Change of Details Form

Transcription

1 Perpetual Trust Services Limited ABN PineBridge Global Dynamic Asset Allocation Fund ARSN Please complete the relevant sections of the Application Form in capital letters using a black pen. 1. INVESTORS INFORMATION Account / Unitholder Code Change of Details Form Account / Unitholder Name 2. CHANGE OF CONTACT DETAILS AND RESIDENCY STATUS FOR TAX PURPOSES Please provide your address and we will provide you with notification of new account correspondence as it becomes available. INDIVIDUAL/JOINT INVESTORS/SOLE TRADER DETAILS Complete this section if you are investing in your own names, including as a sole trader. INVESTOR 1 Title Tax File Number or Exemption Code Country of Residence for Tax Purposes (if not Australia) Residential Address (not a PO Box) Mobile Number Telephone (we encourage you to provide your address so that you can receive a copy of all relevant reports) Certain reports will only be sent by . Are you an Australian resident for tax purposes? Yes No Are you a United States of America (US) citizen or resident of the US for tax purposes? Yes No If yes, provide your US Taxpayer Identification Number 1

2 INVESTOR 2 (only applicable for joint Investors) Title Tax File Number or Exemption Code Country of Residence for Tax Purposes (if not Australia) Residential Address (not a PO Box) Mobile Number Telephone Are you an Australian resident for tax purposes? Yes No Are you a United States of America (US) citizen or resident of the US for tax purposes? Yes No If yes, provide your US Taxpayer Identification Number If there are more than 2 individuals please provide details and attach to this Form. SIGNING AUTHORITY (for applications with two or more individuals) Any one investor to sign; or All investors to sign If no selection is made, all investors will be required to sign. ADDITIONAL INFORMATION FOR SOLE TRADER (only applicable if applying as a Sole Trader) Full Business Name (if any) ABN (if obtained) Address of Principal Place of Business (not a PO Box). If same as residential address given above, mark As Above. 2

3 COMPANY (INCLUDING CORPORATE TRUSTEE) DETAILS Complete this section if you are investing for, or on behalf of, a company (including as the Corporate Trustee for a Trust/ Superannuation Fund). Full Company Name Country of Formation, Incorporation or Registration Country of Residence for Tax Purposes (if not Australia) Tax File Number or Exemption (Australian residents) ACN/ABN (if registered in Australia) Name of Regulator (if licensed by an Australian Commonwealth, State or Territory statutory regulator) Name of Two Directors and : Director 1 Full Name Director 2 Full Name (if not a Sole Director Company) Registered Business Address in Australia or in Country of Formation Principal Place of Business (not a PO Box address) If an Australian Company, registration status with ASIC. Proprietary Company Public Company If a Foreign Company, registration status with the relevant foreign registration body. Private/Proprietary Company Public Company Other Please Specify Name of Relevant Foreign Registration Body Foreign Company Identification Number Is the Company Listed? No Yes Name of Market/Stock Exchange If the company is registered as a proprietary company by ASIC or is a private company registered by a foreign registration body, please list the name of each director of the company. Director 1 Full Name Director 4 Full Name Director 2 Full Name Director 5 Full Name Director 3 Full Name Director 6 Full Name If there are more than 6 Directors please provide full names on a separate page and attach to this Application Form. 3

4 If the company is an Australian proprietary or a foreign private company which is NOT regulated, please provide details for each beneficial owner having more than 25 per cent of the company s issued share capital. Beneficial Owner 1 Residential Address (not a PO Box address) Beneficial Owner 2 Residential Address (not a PO Box address) Beneficial Owner 3 Residential Address (not a PO Box address) CONTACT PERSON DETAILS (Financial Adviser details not accepted) Postal Address Mobile Number Telephone (we encourage you to provide your address so that you can receive a copy of the relevant reports) Certain reports will only be sent by . If the company is a US Company (a company created in the US, established under the laws of the US or a US taxpayer): Provide the company s US Taxpayer Identification Number (TIN): 4

5 Indicate whether the Company is an exempt payer for US tax purposes: Yes No If the company is a Financial Institution (a custodial or depository institution, an investment entity or a specified insurance company for FATCA purposes): Provide the company s Global Intermediary Identification Number (GIIN) if applicable: If the company does not have a GIIN, please provide its FATCA status: If the company is a Non-Financial Proprietary Company (a proprietary company or foreign private company that is not a Financial Institution) and any of the above Beneficial Owners are US citizens or residents of the US for tax purposes: Please provide their US Taxpayer Identification Number (TIN) Given names in full US TIN TRUST/SUPERANNUATION FUND DETAILS Complete this section if you are investing for, or on behalf of, a Trust/Superannuation Fund. Full Name of Trust/Superannuation Fund Country of Establishment Country of Residence for Tax Purposes (if not Australia) Tax File Number or Exemption Code ABN (if any) TYPE OF TRUST (Please tick ONE box from the following list to indicate the type of Trust and provide the required information) Type A Regulated Super Fund (e.g. self-mananged superannuation fund) Name of Regulator (e.g. ASIC, APRA, ATO) Registration/Licensing details Type B Name of Regulator Other Regulated Trust (not Regulated Super Fund) Registration/Licensing details Type C Unregulated Trust Trust Description (e.g. family, unit, charitable, discretionary Do the terms of the Trust identify the beneficiaries by reference to a membership of a class? Yes Describe the class of beneficiaries below (e.g. unit holders, family members of named person, charitable purposes) No Provide the full names of all company and individual beneficiaries 5

6 Beneficiary 1 Full Name Beneficiary 4 Full Name Beneficiary 2 Full Name Beneficiary 5 Full Name Beneficiary 3 Full Name Beneficiary 6 Full Name If there are more than 6 beneficiaries please provide their full names on a separate page and attach to this Form. If you have selected type B above, please provide the Trust s Global Intermediary Identification Number (GIIN) if applicable: If the Trust does not have a GIIN, please provide its FATCA status: If you have selected Type C above, please tick one of the following categories that apply to the Trust and complete the required information: United States Trust (A trust created in the US, established under the laws of the US or a US taxpayer). Provide the Trust s US Taxpayer Identification Number (TIN): Indicate whether the Trust is an exempt payer for US tax purposes: Yes No Financial Institution (a trust that is primarily established for custodial or investment purposes). Provide the Trust s Global Indemnity Identification Number (GIIN), if applicable: If the Trust does not have a GIIN, please provide its FATCA status: Other (Trusts that are not US Trusts, Financial Institutions or do not have a Financial Institution Trustee). Are any of the Trust beneficiaries, trustees or settlors US citizens or residents of the US for tax purposes: Yes No 6

7 INDIVIDUAL TRUSTEE DETAILS INDIVIDUAL TRUSTEE 1 Title Residential Address (not a PO Box) Mobile Number Telephone (we encourage you to provide your address so that you can receive a copy of all relevant reports) Certain reports will only be sent by . Are you an Australian resident for tax purposes? Yes No Are you a United States of America (US) citizen or resident of the US for tax purposes? Yes No If yes, provide your US Taxpayer Identification Number INDIVIDUAL TRUSTEE 2 Title Residential Address (not a PO Box) (we encourage you to provide your address so that you can receive a copy of all relevant reports) Certain reports will only be sent by . Are you an Australian resident for tax purposes? Yes No Are you a United States of America (US) citizen or resident of the US for tax purposes? Yes No If yes, provide your US Taxpayer Identification Number 7

8 3. CHANGE OF FINANCIAL ADVISER DETAILS (IF APPLICABLE) If you are investing through a financial adviser, please give your consent, by ticking the appropriate box below, for us to provide them with access to information about your investments and authorise them to make enquiries on your behalf. I wish my financial adviser to receive information about my investments. By entering my financial adviser details below I acknowledge and agree they will have access to information about my investment and may receive copies of my statements by or post. I do not wish my financial adviser to receive information about my investments. Adviser Details Adviser/ contact name Full registered name Trading name (if different from registered name) Registered address (Note: PO Box is not acceptable) State Postcode Postal Address (if different From the above) (Note: PO Box is not acceptable) State Postcode AFSL number Adviser stamp Business number ( ) Fax number ( ) Mobile number address Dealer Group Details (If Applicable) Dealer group name Dealer group address (Note: PO Box is not acceptable) State Postcode AFSL number Adviser stamp Business number ( ) Fax number ( ) Mobile number address I [ ] confirm that I have satisfied the requirements of the AML/CTF for the customer identification procedure for this client as their Financial Adviser. Certified copies of identity documents must be included with the Application. Signature of Financial Adviser 8

9 4. CHANGE OF DISTRIBUTION INSTRUCTIONS Please tick the relevant box below to change how you would like your distributions paid. If no selection is made, your previous nomination will continue to apply. Fund Reinvest Pay to Bank PineBridge Global Dynamic Asset Allocation Fund 5. CHANGE OF ACCOUNT DETAILS Bank Account Details for Distribution and Redemption Payments (This section must be completed for payments from the Fund to your bank) Australian Bank/Institution Branch Account Name BSB Account Number The name of your nominated bank account must be the same as the investor s name. 9

10 6. DECLARATION AND SIGNATURES I/we declare and agree each of the following: I/we have read the Product Disclosure Statement to which this application applies and have received and accepted the offer in it. If I am/we are a Retail Client, I/we have obtained independent financial advice from a Licensed Financial Adviser. My/our application is true and correct. I am/we are bound by any terms and conditions contained in the Product Disclosure Statement and the provisions of the Constitution of the Fund as amended from time to time. I/we have legal power to invest. If this is a joint application, each of us agrees that our investment is as joint tenants. Each of us is able to operate the account and bind the other to any transaction including investments or withdrawals by any available method. If investing as trustee on behalf of a super fund or trust I/we confirm that I am/we are acting in accordance with my/our designated powers and authority under the trust deed. In the case of a super fund, I/we also confirm that it is a complying fund under the Superannuation Industry (Supervision) Act I/we acknowledge that none of Perpetual Trust Services Limited or any of their related entities, officers or employees or any related company or any of the appointed service providers including the investment manager and custodian guarantee the repayment of capital or the performance of the Fund or of any particular rate of return by the Fund. I/we agree to the anti-money laundering and counter-terrorism financing statements contained in the Product Disclosure Statement. I/we agree to provide further information or personal details to Perpetual Trust Services Limited and the Administrator to provide such information to the Manager, if required to meet their obligations under any anti-money laundering and counter-terrorism law and regulations or to enable them to fulfil their role in the operation of the Fund, and acknowledge that processing or my/our application may be delayed and will be processed at the unit price applicable for the business day on which all required information has been received and verified. I/we have read and understood the privacy disclosure as detailed in the Product Disclosure Statement. I/We consent to my/our personal information being collected, held, used and disclosed in accordance with the privacy disclosure. If I/we have appointed an authorised representative, I/we release, discharge and indemnify Perpetual Trust Services Limited from any loss, expense, action or other liability which may be suffered by, brought against you or Perpetual Trust Services Limited for any action or omissions by the authorised representative whether authorised by me/us or not. I/we certify that the FATCA information provided is reasonable based on the documentation provided. I/we acknowledge and agree that: Perpetual Trust Services Limited may be required to pass on my/our personal information or information about my/our investment to the relevant regulatory authorities, including for compliance with the Anti-Money Laundering and Counter- Terrorism Act 2006 or associated regulation and any tax-related requirements for tax residents of other countries. Signature 1* Signature 2* Full Name Full Name Date Date Tick capacity (mandatory for companies): Tick capacity (mandatory for companies): Sole Director and Company Secretary Director Secretary Director Secretary *Joint applicants must both sign. *For Individual Trustee Trust/Superannuation Funds each individual Trustee must sign. *For Corporate Trustee Trust/Superannuation Funds 2 Directors, a Director and Secretary or Sole Director must sign. Post your original signed Change of Details Form to the custodian: State Street Australia Limited Unit Registry Level 14, 420 George Street Sydney NSW 2000 Australia 10