t/a Broker Solutions. Merrion receives a fee from MMPI t/a Broker Solutions to cover custody charges applicable to these client accounts. SECTION 1A: Execution Only Account Investor Type: **If pension account, please provide the following details. Pension Legal Name: **Pension Tax Reference No. EXECUTION ONLY SERVICE Merrion Private provides an Execution Only Custody service for investors who require services of a broker to Invest in Broker Solutions products. Merrion does not provide any investment advice or advise on the merits of any transactions. 2/11 All questions marked with an asterisk* are mandatory. Version 1.01

11 SECTION 1B: GENERAL INFORMATION INVESTOR 1: Please provide personal details of the beneficial owner. Name: *Please confirm if you wish to opt into receiving electronic contract notes and statements in replacement of posted mail once this service becomes available. YES NO If YES, please supply the relevant address if different to above: *Employment Status: Please specify your employment status and occupation (noting if permanent or temporary). Employed Occupation: Self-employed Other (student, retired, etc.) *Please provide details Version 1.01 All questions marked with an asterisk*are mandatory. 3/11

12 INVESTOR 2: (If joint account or trustee if Pension account) Please provide personal details of the additional beneficial owner: Name: *Employment Status: Employed Please specify your employment status and occupation (noting if permanent or temporary). Occupation: Self-employed Other (student, retired, etc.) *Please provide details:. 4/11 All questions marked with an asterisk* are mandatory. Version 1.01

13 Client Application Form *SECTION 2: SOURCE OF OVERALL WEALTH Please indicate how your overall wealth was accumulated (you may select more than one option). INVESTOR 1 INVESTOR 2 (if joint account) Employment/Savings Inheritance/Gift Settlement (e.g. divorce, court award, etc.) Sale of business Other (please specify below) Version 1.01 All questions marked with an asterisk*are mandatory. 5/11

14 *SECTION 3: SECTION 3A: SOURCE OF FUNDS SOURCE OF FUNDS Please indicate the source of your initial transfer to Merrion (you may complete more than one option). Salary/Bonus Savings Transfer from other investment provider Inheritance/Gift Lump Sum on Retirement Redundancy Payment Sale of Property Sale of Shares Settlement (e.g. divorce, court award, etc.) Other (please specify below) INVESTOR 1 INVESTOR 2 (if joint account) Other: Other: SECTION 3B: BANK DETAILS Please indicate the details of your bank account from which you will transfer the funds to and from Merrion. Please note: this must be a bank account in the name solely or jointly in your name as no third-party payment requests will be accepted (joint applications can accept bank account details in the name of one or more of the account holders). In the case of Pension Investments, bank details must be for the Pension scheme. Bank Name/Branch: Currency: 6/11 All questions marked with an asterisk*are mandatory. Version 1.01

15 *SECTION 4: REPORTABLE INFORMATION SECTION 4A: COMMON REPORTING STANDARDS (CRS) The Standard for Automatic Exchange of Financial Account Information, also known as the Common Reporting Standard (CRS), is a single global standard on Automatic Exchange of Information (AEOI). It was approved by the Organisation for Economic Co-operation and Development (OECD) in February 2014 and draws on earlier work of the OECD and the EU, global anti-money laundering standards and the Model FATCA Intergovernmental Agreement. The CRS sets out the financial information to be exchanged, the financial institutions required to report, along with common due diligence standards to be followed by financial institutions. Please note that in certain circumstances, where you are identified as a tax resident in country(s) outside of Ireland, we will be obliged to share this information with the relevant tax authority via the Irish Revenue. Individual self-certification to be completed by investors, including joint holders. Please provide the full list of countries in which you are a tax resident along with your relevant Tax Identification Number (TIN) or equivalent tax identifier (e.g.pps or Social Security number) for your tax jurisdiction. If you are resident for tax purposes in more than 3 countries, please provide details in writing. Country: TIN: INVESTOR 1 INVESTOR 2 (if joint account) Country: TIN: Country: TIN: Country: TIN: Country: TIN: Country: TIN: INVESTOR 1 INVESTOR 2 (if joint account) Country /State of Birth: Version 1.01 All questions marked with an asterisk*are mandatory. 7/11

16 Client Application Form SECTION 4B: FOREIGN ACCOUNT TAX COMPLIANCE ACT (FATCA) The Foreign Account Tax Compliance Act (FATCA) is an initiative introduced by the US government aimed at combating tax evasion by US citizens, US tax resident individuals/entities and certain entities with US controlling persons, holding assets or investments through foreign accounts. The Irish government signed an Inter-Governmental Agreement (IGA) with the US government, under which the Irish government agreed to apply the provisions of FATCA. The provisions of the IGA have been incorporated into Irish law. Under FATCA, financial institutions in Ireland are obliged to obtain and, when required, report specified information in relation to certain accounts held by US citizens, US tax resident individuals/entities and certain entities with US Controlling Persons to the Irish Revenue for onward transmission to the US Internal Revenue Service (IRS). For more information on FATCA, see www. revenue.ie or Please note that in certain circumstances we may be obliged to share this information with the relevant tax authority. Individual self-certification to be completed by investors, including joint holders. Note: You are generally defined as a US person or US tax resident if you were born in the United States of America ( US ) or you are/ have been a US citizen/the holder of US passport/green Card. INVESTOR 1 INVESTOR 2 I confirm that I AM a U.S. Citizen or YES YES resident in the U.S. for tax purposes. NO NO If yes, please provide your U.S. Federal Taxpayer Identifying Number (U.S. TIN). U.S.TIN: U.S.TIN: SECTION 5: DOCUMENTATION REQUIRED TO ACTIVATE A MERRION ACCOUNT 1. Duly completed Client Application Form 2. Certified** proof of identification (e.g. passport, driving licence, identity card) 3. Certified** proof of address issued within the last 6 months, (e.g. bank statement, utility bill, government-issued correspondence). 4. For Pension accounts, please also provide a copy of the Revenue Approval letter. Please note: All documentation must be submitted and received by Merrion prior to the commencement of the business relationship. Under General Data Protection regulations ( GDPR ) your personal information is collected in response to your request for Merrion to provide investment services such as receiving and executing orders ( the service ) to you. In line with GDPR, Merrion will only collect data for a specific purpose, use it only for that purpose and retain it only for as long as it meets that purpose. Please review our Data Protection Notice at for the detail on the purposes for which data is processed, the legal basis for processing and disclosure of your personal information and security and safeguarding arrangements concerning your personal information Under the Criminal Justice (Money Laundering and Terrorist Financing) Act 2010 and the Criminal Justice Act 2013, Merrion is required to keep all AML documentation up to date and may seek further documentation at any time.. 8/11 Version 1.01

17 **All documentation e.g. proofs of identity and address must be certified and stamped to be a true copy of the original. The list of those who can certify documentation includes but is not limited to: Garda (police), practising chartered accountants, certified public accountants, notaries public, practising solicitors, embassy/consular staff, regulated financial/credit institution staff, Peace Commissioners or Commissioners for Oath. *SECTION 6: DECLARATIONS Please confirm by ticking the circle. *Please note that once signed, this will constitute a legally binding contract. If you have any queries, please contact Merrion for clarification or consult your independent legal advisor. I/We confirm that the information provided is true and accurate and that Merrion may rely solely on this information. I/We acknowledge that any false declaration may result in the loss of our right to hold Merrion responsible for any failure to comply with its obligations in relation to assessment of the appropriateness of the service provided. I/We confirm that we will provide all documentation as requested by Merrion, whether as part of the application process or ongoing monitoring. We acknowledge that Merrion may forward such requests at any stage and that any failure to provide additional documentation/information may result in delay of processing of my/our application as well as future payments. I/We also confirm that Merrion will be notified as soon as possible in relation to any material changes to my/our circumstances. I/We have read, understood and accepted the Client Asset Key Information Document ( CAKID ). I/We have read, understood and accepted the Terms of Business at content/uploads/2018/04/data_protection_notice.pdf as amended from time to time and consent to be bound by them. I/We hereby agree to an account(s) being opened with Merrion Stockbrokers Ltd ( Merrion, the Firm ) I/We confirm to Merrion that we have authorised our Financial Broker to transmit my/our order and information about me/us to the relevant product producer and have authorised the product producer to, in turn, transmit my/our order and information about me/us to Merrion and we hereby confirm to Merrion that it can rely on any such order or information so transmitted to it. Investor 1: Signature: Date: / / Investor 2: Version /11

18 Client Application Form *SECTION 7: DECLARATIONS CONT D If joint account, please indicate Authorised Signatories: We confirm that Merrion may accept instructions from ANY one of the account holders in relation to general operation of accounts (e.g. change of details), transfer of funds in and out of the account(s) as well as entering into transactions. Instructions can be issued either in writing (e.g. e- mail, letter) or over the recorded line. OR We confirm that Merrion may only act when instructed by ALL of the account holders in relation to general operation of accounts (e.g. change of details), transfer of funds in and out of the account(s) as well as entering into transactions. Instructions can be issued either in writing (e.g. e- mail, letter) or over the recorded line. Would you like your accountant or financial advisor to receive your Merrion tax pack directly? If applicable, please provide details. ** ** Please note, tax packs are only issued upon request for fee paying advisory and discretionary clients; there is an additional charge for execution only clients. Contact Name: Firm Name:. 10/11 Version 1.01

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