Canaccord Genuity Investment Funds plc

Transcription

1 To us there are no foreign markets. Canaccord Genuity Investment Funds plc Application Form This Application Form, together with the FATCA Self-Certification Form, the Declaration of Residency and the Money Laundering Verification Form constitutes your agreement to subscribe for Shares in Canaccord Genuity Investment Funds plc (the Company ). All sections must be completed in their entirety. You should post or fax your subscription (in which case the original must also be forwarded) to the Administrator s address below. Please note that if this is your first investment in shares of The Company the original fully signed Application Form must be returned to the Administrator. No dividend payments will be processed prior to receipt of this original signed Application Form and supporting documentation. If you are unable to complete any part of this form, please contact the Administrator at: Transfer Agency Department, Northern Trust International Fund Administration Services (Ireland) Ltd George s Court, Townsend Street, Dublin 2, Ireland T: F: E: cgwmenquiries@ntrs.com Section 1 - Application Form 1. Investment details I/We the undersigned declare that the Key Investor Information Document (the KIID ) for the relevant Fund(s) has been provided to me/us in good time prior to making this application for shares and that I/we have read and reviewed the KIID as well as the Prospectus of the Company and its supplements. I/We the undersigned hereby acknowledge and agree that the up-to-date KIID for each share class of the Fund(s) is available at the Investment Manager s website canaccord.com/wm, and that I/we will read and review the most up-to-date version of the relevant KIID prior to making any subsequent applications for shares in the Company. I/We the undersigned acknowledge that by signing this subscription form that I/we give full consent to receiving the KIID by means of electronic communication including these being made available at the Investment Manager s website. I/we the undersigned acknowledge that I/we have regular access to the internet and that the provision of information to me/us by means of a website is appropriate. I/We the undersigned am/are aware that I/we can also obtain upon request and free of charge paper copies of the Prospectus, latest annual and semi-annual reports, KIID and other information from the Administrator at the address above or telephone number above. I/We the undersigned wish to invest (indicate monetary amount or number of shares below) in the following Sub-Fund(s) and share classes: Sub-Funds and share classes CGWM Select Income Fund ISIN Minimum Investment Subsequent Investment Subscription Amount Number of Shares CGWM Select Income Fund - B IE00B3BRDP66 GBP5,000 GBP1,000 CGWM Select Diversity Fund CGWM Select Diversity Fund B IE00B3BRDG75 GBP5,000 GBP1,000 CGWM Select Affinity Fund CGWM Select Affinity Fund B IE00B3BRDD45 GBP5,000 GBP1,000 CGWM Select Opportunity Fund CGWM Select Opportunity Fund IE00B3BRDQ73 GBP5,000 GBP1,000 APP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 1

2 Application Form Sub-Funds and share classes ISIN Minimum Investment Subsequent Investment Subscription Amount Number of Shares CGWM Select Global Diversity Fund CGWM Select Global Diversity Fund - B Shares CGWM Select Global Diversity Fund B SGD Hedged CGWM Select Global Diversity Fund T USD (Accumulation) CGWM Select Global Diversity Fund T GBP Hedged (Accumulation) CGWM Select Global Diversity Fund T EUR Hedged (Accumulation) CGWM Select Global Diversity Fund T SGD Hedged (Accumulation) IE00B3BRDM36 USD5,000 USD1,000 IE00B54L8R61 USD5,000 USD1,000 IE00BSJCDR08 USD5,000 USD1,000 IE00BSJCDS15 USD5,000 USD1,000 IE00BSJCDT22 USD5,000 USD1,000 IE00BSJCDV44 USD5,000 USD1,000 CGWM Select Global Affinity Fund CGWM Select Global Affinity Fund B Shares CGWM Select Global Affinity Fund B SGD Hedged CGWM Select Global Affinity Fund T USD (Accumulation) CGWM Select Global Affinity Fund T GBP Hedged (Accumulation) CGWM Select Global Affinity Fund T EUR Hedged (Accumulation) CGWM Select Global Affinity Fund T SGD Hedged (Accumulation) IE00B3BRDJ07 USD5,000 USD1,000 IE00B7R58130 USD5,000 USD1,000 IE00BSJCJG13 USD5,000 USD1,000 IE00BSJCJH20 USD5,000 USD1,000 IE00BSJCJJ44 USD5,000 USD1,000 IE00BSJCJK58 USD5,000 USD1,000 CGWM Select Global Opportunity Fund CGWM Select Global Opportunity Fund IE00B3BRDK12 USD5,000 USD1,000 CGWM Select Global Opportunity Fund SGD Hedged CGWM Select Global Opportunity Fund T USD (Accumulation) CGWM Select Global Opportunity Fund T GBP Hedged (Accumulation) CGWM Select Global Opportunity Fund T EUR Hedged (Accumulation) CGWM Select Global Opportunity Fund T SGD Hedged (Accumulation) IE00B7V99524 USD5,000 USD1,000 IE00BSJCJ725 USD5,000 USD1,000 IE00BSJCJ832 USD5,000 USD1,000 IE00BSJCJ949 USD5,000 USD1,000 IE00BSJCJB67 USD5,000 USD1,000 CGWM Total Return Bond Fund CGWM Total Return Bond Fund IE00B03NZW28 GBP10,000 GBP5,000 CGWM Bond Fund CGWM Bond Fund A Shares IE00BGLP1Z72 GBP5,000 GBP1,000 CGWM Bond Fund A EUR Hedged IE00BGLP2096 GBP5,000 GBP1,000 CGWM Bond Fund A USD Hedged IE00BGLP2104 GBP5,000 GBP1,000 CGWM REMAP 4 Fund CGWM REMAP 4 Fund D Shares IE00B99BF239 GBP 50,000 GBP1,000 CGWM REMAP 4(i) Fund CGWM REMAP 4(i) Fund D Shares IE00B99BF452 GBP 50,000 GBP1,000 AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 2

3 Sub-Funds and share classes ISIN Minimum Investment Subsequent Investment Subscription Amount Number of Shares CGWM REMAP 5 Fund CGWM REMAP 5 Fund D Shares IE00B99BF676 GBP 50,000 GBP1,000 Please note The minimum and subsequent investments are set out above or are the equivalent in USD, SGD or EUR With regards to the CGWM REMAP Funds, the D Shares are only available to retail investors who receive advice from and pay a separate fee to financial intermediary/advisor. If payment is not being made in the Fund s base currency, then please note that foreign exchange will be arranged by the Administrator of the Fund in accordance with the procedures employed by the Administrator for foreign exchange transactions. 2. Details of applicant(s) Unit Holder 1 Mr/Mrs/Miss/Ms/title: First name/family name/company name: Unit Holder 2 Mr/Mrs/Miss/Ms/title: First name/family name/company name: Address inc street/town/country/postcode: Address inc street/town/country/postcode: Telephone: Fax: Telephone: Fax: Mailing address (if different from the address of the first named holder): If more than two applicants add an additional page with their details and tick here: 3. Bank details for payment of subscription If subscriptions are not being paid in the Fund s base currency, then please note that foreign exchange will be arranged by the Administrator of the fund in accordance with the procedures employed by the Administrator for foreign exchange transactions. Subscriptions should be made by TT or BACS as follows: Sterling (GBP) Payments: Northern Trust (Guernsey) Limited PO Box 71, Trafalgar Court, Les Banques, St Peter Port, Guernsey GY1 3DA SWIFT Code: BBCOGGSP Sort code: For further credit to account number: CGWM Select Income Fund CGWM Select Diversity Fund CGWM Select Affinity Fund CGWM Select Opportunity Fund CGWM Select Global Opportunity Fund CGWM Select Global Affinity Fund CGWM Select Global Diversity Fund CGWM Total Return Bond Fund CGWM Bond Fund CGWM REMAP 4 Fund CGWM REMAP 4(i) Fund CGWM REMAP 5 Fund US Dollar (USD) Payments: The Northern Trust International Banking Corporation, 40 Broad Street, 10th Floor, New Jersey NY SWIFT Code: CNORUS33 CHIPS UID: 0112/ Fedwire/ABA: A/C name: Northern Trust (Guernsey) Limited (BBCOGGSP) A/C No: For further credit to account number: CGWM Select Income Fund CGWM Select Diversity Fund CGWM Select Affinity Fund CGWM Select Opportunity Fund CGWM Select Global Opportunity Fund CGWM Select Global Affinity Fund CGWM Select Global Diversity Fund CGWM Total Return Bond Fund CGWM Bond Fund CGWM REMAP 4 Fund CGWM REMAP 4(i) Fund CGWM REMAP 5 Fund AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 3

4 Euro (EUR) Payments: Societe Generale, Paris BIC Code: SOGEFRPP A/C No: A/C name: Northern Trust (Guernsey) Limited BIC Code: BBCOGGSP For further credit to account number: CGWM Select Income Fund - GB75 BBCO CGWM Select Diversity Fund - GB91 BBCO CGWM Select Affinity Fund - GB26 BBCO CGWM Select Opportunity Fund - GB58 BBCO CGWM Select Global Diversity Fund - GB10 BBCO CGWM Select Global Affinity Fund - GB42 BBCO CGWM Select Global Opportunity Fund - GB74 BBCO CGWM Total Return Bond Fund - GB72 BBCO CGWM Bond Fund - GB38 BBCO CGWM REMAP 4 Fund - GB75 BBCO CGWM REMAP 4(i) Fund - GB75 BBCO CGWM REMAP 5 Fund - GB75 BBCO Singapore Dollar (SGD) Payments: The Hongkong & Shanghai Banking Corporation, Singapore 60B Orchard Road The Atrium at Orchard Singapore Swift Code: HSBCGSG A/C No: A/C name: Northern Trust (Guernsey) Limited (BBCOGGSP) For further credit to account number: CGWM Select Income Fund CGWM Select Diversity Fund CGWM Select Affinity Fund CGWM Select Opportunity Fund CGWM Select Global Diversity Fund CGWM Select Global Affinity Fund CGWM Select Global Opportunity Fund CGWM Total Return Bond Fund CGWM Bond Fund CGWM REMAP 4 Fund CGWM REMAP 4 (i) Fund CGWM REMAP 5 Fund Reference: Fund name and client register no or agent no. When sending monies quote FUND NAME and IBAN A/C No. with the investors FULL NAME as reference. Alternatively for each fund the reference is: CGWM Select Income Fund IBAN A/C.: GB75 BBCO CGWM Select Diversity Fund IBAN A/C.: GB91 BBCO CGWM Select Affinity Fund IBAN A/C.: GB26 BBCO CGWM Select Opportunity Fund IBAN A/C.: GB58 BBCO CGWM Select Global Diversity Fund IBAN A/C.: GB10 BBCO CGWM Select Global Affinity Fund IBAN A/C.: GB42 BBCO CGWM Select Global Opportunity Fund IBAN A/C.: GB74 BBCO CGWM Total Return Bond Fund IBAN A/C.: GB72 BBCO CGWM Bond Fund IBAN A/C.: GB38 BBCO CGWM REMAP 4 Fund IBAN A/C.: GB75 BBCO CGWM REMAP 4(i) Fund IBAN A/C.: GB75 BBCO CGWM REMAP 5 Fund IBAN A/C.: GB75 BBCO When sending payment by TT, please quote: Applicant s name Bank Bank account number Fund name Confirmation note number (if one has been issued) 4. Dividend information and redemption payment Please tick the preferred dividend option: Cash Reinvestment Pay proceeds to: Name of bank: Account name: Account number: Sort code: Address: Postcode: Please note that the Company will automatically re-invest any distribution entitlements in further shares of the same class: 1. Unless distributions are in excess of US$100, 50 or 100 or currency equivalent, and instructions in writing to the contrary are received from the Shareholder at least 21 days prior to the relevant distribution date; 2. If distributions are less than US$100, 50 or 100 or currency equivalent in value; 3. In all cases where the Shareholder s anti-money laundering documentation is incomplete or has not been completed to the satisfaction of the Administrator. Please note bank charges may be deducted. Please see the main prospectus for further details. No third party payments will be undertaken. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 4

5 If the section is not completed, redemption will be paid in favour of the registered shareholder or in favour of the joint registered shareholders as appropriate, and sent to the registered address of the first named shareholder or to the mailing address. The present instruction shall apply to the relevant Fund and shall be valid until cancelled by me/us in writing. Joint applicants acknowledge that they are also bound by these instructions. A telegraphic transfer fee of 20/ 37.50/US$45 or currency equivalent will be applied to dividends or redemptions paid in this way. 5. Detail of Agent/Nominee/Intermediary This section only needs to be completed where there is an agent/nominee or intermediary. Where there is no such agent this section does not need to be completed. Total front end fee: % Commission to pay to agent: % Name: Contact: Telephone: Fax: Address: Postcode: Note: Any Intermediary recorded above hereby confirms that they are complying with all necessary laws and regulations in entering or soliciting a third party to enter into this contract. In addition to verifying the source of funds, Intermediaries are obliged to verify the identity of any investor located outside a country listed in Schedule E to the Guidance Notes issued by the Irish Financial Services Regulatory Authority as may be amended from time to time. Intermediaries falling into this category should supply the information detailed in the relevant section of the Money Laundering Verification Form. Unless this information is supplied, the Shares will not be registered by the Administrator. Dealing procedure All application, redemption, transfer requests and instructions in relation to the Shares in the relevant funds must be received before the times specified in the relevant supplement of the Prospectus for each fund. Applications, redemptions and transfer request received after that time will generally be deemed to have been received for the next Dealing Day. No redemption payment will be made until the original application form has been received from the investor and the Administrator is satisfied that all of the necessary anti-money laundering checks have been completed in full. By ticking here, I hereby consent to the provision of contract notes, statements and other reports, by secured and encrypted electronic transmission, which may be issued from time to time by the administrator in respect of my holdings in the Fund. Section 2 Declaration of Residence Outside of The Republic of Ireland Applicants resident outside Ireland are required by the Irish Revenue Commissioners to make the following declaration which is in a format authorised by them, in order to receive payment without deduction of tax. It is important to note that this declaration, if it is then still correct, shall apply in respect of any subsequent acquisitions of shares. Terms used in this declaration are defined in the Prospectus. Declaration on own behalf I/we* declare that I am/we are* applying for the shares on my own/our own behalf/on behalf of a company* and that I am/we are/the company* is entitled to the shares in respect of which this declaration is made and that I am/we are/the company is* not currently resident or ordinarily resident in Ireland, and should I/we/the company* become resident in Ireland I will/we will* so inform you, in writing, accordingly. *Delete as appropriate (mandatory) Declaration as Intermediary I/we* declare that I am/we are* applying for shares on behalf of persons: who will be beneficially entitled to the shares; and, who, to the best of my/our* knowledge and belief, are neither resident nor ordinarily resident in Ireland. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 5

6 I/we* also declare that: unless I/we* specifically notify you to the contrary at the time of application, all applications for shares made by me/us* from the date of this application will be made on behalf of such persons; and, I/we* will inform you in writing if I/we* become aware that any person, on whose behalf I/we* holds shares, becomes resident in Ireland. *Delete as appropriate (mandatory) Signature and declaration I / We declare that the information contained in this form and any attached documentation is true and accurate to the best of my/our* knowledge and belief. (*delete as applicable) Date: Signed: Signatory capacity if applicable: (i.e. Director/Manager) In the case of joint holders, ALL holders must complete this declaration. Important notes 1. Non-resident declarations are subject to inspection by the Irish Revenue Commissioners and it is a criminal offence to make a false declaration. 2. To be valid, the application form (incorporating the declaration required by the Irish Revenue Commissioners) must be signed by the applicant. Where there is more than one applicant, each person must sign. If the applicant is a company, it must be signed by the company secretary or another authorised officer. 3. If the application form (incorporating the declaration required by the Irish Revenue Commissioners) is signed under power of attorney, a copy of the power of attorney must be furnished in support of the signature. Section 3 Declaration of Residence Within The Republic of Ireland¹ Declaration referred to in section 739D(6) Taxes Consolidation Act, 1997 I declare that the information contained in this declaration is true and correct. I also declare that I am applying for the shares on behalf of the applicant named below who is entitled to the shares in respect of which this declaration is made and is a person referred to in Section 739D (6) of the Taxes Consolidation Act, 1997, being a person who is: (please tick as appropriate). A pension scheme A company carrying on life business within the meaning of section 706 TCA 1997 An investment undertaking A special investment scheme A unit trust to which section 731(5) (a) TCA 1997 applies; A charity being a person referred to in section 739D(6)(f)(i) TCA 1997; A qualifying management company A specified company AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 6

7 Entitled to exemption from income tax and capital gains tax by virtue of sections 784A(2), and 787I of the TCA 1997, (see further requirements for Qualifying Fund Manager below) A credit union to which Section 2 of the Credit Union Act, 1997 applies. Additional requirement where the declaration is completed on behalf of a pension scheme, a company carrying on life business within the meaning of section 706 TCA 1997, an investment undertaking, a special investment scheme, a unit trust to which section 731(5) (a) TCA applies, a qualifying management company or a credit union to which Section 2 of the Credit Union Act 1997 applies. I undertake that, in the event that the shares cease to be assets of the *pension scheme/company carrying on life business within the meaning of section 706 TCA 1997/investment undertaking/special investment scheme/unit trust to which section 731(5) (a) TCA applies/qualifying management company/credit union to which Section 2 of the Credit Union Act 1997 applies, including a case where the shares are transferred to another such entity, I will, by written notice, bring this fact to the attention of the investment undertaking accordingly. (*Delete as appropriate). Return of Values (Investment Undertakings) Regulations 2013 The Company must collect additional information in order to satisfy Return of Values (Investment Undertakings) Regulations 2013 (S.I.245 of 2013). Therefore any individual, company or any unincorporated body of persons which are an Irish resident must provide the following additional information and documentation: Tax Identification Number (TIN)/PPS Number: Any one of the following additional documents are required to verify the TIN or PPS Number (either a copy or the original is sufficient) P60 P45 P21 Balancing Statement Pay Slip (where employer is identified by name or tax number) Drug Payment Scheme Card European Health Insurance Card Tax Assessment Tax Return Form PAYE Notice of Tax Credits Child Benefit Award Letter/Book Pension Book Social Services Card Public Services Card In addition, any printed documentation issued by the Revenue Commissioners or by the Department of Social Protection which contain your name, address and tax reference number will also be acceptable. In the case of joint account holders, the additional documentation is required for each applicant. Your personal information will be handled by the Administrator or it s duly appointed delegates as Data Processor for the Company in accordance with the Data Protection Acts 1988 to Your information provided herein will be processed for the purposes of complying with the Return of Values (Investment Undertakings) Regulations 2013 and this may include disclosure to the Irish Revenue Commissioners. Please see the table below for a list of exempted unit holders: Unit Holders The following resident entities from which the investment undertaking (IU) has obtained a duly completed resident entity declaration: Pension Schemes Companies carrying on a Life Assurance business Another investment undertaking Special investment schemes Unit trusts to which section 731(5) applies Charities Certain IFSC companies ARFs; AMRFs PRSA providers Credit Unions Companies, where the IU is a money market fund NAMA The National Pensions Reserve Fund Taxes Consolidation Act 1997 ref s.739d(6)(a) s.739d(6)(b) s.739d(6)(c) s.739d(6)(d) s.739d(6)(e) s.739d(6)(f) s.739d(6)(g) s.739d(6)(h) s.739d(6)(i) s.739d(6)(j) s.739d(6)(k) s.739d(6)(ka) s.739d(6)(l) AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 7

8 Section 110 Companies Unit holders where the IU, immediately before a chargeable event, holds a non-resident declaration made by the person who made the investment; or where the IU has put in place equivalent measures with the written approval of the authorised Revenue officer. A Unit holder who holds units which are held in a recognised clearing system. s.739d(6)(m) s.739d(7); s.739d(7b) s.739b(1)(d)(i)(iii) s.739g(3) Additional requirements where the declaration is completed on behalf of a Charity I also declare that at the time of making this declaration, the shares in respect of which this declaration is made are held for charitable purposes only; and Form part of the assets of a body of persons or trust related by the Revenue Commissioners as a body or trust established for charitable purposes only, or are, according to the rules or regulations established by statute, charter, decree, deed of trust or will, held for charitable purposes only and are so treated by the Revenue Commissioners; I undertake that, in the event that the person referred to in paragraph (7) (d) of Schedule 2B TCA 1997 ceases to be a person referred to in Section 739D(6)(f)(i) TCA 1997, I will by written notice, bring this fact to the attention of the investment undertaking accordingly. Additional requirements where the declaration is completed by a Qualifying Fund Manager I also declare that at the time this declaration is made, the shares in respect of which this declaration is made; Are assets of an *approved retirement fund/an approved minimum retirement fund; and Are managed by the declarant for the individual named below who is beneficially entitled to the shares. I undertake that, if the shares cease to be assets of the *approved retirement fund/the approved minimum retirement fund, including a case where the shares are transferred to another such fund, I will, by written notice, bring this fact to the attention of the investment undertaking accordingly. (*Delete as appropriate). Additional requirements where the declaration is completed by an Intermediary I/we* declare that I am/we are* applying for shares/units on behalf of persons who to the best of my/our* knowledge and belief, have beneficial entitlement to each of the units in respect of which this declaration is made; and is a person referred to in section 739D(6) TCA I/we* also declare that unless I/we* specifically notify you to the contrary at the time of application, all applications for shares/units made by me/us* from the date of this application will be made on behalf of persons referred to in section 739D(6) TCA 1997; and I/we* will inform you in writing if I/we* become aware that any person ceases to be a person referred to in section 739D(6) TCA * Delete as appropriate Name of Applicant: ²Irish Tax Reference Number of Applicant: ³Authorised Signatory: (Declarant) (Mr/Ms/etc.): Capacity in which declaration is made: Date: Important notes 1. This is a form authorised by the Revenue Commissioners which may be subject to inspection. It is an offence to make a false declaration. 2. Tax reference number in relation to a person, has the meaning assigned to it by Section 885 TCA 1997 in relation to a specified person within the meaning of that section. In the case of a charity, quote the Charity Exemption Number (CHY) as issued by the Revenue. In the case of a qualifying fund manager, quote the tax reference number of the beneficial owner of the shares. 3. In the case of (i) an exempt pension scheme, the administrator must sign the declaration (ii) a retirement annuity contract to which Section 784 or 785 applies, the person carrying on the business of granting annuities must sign the declaration (iii) a trust scheme, the trustees must sign the declaration. In the case of a charity, the declaration must be signed by the trustees or other authorised officer of a body of persons or trust established for charitable purposes only within the meaning of Sections 207 and 208 TCA In the case of a company, the declaration must be signed by the company secretary or other authorised officer. In the case of a unit trust it must be signed by the trustees. In any other case, it must be signed by an authorised officer of the entity concerned or a person who holds a power of attorney from the entity. If the latter, a copy of the power of attorney should be furnished in support of this declaration. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 8

9 Section 4 (i) FATCA Entity Self Certification Instructions for completion We are obliged under section 891E of the Taxes Consolidation Act 1997 (as amended) and regulations made pursuant to that section to collect certain information about each investor s tax arrangements. Please complete the sections below as directed and provide any additional information that is requested. Please note that in certain circumstances we may be obliged to share this information with relevant tax authorities. Unless otherwise stated, all terms identified in italics are as defined in the Agreement between the Government of Ireland and the Government of the United States of America to Improve International Tax Compliance and to Implement FATCA (the Agreement ), a copy of which is available on the Irish Revenue website at or at If any of the information below about the Investor s tax residence or FATCA classification changes in the future, please ensure that we are advised of these changes promptly. If you have any questions about how to complete this form, please contact your tax advisor. Investors that are indviduals should not complete this form and should complete the form entitled Individual Self-Certification Section 1: Investor Identification (Only to be completed if using the Self-Certification as a standalone document and not part of the application form) Investor Name: Fund Name: Registered Address: Number: Street: City, Town, State, Province or Country: Postal Code: Country: Mailing Address (if different from above) Number: Street: City, Town, State, Province or Country: Postal Code: Country: Country of Incorporation: Section 2: Specified US Person Please tick either (1) or (2) below. 1. The Entity is a Specified US Person and the Entity s US Federal Taxpayer Identifying number (US TIN) is as follows: U.S. TIN: 2. The Entity is not a Specified US Person (please also complete Sections 3 and 4) AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 9

10 Section 3: Declaration of Tax Residency (Note: Declaration of tax residency is requested in the context of the OECD Common Reporting Standard ( CRS ), an initiative to implement automatic exchange of financial account information on a global basis.) Please indicate the Entity s place of tax residence (if resident in more than one country please detail all countries of tax residence and associated tax identification numbers). Country of Tax Residency: Tax ID Number: Section 4: Entity s FATCA Classification 4.1 Financial Institutions: If the Entity is a Financial Institution, please tick one of the below categories, and provide the Entity s GIIN at Irish Financial Institution or a Partner Jurisdiction Financial Institution 2. Registered Deemed Compliant Foreign Financial Institution 3. Participating Foreign Financial Institution 4.2 Please provide the Entity s Global Intermediary Identification number (GIIN) 4.3 If the Entity is a Financial Institution but unable to provide a GIIN, please tick one of the below reasons: 1. Partner Jurisdiction Financial Institution and has not yet obtained a GIIN 2. The Entity has not yet obtained a GIIN but is sponsored by another entity which does have a GIIN. Please provide the sponsor s name and GIIN. Sponsor s Name: Sponsor s GIIN: 3. Exempt Beneficial Owner 4. Certified Deemed Compliant Foreign Financial Institution (including a deemed compliant Financial Institution under Annex II of this Agreement) 5. Non-Participating Foreign Financial Institution 6. Expected Foreign Financial Institution 7. U.S. person but not a Specified U.S. Person AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 10

11 4.4 Non-Financial Institutions: If the Entity is not a Financial Institution, please confirm the Entity s FATCA status below: 1. The Entity is an Active Non-Financial Foreign Entity or 2. The Entity is a Passive Non-Financial Foreign Entity (if the Entity is a Passive Non-Financial Foreign Entity, please provide details of any Controlling Persons (whose percentage of ownership is 25% or greater) which are U.S. citizens or resident in the U.S. for tax purposes. The term Controlling Persons is to be interpreted in a manner consistent with the recommendations of the Financial Action Task Force. 3. The Entity is an Expected Non-Financial Foreign Entity Full Name Date of Birth Full Residence Address Details of Controlling Person s Beneficial Ownership Tax Reference Number 4. The Entity is a U.S. person but not a Specified U.S.person Section 5: Declarations and Undertakings I/We declare (as an authorised signatory of the Entity) that the information provided in this Form is, to the best my/our knowledge and belief, accurate and complete. I/We undertake to advise the recipient promptly and provide an updated Self-Certification where any change in circumstance occurs which causes any of the information contained in this form to be incorrect. Authorised Signature(s): Capacity in which declaration is made: Date: AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 11

12 Section 4 (ii) FATCA INDIVIDUAL SELF CERTIFICATION Instructions for completion We are obliged under section 891E of the Taxes Consolidation Act 1997 (as amended) and regulations made pursuant to that section to collect certain information about each investor s tax arrangements. Please complete the sections below as directed and provide any additional information that is requested. Please note that in certain circumstances we may be obliged to share this information with relevant tax authorities. All terms identified in italics are as defined in the Agreement between the Government of Ireland and the Government of the United States of America to Improve International Tax Compliance and to Implement FATCA (the Agreement ), a copy of which is available on the Irish Revenue website at www. revenue.ie or at If any of the information below about your tax residence or FATCA classification changes in the future, please ensure that we are advised of these changes promptly. If you have any questions about how to complete this form, please contact your tax advisor. Please note that where there are joint account holders each investor is required to complete a separate Self-Certification form. Section 1: Investor Identification (Only to be completed if using the Self-Certification as a standalone document and not part of the application form) Investor Name: Fund Name: Residential Address: Number: Street: City, Town, State, Province or Country: Postal Code: Country: Mailing Address (if different from above) Number: Street: City, Town, State, Province or Country: Postal Code: Country: Country of Birth: Date of Birth: AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 12

13 Section 2: Declaration of US Citizenship or US Residence for Tax purposes Please tick either (1) or (2) and complete as appropriate. 1. I confirm that I am a US citizen and/or resident in the US for tax purposes and my US federal taxpayer identifying number: (US TIN) is as follows OR 2. I confirm that I am not a US citizen or resident in the US for tax purposes. Section 3: Declarations and Undertakings I declare that the information provided in this Form is, to the best my knowledge and belief, accurate and complete. I undertake to advise the recipient promptly and provide an updated Self-Certification form where any change in circumstance occurs which causes any of the information contained in this form to be incorrect. Authorised Signature: Date: ¹ Must be over 18 years of age. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 13

14 Section 5 Money Laundering Requirements and EU Savings Directive Anti-Money Laundering verification requirements In accordance with The Criminal Justice (Money Laundering and Terrorist Financing) Acts, 2010 and Guide to completing this form. Part I This section must be completed by all applicants and transferees Part II This section can only be completed by banks, providers of financial services and nominee companies acting on their own account and if authorised and regulated in the Member States of the EU, Australia, Canada, Hong Kong, Iceland, Japan, Norway, Singapore, South Africa, South Korea, Switzerland, The United States of America, The Channel Islands and the Isle of Man. Part III This section is only applicable to individual & joint account investors investing directly into the Fund, i.e. not through an intermediary. Part IV This section is applicable to Intermediaries, Financial Agents and Nominees acting on behalf of third parties. Part V This section is to be completed if an unregulated Nominee Company is acting as intermediary or nominee for investors and the Nominee Company is owned by a Relevant Third Party. Part VI To be completed by all individual & joint account investors who are EU residents not residing in Ireland. Part VII This section is applicable to other investors investing directly into the Fund. In the case of joint account holders, the additional documentation is required for each applicant. PART I ALL Full name(s) and full current permanent address/registered office of applicants(s)/transferee(s): Mr/Mrs/Miss/Ms/Company Name: Address/Registered Office: Date of Birth¹ (if applicable): Country of Birth/Registration: Full name where applicable of any beneficial owner of investor who owns more than 25% of company / Partnership / LLC / CIS / Trust / Public body: 1: 3: 2: 4: DECLARATION - I/We declare that the information contained in this form, including the section entitled Representations and Warranties at pages 14 to 15, and any attached documentation is true and accurate to the best of my/our knowledge and belief. Date: Signed: Signatory capacity if applicable: (i.e. Director/Manager) In the case of joint holders, ALL holders must complete this declaration. * Must be over 18 years of age. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 14

15 PART II Financial Company, Bank, Nominee, etc. Please tick the following, if appropriate: I/We are a bank/provider of financial services or a nominee company/nominee account which is part of/used by a bank/provider of financial services authorised and regulated in the Member States of the EU, Australia, Canada, Hong Kong, Iceland, Japan, Norway, Singapore, South Africa, South Korea, Switzerland, The United States of America, The Channel Islands and the Isle of Man. Yes If the answer is Yes, please supply the name of the regulated entity and also the name of your regulator: If you are acting on behalf of a third party see Part IV PART III Individuals and Joint Account Holders If you, as applicant(s) or transferee(s) is/are an Individual(s) please supply the following documents. In the case of joint account holders, please supply the relevant documentation in respect of all holders. A copy photographic identity document and a copy non-photographic identity document. Note: the Company or the Administrator may require further documentation to be provided upon written request. PART IV To be completed by Financial Agents, Nominees and Intermediaries As an intermediary/agent/nominee company authorised and regulated in the Member States of the EU, Australia, Canada, Hong Kong, Iceland, Japan, Norway, Singapore, South Africa, South Korea, Switzerland, The United States of America, The Channel Islands and the Isle of Man, you must provide; 1. Standard reliance letter (a template can be obtained from the Administrator) 2. Relevant Third Party s Authorised Signatory List 3. Proof of regulatory status of Relevant Third Party PART V If Nominee Company is unregulated and is acting as intermediary or nominee for investors and the nominee company is owned by a Relevant Third Party If the Nominee Company is unregulated and is acting as intermediary or nominee for investors the following documents are required; 1. Standard reliance letter (a template can be obtained from the Administrator) 2. Documentation in accordance with the legal form of the Nominee Company 3. Proof of regulatory status of Relevant Third Party Relevant Third Party Note - A Relevant Third Party is a regulated entity in the Member States of the EU, Australia, Canada, Hong Kong, Iceland, Japan, Norway, Singapore, South Africa, South Korea, Switzerland, The United States of America, The Channel Islands and the Isle of Man ; that is a credit institution, or that is a financial institution, or who is an external accountant or auditor and who is also a member of a designated accountancy body, or is a member of a designated accountancy body, auditor, tax adviser, legal professional or trust or company service provider subject to mandatory professional registration or mandatory professional supervision under the laws of the other Member State. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 15

16 PART VI Individual and Joint Investors Only those Resident in EU (outside of Ireland) EU SAVINGS DIRECTIVE 2003/48/EC to be completed if an EU Resident residing outside of Ireland. As paying agent for the Company, we must collect additional information in order to satisfy the EU Savings Directive requirements. Therefore, individuals who are EU residents and reside outside of Ireland must provide the following additional information & documentation: Tax Identification Number (TIN) (mandatory) Please leave blank if your tax identification number does not appear on your passport, photo identity card or other proof of identity provided. Issuing Country of your Passport / Photo Identity Card Additional documents required (only if investing directly in your own or joint names i.e. whether or not it is via an intermediary): 1. Proof of Tax Identification Number (TIN) if available (e.g. photo identity card which shows the tax identification number or correspondence from your local tax office) 2. Tax Residency Certificate (TRC) (where the place of issuing country of passport differs from country of tax residence) In the case of joint account holders, the additional documentation is required for each applicant. Your personal information will be handled by Northern Trust or it s duly appointed delegates as Data Processor for the Company in accordance with the Data Protection Acts 1988 to Your information provided herein will be processed for the purposes of complying with the EU Savings Directive 2003/48/EC and this may include disclosure to the Irish Revenue Commissioners. PART VII OTHER INVESTORS (Standard Customer Due Diligence) If you, as applicant or transferee, fall under one of the investor categories outlined below please provide documents evidencing the requested information. Listed Company For a Listed Company in a Prescribed Country Proof of Listing on a recognised stock exchange in a Prescribed Country and Authorised Signatory List. Otherwise see 1-10 below. 1. Proof of listing. 2. Full name. 3. Registered number. 4. Registered office address. 5. Principal business address. 6. Names of Directors. 7. Proof of identity of two Directors or one Director and one authorised signatory (in accordance with Part III above). 8. Verify (by providing documentation as per entity type) any beneficial owners who own more than 25% of the share capital, profit or voting rights or otherwise exercise control over the management of the company. Where the beneficial owner is a corporate entity, the Administrator requires details of ultimate beneficial owners (this can be demonstrated through an organisation chart signed by an authorised signatory or shareholder register or other company documentation etc). 9. Verification of identity from: Search of the relevant company registry; and/or Copy of Certificate of incorporation or equivalent; and/or Copy of Memorandum and Articles of Association or equivalent; and/or Copy of latest audited financial statements. 10. Authorised signatory list. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 16

17 Private and Unlisted Company 1. Full name. 2. Registered number. 3. Registered office address. 4. Principal business address. 5. Names of directors. 6. Proof of identity of two directors or one director and one authorised signatory (in accordance with Part III above). 7. Verify (by providing documentation as per entity type) any beneficial owners who own more than 25% of the share capital, profit or voting rights or otherwise exercise control over the management of the company. Where the beneficial owner is a corporate entity, the Administrator requires details of ultimate beneficial owners (this can be demonstrated through an organisation chart signed by an authorised signatory or shareholder register or other company documentation etc). 8. Verification of identity from: Search of the relevant company registry; and/or Copy of Certificate of incorporation or equivalent; and/or Copy of Memorandum and Articles of Association or equivalent; and/or Copy of audited financial statements. 9. Authorised signatory list. Note: the Company or the Administrator may require further documentation to be provided upon written request. Partnership 1. Full name. 2. Registered office address. 3. Principal business address. 4. Names of all partners (where not a Partnership Fund); or 5. If a Partnership Fund, verify (by providing documentation as per entity type) names of General Partner and partners who own more than 25% of the partnership capital, profit or voting rights or otherwise exercise control over the management of the Partnership Fund and listing of directors, if appropriate. Where the beneficial owner is a corporate entity, the Administrator requires details of ultimate beneficial owners (this can be demonstrated through an organisation chart signed by an authorised signatory or shareholder register or other company documentation etc). 6. Verification of identity of General Partner, or two partners, or one partner and one authorised signatory (in accordance with Part III above). 7. Constitutional Document (e.g. Partnership Agreement). 8. Authorised signatory list. Note: the Company or the Administrator may require further documentation to be provided upon written request. LLC 1. Full name. 2. Registered office address. 3. Principal business address. 4. Names of Managing Members. 5. Verification of identity of two Managing Members or one Managing Member and one authorised signatory (in accordance with Part III above). 6. Verify (by providing documentation as per entity type) members who own more than 25% of the share capital, profit or voting rights or otherwise exercise control over the management of the LLC. Where the beneficial owner is a corporate entity, the Administrator requires details of ultimate beneficial owners (this can be demonstrated through an organisation chart signed by an authorised signatory or shareholder register or other company documentation etc). 7. Constitutional Document (e.g. Certificate of formation). 8. Operating agreement. 9. Authorised signatory list. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 17

18 Collective Investment Scheme 1. Full name of CIS. 2. Registered address of CIS. 3. Prospectus or equivalent. 4. Name and address of scheme promoter. 5. Name and address of scheme administrator. 6. Name and address of entity carrying out anti-money laundering checks upon the scheme investors and confirmation that entity is regulated for AML purposes. 7. Verify (by providing documentation as per entity type) any investors who own more than 25% of the share capital. 8. Authorised signatory list. Trust, Foundation or similar entity 1. Full name of trust. 2. Registered address of trust. 3. Legal form of the trust, foundation or similar entity. 4. Trust deed or equivalent or confirmation of the entity to an appropriate register. 5. Nature / purpose of the Trust etc. 6. Names of all trustees. 7. Verification of identity of two trustees or one trustee and one authorised signatory (in accordance with Part III above). 8. Name of settler. 9. Verify (by providing documentation as per entity type) any beneficial owners who own at least 25% of the share capital or voting rights or otherwise exercises control over the trust. Where the beneficial owner is a corporate entity, the Administrator requires details of ultimate beneficial owners (this can be demonstrated through an organisation chart signed by an authorised signatory or shareholder register or other company documentation etc). 10. Authorised signatory list. Pension Scheme For an employee sponsored pension scheme in the EU proof of registration from the relevant tax authorities. Otherwise items 1-6 below. 1. Full name. 2. Registered office address. 3. Authorised signatory list. 4. Confirmation of registration (as appropriate) from the relevant tax authorities or pension s board or items 5 and 6 below. 5. Names of Trustees/Directors/Governors/Board Members or equivalent. 6. Constitutional/Formation Document (e.g. Trust Deed). Charity Extract from the relevant Charities Register e.g. UK Charities Commission or 1-9 below. 1. Full name. 2. Nature/purpose including the nature of the funding. 3. Registered office address. 4. Principal business address. 5. Authorised signatory list. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 18

19 6. Names of Trustees/Directors/Governors/Board Members or equivalent. 7. Verification of identity of two Trustees/Directors/Governors/Board Members or one Trustee/Director/Governor/Board Member and one authorised signatory (in accordance with Part III above). 8. Names of beneficiaries (where ascertainable). 9. Constitutional/Formation Document. Club or Society 1. Full name. 2. Registered office address. 3. Nature/Purpose including the nature of funding. 4. Confirmation of the legal status. 5. Constitutional/Formation Document (e.g. Trust Deed) and / or copy of audited financial statements (if available). 6. Names of officers. 7. Verification of identity of two officers of the Club/Society or one officer and one authorised signatory (in accordance with Part III above). 8. Authorised signatory list. Note: the Company or the Administrator may require further documentation to be provided upon written request. Public Body For a Public Body in a Prescribed Country background from a reliable source (e.g. internet search) and Authorised Signatory List. Otherwise see 1-9 below. 1. Full name. 2. Nature and status. 3. Registered office address. 4. Name of the home state authority and nature of its relationship with public body. 5. Ownership of the entity. 6. Names of main public body officials. 7. Verify (by providing documentation as per entity type) all persons who own or control over 25% of the entity s share capital, profit or voting rights or otherwise exercises control over the management of the entity. Where the beneficial owner is a corporate entity, the Administrator requires details of ultimate beneficial owners (this can be demonstrated through an organisation chart signed by an authorised signatory or shareholder register or other company documentation etc). 8. Authorised signatory list. 9. Appropriate background information on the entity (e.g. via internet search). School, College or University 1. Full name. 2. Registered office address. 3. Authorised signatory list. 4. Verification of identity from relevant registers and/or from obtaining appropriate background information on the entity (e.g. via internet search). 5. Verification of identity of two officials or one official and one authorised signatory or 6 and 7 below. 6. Confirmation of ownership of the entity. In particular, confirmation of public ownership or independent ownership. 7. Names of main officials. Jurisdictions assessed by the Administrator to operate comparable AML/CTF controls The Member States of the EU, Australia, Canada, Hong Kong, Iceland, Japan, Norway, Singapore, South Africa, South Korea, Switzerland, The United States of America, The Channel Islands and the Isle of Man. AAPP0087 Canaccord Genuity Investment Funds plc - Application Form March 2015 canaccordgenuity.com 19