E.I. STURDZA FUNDS PLC APPLICATION FORM

Transcription

1 E.I. STURDZA FUNDS PLC APPLICATION FORM If you want to apply for shares in E.I. Sturdza s p.l.c. (the Company ) please complete this Application Form. All applications for Shares must be received by post delivery or fax (with the original to follow by post soon after) by the Administrator no later than the Dealing Deadline specified in the relevant Supplement. The Administrator may accept applications by electronic communication, subject to prior written agreement. The contact details of the Administrator are as follows: HSBC Securities Services (Ireland) Limited 1 Grand Canal Square, Grand Canal Harbour Dublin 2, Ireland Telephone: Fax: ifsinvestorqueries@hsbc.com (queries only) Terms defined in the Company s Prospectus shall have the same meaning in this Application Form. This Application Form consists of the following parts, please ensure you read, understand and complete all parts of the Application Form before signing: Application Form Appendix 1 Client Due Diligence Requirements Appendix 2 Individual Self Certification Appendix 3 Entity Self Certification Appendix 4 Declarations Appendix 5 Declaration of Residence Outside Ireland Appendix 6 Return of Values (Investment Undertakings) Regulations 2013 Appendix 7 Details of the Sub and Share Classes of E.I. Sturdza s plc Appendix 8- Common Reporting Standard-Customer Information Notice 1

2 If the holding is to be registered in more than two names (maximum four) each additional holder must provide full details and a signature on a separate piece of paper. Please use BLOCK CAPITALS. INVESTOR DETAILS FOR ENTITIES Registered Name Registered Address Correspondence Address (if different) Postcode Incorporation/Registration Date Postcode Jurisdiction of Incorporation/Registration Contact Name Telephone Number Address Facsimile Number We hereby declare that the entity was incorporated under the laws of... (country) and that it is not a financial intermediary. INVESTOR DETAILS FOR INDIVIDUALS Full Name Home Address Correspondence Address (if different) Postcode Date of Birth Postcode Address Country of Birth Facsimile Number (include country code) Citizenship Telephone Number (include country code) I/We declare that I am a/we are private investor(s) who is/are making this application on my/our own behalf and not in any way as representative(s) of any other party. DEALING INSTRUCTIONS I/We want to invest in E.I. Sturdza s p.l.c. pursuant to the terms and conditions of the Prospectus of the Company (together with any applicable Supplements). I/We confirm I/we have received this documentation. Yes No Please complete the subscription amount or number of shares for the relevant fund in which you want to invest in the following table. Applications are accepted in either cash subscriptions or share amount subscriptions. Please note the minimum subscription and minimum subsequent investment amounts in the Appendix 7. 2

3 Share Class ISIN Subscription Amount in Cash Strategic China Panda USD Class IE00B3DKH950 Hedged Euro Class IE00B3DKHB71 Strategic Euro Bond Nippon Growth (UCITS) Strategic Europe Value Hedging Sterling Class Hedged CHF Class USD Institutional Class Euro Hedged Institutional Class Sterling Hedged Institutional Class CHF Hedged Institutional Class Euro Distributing Class Euro Accumulating Class CHF Accumulating Class Euro Institutional Class CHF Institutional Class Euro R Class USD Hedged R Class JPY Class A JPY Class B Accumulating JPY Class C Distributing JPY Class D Institutional Euro Hedged Class CHF Hedged Class GBP Hedged Class USD Hedged Class Euro Hedged Institutional Class CHF Hedged Institutional Class GBP Hedged Institutional Class USD Hedged Institutional Class Euro Hedged R Class USD Hedged R Class Euro Class CHF Class GBP Class USD Class Euro Institutional Class CHF Institutional Class GBP Institutional Class USD Institutional Class Euro R Class USD R Class Euro Institutional Distributing Class CHF Super Institutional Class Euro Super Institutional Class GBP Super Institutional Class USD Super Institutional Class IE00B3DKHD95 IE00BHBF1323 IE00BHBF1430 IE00BHBF1547 IE00BHBF1653 IE00BHBF1760 IE00B45CFR06 IE00B45CGH72 IE00B904Y805 IE00B86MPF55 IE00B9096X40 IE00BP8G3M77 IE00BP8G3N84 IE00B45CFP81 IE00B563Q870 IE00B58VV065 IE00B97RRK58 IE00B991XL80 IE00BGHQ9L68 IE00BGHQ9K51 IE00BGHQ9M75 IE00B95WDX70 IE00BGHQ9P07 IE00BGHQ9N82 IE00BGHQ9Q14 IE00BP8G3P09 IE00BP8G3Q16 IE00B5VJPM77 IE00B8431S50 IE00B84BZX23 IE00BHBF1984 IE00B7TRTL43 IE00B76Y2204 IE00B90YC864 IE00BHBF1B05 IE00BP8G3R23 IE00BP8G3S30 IE00BYNK3Z05 IE00BD03RK81 IE00BD03RJ76 IE00BD03RL98 IE00BD03RM06 Subscription Amount in Shares 3

4 Strategic Global Bond Strategic US Momentum and Value Strategic Global Quality Strategic European Smaller Companies Strategic Quality Emerging Bond USD Class RMB Class CHF Hedged Class EUR Hedged Class USD Class CHF Hedged Class EUR Hedged Class GBP Hedged Class USD Institutional Class CHF Hedged Institutional Class EUR Hedged Institutional Class GBP Hedged Institutional Class EUR Hedged R Class USD R Class Euro Class GBP Class USD Class CHF Class Euro Institutional Class GBP Institutional Class USD Institutional Class CHF Institutional Class Euro Super Institutional Class GBP Super Institutional Class USD Super Institutional Class CHF Super Institutional Class Euro Class Euro Class X USD Class CHF Class CHF Institutional Class Euro Institutional Class USD Institutional Class CHF Class CHF Distributing Class CHF Institutional Class CHF R Class EUR Class EUR Distributing Class EUR Institutional Class EUR R Class GBP Class GBP Distributing Class GBP Institutional Class GBP R Class USD Class USD Distributing Class USD Institutional Class USD R Class IE00B7WNNX93 IE00B815YM90 IE00BD03RS67 IE00BD03RR50 IE00B7H11M39 IE00BFH59L67 IE00BFH59J46 IE00BFH59K50 IE00BFH59M74 IE00BFH59Q13 IE00BFH59N81 IE00BFH59P06 IE00BP8G3T47 IE00BP8G9L80 IE00BTC0JQ94 IE00BTC0JR02 IE00BTC0JS19 IE00BTC0JT26 IE00BTC0JV48 IE00BTC0JW54 IE00BTC0JX61 IE00BTC0JY78 IE00BD37M579 IE00BD37M686 IE00BD37M793 IE00BD37M801 IE00BWCGWH04 IE00BWCGWF89 IE00BWCGWG96 IE00BWCGWD65 IE00BD03RQ44 IE00BD03RN13 IE00BD03RP37 IE00BYPK4X35 IE00BYPK4Z58 IE00BYPK5072 IE00BYPK5296 IE00BYPK4Q67 IE00BYPK4R74 IE00BYPK4S81 IE00BYPK4V11 IE00BYPK5304 IE00BYPK5411 IE00BYPK5635 IE00BYPK5742 IE00BYPK4L13 IE00BYPK4N37 IE00BYPK4P50 IE00BYPK4W28 4

5 Payment Method Investments must be made by electronic transfer in the currency of the /Class of Investment. Subscription monies must be received by the Administrator in the correct currency, for the account of the relevant, no later than the Valuation Point as set out in the relevant Supplement. If payment in full has not been received by the relevant times stipulated above, the application may be refused and the Shares cancelled. I/We hereby indemnify the Company and the Administrator against any loss, liability, cost or expenses arising out of or in connection with failed settlement arrangements. Please note that the details of both the Intermediary Bank and the Beneficiary Bank must be quoted on your transfer instructions. The details below should assist you with the transfer. USD PAYMENTS EUR PAYMENT GBP PAYMENTS Correspondent HSBC Bank USA, Inc. HSBC Bank plc, London HSBC Bank plc, London Bank: SWIFT: MRMDUS33 MIDLGB22 MIDLGB22 ABA: Sort Code: Beneficiary Account: Beneficiary Name: HSBC Bank, plc London SWIFT: MIDLGB22 Sort Code: Beneficiary Account: Beneficiary Name: HSSI USD Collection A/c HSSI EUR Collection A/c HSSI GBP Collection A/c IBAN: GB43MIDL GB90MIDL GB68MIDL Reference: e.g. /Investor Name e.g. /Investor Name e.g. /Investor Name JPY PAYMENTS CHF PAYMENTS Correspondent HSBC, Tokyo Credit Suisse AG, Zurich Bank: SWIFT: HSBCJPJT CRESCHZZ80A ABA: Sort Code: Beneficiary Account: CH Beneficiary Name: HSBC Bank plc, London HSBC Bank Plc, London SWIFT: MIDLGB22 MIDLGB22 Sort Code: Beneficiary Account: Beneficiary Name: HSSI JPY Collection A/c HSSI fbo SRHD MNS CHF Collection A/C IBAN: GB24MIDL GB02MIDL Reference: e.g. /Investor Name e.g. /Investor Name 5

6 Bank Details Redemption Payments Please provide bank details for redemption payments. All payments will be made by electronic transfer. Name of Beneficiary Bank: Name of Correspondent Bank: Full Postal Address of Beneficiary Bank: Full Postal Address of Correspondent Bank: SWIFT/Sort Code: SWIFT/Sort Code: Account Name: Account Number/IBAN: Bank Details Dividend Payments If different to the above please provide bank details for dividend payments. All payments will be made by electronic transfer. Name of Beneficiary Bank: Name of Correspondent Bank: Full Postal Address of Beneficiary Bank: Full Postal Address of Correspondent Bank: SWIFT/Sort Code: SWIFT/Sort Code: Account Name: Account Number/IBAN: Bank Details Notes 1. A correspondent bank may be required where the currency being paid is to a country other than the country of origin e.g. USD being paid to a European bank must be routed through a bank based in the United States. 2. Payments will be made in the relevant currency denomination of the share class. 3. All redemption proceeds will be paid to the above bank details, unless specified at the time of the redemption and authorised to the satisfaction of the Administrator. Please tick the box if you wish to receive dividends, if declared. If this box is left blank, dividends, if declared, will be automatically reinvested. 6

7 DATA PROTECTION STATEMENT Your personal information will be handled by the Administrator (as Data Processor on behalf of the Company) in accordance with the Data Protection Acts 1988 to 2003 of Ireland. Your information will be processed for the purposes of carrying out the services of administrator, registrar and transfer agent of the Company and to comply with legal obligations including legal obligations under company law, anti-money laundering and counter terrorist financing legislation. The Administrator or Company may disclose your information to third parties where necessary or for legitimate business interests. This may include disclosure to third parties such as auditors, the Irish Revenue Authorities pursuant to the EU Savings Directive and the Central Bank of Ireland or agents of the Administrator who process the data for anti-money laundering purposes or for compliance with foreign regulatory requirements. The Applicant hereby consents to the processing of his/her information. This may include the recording of telephone calls with the Administrator and/or the Investment Manager for the purpose of confirming data, and the disclosure of his/her information to the Administrator as outlined above and to the Investment Manager. The information may also, for legitimate business reasons, be passed to any company in the Administrator's and/or the Investment Manager's group of companies or agents of the Administrator or Investment Manager, including companies situated in countries outside of the European Economic Area. These countries may not have the same data protection laws as in Ireland. IMPORTANT BEFORE SIGNING PLEASE MAKE SURE YOU HAVE READ, UNDERSTOOD AND COMPLETED THE APPENDICES TO THE APPLICATION FORM Authorised Signatures (all applicants must sign) SIGNATORIES First Signature: Print Name: Date: Second Signature: Print Name: Date: Third Signature: Print Name: Date: Fourth Signature: Print Name: Date: 7

8 Checklist for Completion Application Form Appendix 1 Client Due Diligence Requirements Appendix 2 Individual Self Certification Appendix 3 Entity Self Certification Appendix 4 Declarations Appendix 5 Declaration of Residence Outside Ireland Appendix 6 Return of Values (Investment Undertakings) Regulations 2013 Appendix 7 Details of Sub s and Share Classes of E.I. Sturdza s plc Appendix 8 Common Reporting Standard-Customer Information Notice 8

9 APPENDIX 1 - CLIENT DUE DILIGENCE REQUIREMENTS Corporate Applicants Please supply the following: Certified* copy of Certificate of Incorporation (or equivalent); and or Certified* copy of Memorandum and Articles of Association (or equivalent document showing registered corporate office); and or Certified* copy of latest audited financial statements; Certified* copy of the corporation or entity s list of authorised signatories; List of all directors names, occupations, residential and business addresses, dates of birth, place of birth and citizenship; Identification as per individual investors for two directors or one director and one signatory; Identification as per individual investors of beneficial owners who own more than 25% of the share capital or voting rights; and Tax residency self-certification (refer to Appendix 3). Partnership or Trust Applicants Please supply the following: List of names, date of birth, place of birth, citizenship, occupation and permanent addresses of all partners/trustees/beneficiaries/ where ascertainable settlors; Identification as per individual investor for two Trustees or one Trustee and one authorised signatory / General Partner or two partners and one authorised signatory; Identification as per individual investors of beneficial owners who own more than 25% of the share capital or voting rights; Evidence of the above partners /trustees authority to make investments in the /Company on behalf of the partnership/trust; Certified* authorised signatory list; Certified* copy of partnership agreement/trust deed; and Tax residency self-certification (refer to Appendix 3). Institutional Applicants e.g. pension fund and local authority, please supply the following: Certified* authorised signatory list and properly authorised mandate of persons completing the form to act on behalf of the applicant; Documentary evidence of the regulatory status of the applicant (e.g. Inland Revenue Approval), please contact the Administrator for further details of documents required; and Details of beneficiaries (where ascertainable); and Tax residency self-certification (refer to Appendix 3). Individual Investors Please supply the following: (a) Certified* copy of your passport, national identity card, armed forces identity card or ID issued by a Government body showing the photograph and signature; (b) One form of address verification: for example original or certified* copy of a recent utility bill or bank statement (no more than 6 months old); (c) Tax residency self-certification (refer to Appendix 2); and (d) Where you are a PEP confirmation of your source of wealth is required noting the definitions and requirements detailed in Clause 3 above. Irish Residents (d) In addition to (a), (b) and where applicable (c) where you are an Irish resident investor one form of document on which your tax reference number is printed. The following documentation may be used to verify the tax reference number as required under Regulation 5(4)(a) of the Return of Values (Investment Undertakings) Regulations Including: P60; P45; P21 Balancing Statement; Payslip; 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 or any printed documentation issued by the Revenue Commissioners or by the Department of Social Protection which contains the person s name, address and tax reference number/ppps number. The same procedures should be applied to joint account holders as for individuals. *All certified copies should be certified by a notary public, solicitor, chartered & certified public accountants, practicing solicitors, embassy consular staff, police officer or FATF regulated financial institution or any person so authorised under the laws of your country or domicile (except the authorised signatories lists may be certified by the company secretary). Copies must be marked true copy of original document and stamped by the certifying party. RESTRICTED - 9

10 Instructions for completion APPENDIX 2 INDIVIDUAL SELF CERTIFICATION FOR FATCA AND CRS We are obliged under Section 891E, Section 891F and Section 891G of the Taxes Consolidation Act 1997 (as amended) and regulations made pursuant to those sections 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 legally obliged to share this information, and other financial information with respect to an investor s interests in the with relevant tax authorities. This form is intended to request information only where such request is not prohibited by Irish law. If you have any questions about this form or defining the investor s tax residency status, please refer to the OECD CRS Portal or speak to a tax adviser. For further information on FATCA or CRS please refer to Irish Revenue website at or the following link to the OECD CRS Information Portal at: in the case of CRS only. If any of the information below about the investor s tax residence or FATCA/CRS classification changes in the future, please advise of these changes promptly. Please note that where there are joint or multiple account holders each investor is required to complete a separate Self-Certification form. Sections 1, 2, 3 and 5 must be completed by all investors. Section 4 should only be completed by any individual who is a Controlling Person of an entity investor which is a Passive Non-Financial Entity. For further guidance see. (Mandatory fields are marked with an *) Section 1: Investor Identification Investor Name*: Current Residential Address*: Number: Street: City, Town, State, Province or County: Postal/ZIP Code: Country: Mailing address (if different from above): Number: Street: City, Town, State, Province or County: Postal/ZIP Code: Country: Town or City of Birth*: Country of Birth*: Date of Birth*: Section 2: Declaration of U.S. Citizenship or U.S. Residence for Tax purposes*: RESTRICTED - 10

11 Please tick either (a) or (b) and complete as appropriate. (a) I confirm that [I am]/[the investor is] a U.S. citizen and/or resident in the U.S. for tax purposes and [my]/[its] U.S. federal taxpayer identifying number (U.S. TIN) is as follows: OR (b) I confirm that [I am not]/[the investor is not] a U.S. citizen or resident in the U.S. for tax purposes. Section 3: CRS Declaration of Tax Residency (please note you may chose more than one country)* Please indicate your/the investor s country of tax residence. If resident in more than one country please detail all countries of tax residence and associated taxpayer identification numbers ( TIN ). Please see the CRS Portal for more information on Tax Residency. Country of Tax Residency Tax ID Number Note: provision of a TAX ID number (TIN) is required unless you are tax resident in a jurisdiction that does not issue a TIN. Section 4: Type of Controlling Person (ONLY to be completed by any individual who is a Controlling Person of an entity investor which is a Passive Non-Financial Entity or an Investment Entity located in a Non-Participating jurisdiction and managed by another Financial Institution). For joint or multiple Controlling Persons please complete a separate Self-Certification Form for each Controlling Person. Please Confirm what type of Controlling Person applicable under CRS that Please Entity Name applies to you/the investor by ticking the appropriate box. Tick Controlling Person of a legal person control by ownership Controlling Person of a legal person control by other means Controlling Person of a legal person senior managing official Controlling Person of a trust settlor Controlling Person of a trust trustee Controlling Person of a trust protector Controlling Person of a trust beneficiary Controlling Person of a trust other Controlling Person of a legal arrangement (non-trust) settlor-equivalent Controlling Person of a legal arrangement (non-trust) trustee-equivalent Controlling Person of a legal arrangement (non-trust) protector-equivalent Controlling Person of a legal arrangement (non-trust) beneficiary-equivalent Controlling Person of a legal arrangement (non-trust) other-equivalent RESTRICTED - 11

12 Section 5: Declaration and Undertakings I declare that the information provided in this form is, to the best of my knowledge and belief, accurate and complete. I acknowledge that the information contained in this form and information regarding the Account Holder may be reported to the tax authorities of the country in which this account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the Account Holder may be tax resident where those countries (or tax authorities in those countries) have entered into Agreements to exchange financial account information. I undertake to advise the recipient promptly and provide an updated Self-Certification form where any change in circumstances occurs which causes any of the information contained in this form to be incorrect. Authorised Signature*: Print Name*: Date: (dd/mm/yyyy): Capacity*: RESTRICTED - 12

13 APPENDIX 3 ENTITY SELF CERTIFICATION FOR FATCA AND CRS Instructions for completion We are obliged under Section 891E, Section 891F and Section 891G of the Taxes Consolidation Act 1997 (as amended) and regulations made pursuant to those sections 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 legally obliged to share this information, and other financial information with respect to an investor s interests in the with relevant tax authorities. This form is intended to request information only where such request is not prohibited by Irish law. If you have any questions about this form or defining the investor s tax residency status, please refer to the OECD CRS Portal or speak to a tax adviser. For further information on FATCA or CRS please refer to Irish Revenue website at or the following link to the OECD CRS Information Portal at: in the case of CRS only. If any of the information below about the investor s tax residence or FATCA/CRS classification changes in the future, please advise of these changes promptly. Please note that where there are joint or multiple account holders each investor is required to complete a separate Self-Certification form. (Mandatory fields are marked with an *) Investors that are individuals should not complete this form and should complete the form entitled Individual Self- Certification for FATCA and CRS. Section 1: Investor Identification Investor Name*: (the Entity ) Current Registered Address*: Number: Street: City, Town, State, Province or County: Postal/ZIP Code: Country: Mailing address (if different from above): Number: Street: City, Town, State, Province or County: Postal/ZIP Code: Country: Town or City of Birth*: Country of Birth*: Date of Birth*: Section 2: FATCA Declaration Specified U.S. Person: Please tick either (a),(b) or (c) below and complete as appropriate. RESTRICTED - 13

14 (a) The Entity is a Specified U.S. Person and the Entity s U.S. Federal Taxpayer Identifying number (U.S. TIN) is as follows: U.S. TIN:. Or (b) The Entity is not a Specified U.S. Person (please also complete Sections 3, 4 and 5). Or (c) The Entity is a US Person but not a Specified U.S. Person (please also complete Sections 3, 4 and 5). Section 3: Entity s FATCA Classification* (the information provided in this section is for FATCA, please note your classification may differ from you CRS classification in Section 5): 3.1 Financial Institutions under FATCA: If the Entity is a Financial Institution, please tick one of the below categories, and provide your FATCA GIIN at 3.2. I. Irish Financial Institution or a Partner Jurisdiction Financial Institution II. III. Registered Deemed Compliant Foreign Financial Institution Participating Foreign Financial Institution 3.2 Please provide your Global Intermediary Identification number (GIIN) 3.3 If the Entity is a Financial Institution but unable to provide a GIIN, please tick one of the below reasons; The Entity has not yet obtained a GIIN but is sponsored by another entity which does have a GIIN I Please provide your sponsor s name and sponsor s GIIN : Sponsor s Name: Sponsor s GIIN: II. III. IV. Exempt Beneficial Owner Certified Deemed Compliant Foreign Financial Institution (including a Foreign Financial Institution deemed compliant under Annex II of the Agreement) Non-Participating Foreign Financial Institution V. Excepted Foreign Financial Institution 3.4 Non-Financial Institutions under FATCA: If the Entity is not a Financial Institution, please tick one of the following categories: I. Active Non-Financial Foreign Entity II. III. Passive Non-Financial Foreign Entity (if this box is ticked, please include self-certification forms for each of your Controlling Persons) Excepted Non-Financial Foreign Entity Section 4: CRS Declaration of Tax Residency (please note that you may choose more than one country)* Please indicate your/the investor s country of tax residence for CRS purposes. If resident in more than one country please detail all countries of tax residence and associated taxpayer identification numbers ( TIN ). RESTRICTED - 14

15 If the Entity is not tax resident in any jurisdiction (e.g., because it is fiscally transparent), please indicate that below and provide its place of effective management or country in which its principal office is located. Country of Tax Residency Tax ID Number Section 5: Entity s CRS Classification* (The information provided in this section is for CRS. Please note an Entity's CRS classification may differ from its FATCA classification in Section 3): For more information please see the CRS Standard and associated commentary: 5.1 Financial Institutions under CRS: If the Entity is a Financial Institution, please tick one of the below categories: I. Financial Institution under CRS (other than (II) below) II. An Investment Entity located in a Non-Participating Jurisdiction and managed by another Financial Institution (if this box is ticked, please indicate the name of any Controlling Person(s) of the Entity and complete a separate Individual Self-Certification form for each Controlling Person**) 5.2 Non Financial Institutions under CRS: If the Entity is a Non Financial Institution, please tick one of the below categories: I. II. III. IV. V. Active Non-Financial Entity a corporation the stock of which is regularly traded on an established securities market or a corporation which is a related entity of such a corporation. Active Non-Financial Entity a Government Entity or Central Bank Active Non-Financial Entity an International Organisation Active Non-Financial Entity other than (I)-(III) (for example a start-up NFE or a non-profit NFE) Passive Non-Financial Entity (if this box is ticked, please complete a separate Individual Self-Certification Form for each of your Controlling Person(s)) **Controlling Person s: NB: Please note that each Controlling Person must complete a Separate Individual Self-Certification form. If there are no natural person(s) who exercise control of the Entity then the Controlling Person will be the natural person(s) who hold the position of senior managing official of the Entity. For further information on Identification requirements under CRS for Controlling Persons, see the Commentary to Section VIII of the CRS Standard. RESTRICTED - 15

16 Section 6: Declarations and Undertakings I/We declare (as an authorised signatory of the Entity) that the information provided in this form is, to the best of my/our knowledge and belief, accurate and complete. I acknowledge that the information contained in this form and information regarding the Account Holder may be reported to the tax authorities of the country in which this account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the Account Holder may be tax resident where those countries (or tax authorities in those countries) have entered into Agreements to exchange financial account information. 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)*: Print Name(s)*: Capacity in which declaration is made*: Date: (dd/mm/yyyy)*: RESTRICTED - 16

17 APPENDIX 4 - DECLARATIONS Legal Persons Declaration I/We hereby declare that we are:- 1. a legal person not being an individual and not acting in a representative capacity on behalf of an individual; or 2. an entity liable to corporation tax in Ireland or an equivalent tax in another country; or 3. an undertaking for collective investment in transferable securities ("UCITS") or have elected for the purpose of the EU Savings Directive to be treated as a UCITS. If the Legal Person is unable to make any of these declarations please contact the Administrator. Natural Persons Declaration 1. I/We acknowledge that I/we will provide a certified copy of our Passport or a certified copy of a national identity card which must display a photograph, signature and give details of my/our date and place of birth. I/We will also provide details of my/our tax identification number if this does not appear on the Passport or other identity card provided. Documentary proof such as a certificate of tax residency from a relevant tax authority may also be required. These items are in addition to providing an original or certified proof of my/our permanent resident residential address which may be in the form of an utility bill which is no more than 6 months old. 2. I/We agree undertake to ensure all such information is up to date and will notify the Administrator of any change in the information provided as soon as reasonably possible. 3. I/We agree to indemnify and hold harmless the Administrator in its capacity as "Paying Agent" against any loss liability costs or expenses which may be incurred by the Administrator arising out of or in connection with my /our failure to provide the information required. I/We acknowledge that Shares may not be issued and repurchase proceeds may be frozen until all required information and documentation required by the Administrator pursuant to the EU Savings Directive is provided. Electronic Dealing and Communications Declaration In the event that I/we and subject to prior written agreement with the Administrator decide to send subsequent applications, redemptions and instructions electronically (not including by way of facsimile) acknowledge as follows: 1. I/We acknowledge that electronic communications (not including facsimile) whether by , SWIFT messaging or other electronic means may be an unsafe method of communication and may be lost, subject to delays, interference by third parties, viruses and their confidentiality, security and integrity cannot be guaranteed. Further, I/we acknowledge and understand that electronic communications (not including facsimile) cannot be guaranteed to be error-free. 2. I/We hereby confirm that I/we will not hold the Company, the Investment Manager, the Administrator and the Custodian or any of their directors, officers, employees or agents liable now, or at any time for any loss, damage, financial or otherwise which I/we may suffer arising out of or in connection with any interception or breach of confidentiality or integrity or arising out of or in connection with any delays, inaccuracy, imperfection, lack of quality, ineffective transmission, viruses, alteration or distortion howsoever arising affecting such electronic communication (not including facsimile). 3. I/We undertake to keep each of the Company, the Investment Manager, the Administrator and the Custodian indemnified at all times against, and to save each of the Company, the Investment Manager, the Administrator and the Custodian harmless from all actions, proceedings, claims, losses, damages, costs and expenses which may be brought against the Company, the Investment Manager, the Administrator and the Custodian or suffered or incurred by the Company, the Investment Manager, the Administrator and the Custodian and which shall have arisen either directly or indirectly out of or in connection with me /us sending electronic communications (not including facsimile). I/We acknowledge and understand that electronic communication (not including facsimile) received from us will not be verified by you. 4. I/We confirm that I/we, shall not send or transmit or arrange for any sending or transmitting on our behalf, any electronic communication (including facsimile) which contains a virus or other media damaging to your property or computer systems or which may be defamatory, libellous, slanderous, obscene, abusive, offensive, menacing or immoral and will abide with all relevant laws and regulations and international conventions or treaties governing the content of and the transmission of such electronic communications. 5. In the event that I/we are unable to send you instructions by electronic transmission due to either a failure in or shut-down of my/our or the Administrators or other relevant parties internet system whether temporary or otherwise, I/we will send you instructions by facsimile. 6. The Company, the Investment Manager, the Administrator and the Custodian may rely conclusively upon and shall incur no liability in respect of any action taken upon any notice, consent, request, instruction, electronic instructions, electronic subscriptions and redemptions or other instrument (not including facsimile) believed, in good faith, to be genuine. In respect of all other communications sent electronically by or on behalf of the Company: 7. I/we hereby consent to electronic delivery of notices, communications, reports, fund documentation to the address(s) provided in this Application Form and in consideration of the Administrator issuing notices, communications and reports electronically, 8. I/we hereby agree as follows: use of electronic communications shall be subject to the requirements and authentication procedures of the Administrator, I/we acknowledge that it is not possible to secure and maintain confidential electronic communications ( Electronic Communications ), that any such Electronic Communications can be delivered to a wrong address or that delivery of the same may not be timely; that any such Electronic Communications are capable of being intercepted by third parties at any time and accordingly that the confidentiality, security and integrity of any Electronic Communications cannot be assured. 9. I/we shall not hold the Company or the Administrator or any director, officer, employee or agent thereof, liable now or at any RESTRICTED - 17

18 time for any damage, financial or otherwise, which I/we may suffer as a result of any of the matters outlined above with respect to any Electronic Communication affected between the Company or the Administrator and me/us or any person or entity that we authorise to receive information relating to my / our holding in the Company, or otherwise by reason of any third party receiving, gaining access to, obtaining, altering or distorting any information or documentation transmitted via Internet Communications or by reason of any other inaccuracy, imperfection, lack of quality, ineffective transmission, delay, alteration or distortion howsoever arising affecting such Electronic Communications or in respect of any other document, financial data or other information prepared, circulated or otherwise processed by the Administrator. 10. I/we shall indemnify and keep indemnified the Company and the Administrator and any of its directors, officers, employees or agents against all losses, costs, damages, claims, demands and expenses (including claims or other demands whatsoever taken or made by any internet service provider) which any of them may suffer incur or sustain by reason of, sending Electronic Communications to any party and/ or receiving Electronic Communications from any party and / or dealing with any Electronic Communications in respect of me/us. General Declarations 1. I/We understand that Shares in E.I. Sturdza s plc are issued in registered form, proof of title is evidenced by reference to the Register and Share Certificates will not be issued. 2. I/We, the undersigned, declare that I/we am/are over the age of 18, not a US Person as defined in the Prospectus or a benefit plan as defined in the US Employee Retirement Income Security Act 1974 (as amended, updated or replace from time to time) ( ERISA Plan ) and that I/we are not acting on behalf of a US Person(s) or an ERISA Plan, nor do we intend selling or transferring any Shares which we may purchase to any person who is a US Person or to an ERISA Plan. Should I/we become resident or ordinarily resident in the US or an ERISA Plan I/we will bring this fact to the immediate attention of the Company and the Administrator. 3. I/We acknowledge that the Company intends to take such steps as may be required to satisfy any obligations imposed by (i) the Foreign Account Tax Compliance Act ( FATCA ) or (ii) any provisions imposed under Irish law arising from the intergovernmental agreement between the Government of the United States of America and the Government of Ireland ( IGA ) so as to ensure compliance or deemed compliance (as the case may be) with FATCA or the IGA from 1 July Furthermore, I/We hereby acknowledge that the Company intends to also take such steps as may be required to satisfy any obligations imposed by (i) the Standard for Automatic Exchange of Financial Account Information in Tax Matters ( the Standard ) and, specifically, the Common Reporting Standard ( CRS ) therein or (ii) any provisions imposed under Irish law arising from the Standard or any international law implementing the Standard (to include the Multilateral Competent Authority Agreement on Automatic Exchange of Financial Account Information or the EU Council Directive 2011/16/EU (as amended by Council Directive 2014/107/EU)) so as to ensure compliance or deemed compliance (as the case may be) with the Standard and the CRS therein from 1 January In order for the Company to comply with the above FATCA and CRS obligations, I/We agree to provide to the Company, the Investment Manager and the Administrator the necessary declarations, confirmations and/or classifications at such times as each of them may request and furthermore provide any supporting certificates or documents as each of them may reasonably require in connection with this investment by reason of FATCA or CRS, as described above, or otherwise. Should any information furnished to any of them become inaccurate or incomplete in any way, I/we hereby agree to notify the Company, the Investment Manager and the Administrator immediately of any such change and further agree to immediately take such action as the Company, the Investment Manager, and the Administrator may direct, including where appropriate, redemption of our Shares in respect of which such confirmations have become incomplete or inaccurate where requested to do so by the Company, the Investment Manager and the Administrator (as applicable). If relevant, I/we agree to notify the Administrator of any change to my/our tax residency status. I/we hereby also agree to indemnify and keep indemnified the Company, the Investment Manager and the Administrator against any loss, liability, cost or expense (including without limitation legal fees, taxes and penalties) which may result directly or indirectly as a result of a failure to meet our obligations pursuant to this section or failure to provide such information which has been requested by the Investment Manager and/or the Administrator and has not been provided by me/us, and from any misrepresentation or breach of any warranty, condition, covenant or agreement set forth herein or in any document delivered by me/us to the Investment Manager or the Administrator. I/We further acknowledge that a failure to comply with the foregoing obligations or failure to provide the necessary information required may result in the compulsory redemption of our entire holding in the Company, and that the Company and the Custodian are authorized to hold back from redemption proceeds or other distributions to me/us such amount as is sufficient after the deduction of any redemption charges to discharge any such liability and I/we shall indemnify and keep indemnified the Company and the Custodian against any loss suffered by them or other Shareholders in the Company in connection with any obligation or liability to so deduct, withhold or account. 6. I/We confirm that we have accurately and correctly completed the relevant self-certification form included herein. I/We further confirm that if any information included in the self-certification form subsequently becomes inaccurate or incorrect we will notify the Company, the Investment Manager and/or the Administrator immediately of any such change and agree to immediately take such action as the Company, the Investment Manager and/or the Administrator may direct, including where appropriate, redemption of our Shares. 7. I/We agree to waive any provision of any privacy, banking secrecy or other law or regulation of any jurisdiction and/or the terms of any confidentiality agreement, arrangement or understanding that would, absent such a waiver, prevent the Company s compliance with FATCA and CRS requirements. 8. I/we hereby acknowledge that we should consult our own tax advisers about the applicability of FATCA, CRS and any other reporting requirements with respect to our own situation. 9. I/We, the undersigned, agree that the Administrator may process personal data relating to me/us for the purposes of providing services to the Company, performing its legal and regulatory obligations and conducting financial crime risk management and other activities, including disclosing those data to the Company and to third parties and transferring them internationally, all as more fully described in the Administrator s data privacy statement, a copy of which is available at I/We warrant that I/we have the right and authority to make the investment pursuant to this Application Form, whether the investment is my/our own or is made on behalf of another person or entity and that I/we will not be in breach of any laws or regulations of any competent jurisdiction and I/we hereby agree to indemnify the Company, the Custodian, the Administrator RESTRICTED - 18

19 and other Shareholders for any loss suffered by them arising out of or in connection with this warranty/representation not being true in every respect. 11. I/We, hereby confirm that the Company, the Directors and the Administrator are each authorised and instructed to accept and execute any instructions including subscription and/or redemption instructions, instructions relating to payment of redemption proceeds, given by me/us initially in original format. I/We, hereby also acknowledge that any subsequent instructions including subscription and/or redemption instructions, instructions relating to payment of redemption proceeds can be sent to the administrator by facsimile. I/We acknowledge that facsimile instructions are not secure means of communication, and are aware of the risks involved. I/We hereby indemnify the Company, the Directors and the Administrator and agree to keep each of them indemnified, against any loss of any nature whatsoever arising to each of them arising out or in connection with any of them acting on facsimile instructions. The Company, the Directors and the Administrator may rely conclusively upon and shall incur no liability in respect of any action taken upon any notice, consent, request, instructions or other instrument believed, in good faith, to be genuine or to be signed by properly authorised persons. I/We acknowledge that if I/we request the Administrator to pay redemption proceeds to an account or bank the details of which differ from those held on file I / we understand that payment cannot be affected until such time as an facsimile instruction requesting this change is forwarded by me/us to the Administrator, together with any other documentation required by the Administrator, including original documentation required for anti-money laundering purposes. Similarly, I/we understand that while an initial application will be actioned upon receipt of a fax I/we undertake to confirm this by forwarding an original copy of the completed application form used on initial subscription. I/We acknowledge that redemption proceeds will not be paid out until the original of the application form used on initial subscription together with all documentation required by the Company and the Administrator, including all documentation required for antimoney laundering purposes has been received by the Administrator. 12. I/we hereby acknowledge that I/we have been provided with the current key investor information document(s) ( KIID ) in issue for the relevant Class prior to subscribing for that Class in a. I/we hereby acknowledge that the current key investor information document(s) in issue for the relevant Class may, at the discretion of the Directors, be provided to me/us in paper copy or by means of the website. I/we hereby further acknowledge that should the Directors or the Investment Manager provide the current key investor information document(s) in issue for the relevant Class by means of a the website, I/we may request a paper copy to be delivered to me/us free of charge. I/we hereby further acknowledge that prior to making any further subscription (including any conversion) for the relevant Class in the relevant or other Classes in other s, the relevant and current key investor information document(s) in issue for the relevant Class will be provided to me/us by either requesting from the Company and/or the Investment Manager that a paper copy be delivered to me/us or via the website, if any. 13. I/We, having received and considered a copy of the Prospectus and KIID current at the date of this subscription or as supplemented from time to time, hereby confirm that this Application is based solely on the Prospectus, KIID and material contracts referred to therein, together (where applicable) with the most recent Annual Report and Accounts of the Company and (if issued after such report and accounts) its most recent Unaudited Semi-Annual Report. I/We hereby undertake to observe and be bound by the provisions of the Memorandum and Articles of Association of the Company and apply to be entered in the Register of Shareholders as the holder/holders of the Shares issued in relation to this Application. 14. I/We hereby acknowledge that I/we have read and fully considered and understand the Prospectus in connection with this Application for Shares in the Company and that I/we have evaluated our investment in the Company in the light of our financial condition and resources. I/We confirm that I/we am/are aware of the risks involved in investing in the Company and that an inherent risk in this investment is the potential to lose all of our investment. I/We hereby further acknowledge that I/we are applying for Shares on the basis of the Prospectus and that I/we have not relied on any representations or statements made or information provided by or on behalf of the Company other than information contained in the Prospectus. 15. I/We agree to provide these confirmations to the Company at such times as the Company may request, and to provide on request such certifications, documents or other evidence as the Company may reasonably require to substantiate such representations. 16. I/We agree to notify the Company immediately if I/we become aware that any of the confirmations are no longer accurate and complete in all respects and agree immediately either to sell or to tender to the Company for redemption a sufficient number of Shares to allow the confirmation to be made. 17. I/We hereby accept such lesser number of Shares, if any, than may be specified above in respect of which this Application may be accepted. 18. I/We understand that it may be difficult or even impossible for us to transfer Shares due to the lack of an active secondary market. 19. (In respect of Joint applicants only) We direct that on the death of one of us, the Shares for which we hereby apply be held in the name of and to the order of the survivor or survivors of us or the executor of such survivor or survivors. 20. I/We undertake that I/we will not create or sell to any third party, any form of product which is in any way connected to the performance of the Company or any of its s. 21. I/We hereby acknowledge and agree that subscription monies received by the Administrator prior to investment in a will be held in a Collection Account operated by the Administrator in accordance with the Investor Money Regulations which requires inter alia that such monies are held on a segregated basis. I/We further acknowledge and agree that monies held in the Collection Account will be held by the Relevant Credit Institution on the Administrator s behalf for the benefit of and at the risk of the investors on whose behalf such monies are being held. I/we acknowledge and agree that monies held in the Collection Account are not an asset of the relevant until such time as the monies are transferred to the account of the relevant, that I/we may be exposed to the creditworthiness of the Relevant Credit Institution where the Collection Account is held. I/we accordingly acknowledge and agree that neither the Administrator, the Company, nor the shall have any liability or responsibility from any losses arising in the event of the insolvency or other failure of the Relevant Credit Institution. References to Collection Account, Investor Money Regulations and Relevant Credit Institution have the meaning assigned to them as set out below. Collection Account Investor Money Regulations means the investor money collection account(s) operated by the Administrator for a under administration into which all subscription monies are to be paid by an investor and from which all redemption and distribution proceeds are paid as described under the heading Application for Shares - Collection Account ; means the Central Bank (Supervision and Enforcement) Act 2013 (Section 48(1)) Investor Money Regulations 2015 for Service Providers; RESTRICTED - 19