FATCA SELF-CERTIFICATION FORM 58, Triq San Żakkarija, Il-Belt Valletta VLT 1130 Malta FOR ENTITIES THAT ARE Co. Reg. No. C 2833

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1 Bank of Valletta p.l.c. FATCA SELF-CERTIFICATION FORM 58, Triq San Żakkarija, Il-Belt Valletta VLT 1130 Malta FOR ENTITIES THAT ARE Co. Reg. No. C 2833 FINANCIAL INSTITUTIONS AND ARE ALSO NON U.S. PERSONS Part 1 - Information Please read this Part 1 before completing Parts 2 and 3 of this Self-Certification Form (the Form ). Please note that the completion of this Form is mandatory. This Form is to be completed by Entity Account Holders of Bank of Valletta p.l.c. that are Financial Institutions and that are also Non-U.S. Persons. It is the responsibility of the Entity Account Holder (the Account Holder ) to ensure that the information provided in this Form is correct and complete and to provide Bank of Valletta p.l.c. (the Bank or BOV ) with any additional documentation, information or replacement forms when requested or required by the Bank. If information that the Bank already holds about the Account Holder is discovered to be in conflict with that provided by the Account Holder in this Form, this Form may be rejected. Failure to correctly complete and return this Form to the Bank or failure to provide any additional documentation/information as detailed above, may result in the Bank and/or any of its Subsidiaries having to close the Account Holder s Financial Accounts held with them and/or report the Account Holder to the relevant tax authorities. 1. What is this Form intended for? In recent years, measures aimed at combatting tax evasion have become a major focus of governments worldwide. As a result, cooperation between tax authorities has become critical in the fight against tax evasion and in protecting the integrity of tax systems. A key aspect of that cooperation is exchange of information through the implementation of the Foreign Account Tax Compliance Act ( FATCA ). FATCA is a U.S. tax regulation aimed at combating tax evasion by U.S. taxpayers. On the 16 December 2013, the U.S. Government and the Government of Malta signed an intergovernmental agreement to implement FATCA in Malta. As a result, the Maltese tax authorities became obliged to share information with the U.S. tax authorities on Financial Accounts held with Malta Financial Institutions. Accordingly, this Form is for purposes of compliance by the Bank and its Subsidiaries with the relevant FATCA regulations in Malta, these being: (a) Subsidiary Legislation on Cooperation with other Jurisdiction on Tax Matters Regulations of the 22nd July 2011, as this may be amended from time to time; (b) the Income Tax Act (Cap. 123 Laws of Malta) - LNs numbered 78 and 290 of 2014 on Exchange of Information (United States of America) (FATCA) Order 2014, as amended by LN 30 of 2015 and as may be further amended from time to time; and (c) any guidelines issued pursuant to Article 96(2) of the Income Tax Act (Cap. 123 Laws of Malta) pursuant to (a) above (hereon collectively (a), (b) and (c) referred to as the FATCA Regulations ). BOV and its Subsidiaries are classified as Reporting Malta Financial Institutions under FATCA and are therefore required to report, to the Maltese tax authorities, any Financial Accounts that are held with them by Specified U.S. Persons, certain payments that are made to Non-Participating FFIs as well as individuals and Entities whose status cannot be determined under FATCA. This information will, subsequently, be forwarded by the Maltese tax authorities to the U.S. tax authorities. Please note that BOV and its Subsidiaries do not provide tax advice. No part of this Form, including Appendix 1, are intended to provide, and should not be construed as, constituting tax or legal advice. If you have any questions as to the determination of the Account Holder s Residency for Tax Purposes or the classification of the Account Holder under FATCA, please contact the Account Holder s tax advisor. Unless defined in Appendix 1, definitions of capitalised terms used herein can be found in the FATCA Regulations. CA 117 (04/2017) 2. Why are you being required to complete this Form? By completing Parts 2 and 3 of this Form, you will be providing the Bank with accurate and up-to-date information about the Account Holder. Accordingly, this Form will remain valid unless there is a change in circumstances of the Account Holder which affects any of the information which you, on behalf of the Account Holder, provided herein. Such change/s will render the information contained in this Form incorrect or incomplete. In that case the Account Holder must provide the Bank with a duly updated and signed Form within 90 days of any change/s in circumstances. 1

2 3. What is a Financial Institution under FATCA? Kindly refer to the definition of Financial Institution which is provided in Appendix Format of this Form and details on how the Account Holder is to complete this Form Part 1 (this part of the Form) gives details on the purpose and format of this Form and also details on how the Account Holder is to complete Parts 2 and 3. Part 2 of this Form relates to the identification details of the Account Holder. All fields in Part 2 are to be completed. Part 3 of this Form lists the various classifications of Financial Institutions in terms of FATCA. The individual/s completing/signing this Form on behalf of the Account Holder is/are required to choose the appropriate Financial Institution classification for the Account Holder, and accordingly tick such classification. Part 4 of this Form is the declaration section wherein the duly authorised individual/s signing this Form is/are verifying the correctness and completeness of the information provided in this Form on behalf of the Account Holder. 2

3 Part 2 - Identification of Account Holder Please complete this Part 2 in BLOCK LETTERS. All fields are required to be completed. If there are any fields which do not apply to the Account Holder, please mark as Not Applicable. Customer code: (for office use only) Legal name of Account Holder: Registered address of Account Holder: Communication address of Account Holder: Country of incorporation or organisation of Account Holder: Registration number of Account Holder: Telephone / Mobile number/s (including country code) of Account Holder: 3

4 Part 3 - Financial Institution Classification Please complete this Part 3 by providing the Account Holder s status under FATCA by ticking one of the following: 1. Reporting Model 1 FFI Pursuant to the FATCA Regulations, I/we certify that the Account Holder is a Financial Institution and qualifies as a Reporting Model 1 FFI. Please provide the GIIN of the Account Holder below: Participating FFI Pursuant to the FATCA Regulations, I/we certify that the Account Holder is a Financial Institution and qualifies as a Participating FFI and accordingly is (please select or complete the appropriate classification and provide the GIIN below): a. A Participating FFI that has agreed to comply with the requirements of an FFI Agreement (including a Participating FFI that is a qualified intermediary (QI) branch of a Reporting U.S. Financial Institution that has agreed to comply with the requirements of an FFI Agreement); or b. A Participating FFI described in a Model 2 IGA that has agreed to comply with the requirements of an FFI Agreement. Please provide the GIIN of the Account Holder below: Non-Participating Financial Institution (including a Limited FFI) Pursuant to the FATCA Regulations, I/we certify that the Account Holder is a Financial Institution and is treated as a Non-Participating FFI (including a Limited FFI) and accordingly cannot provide a GIIN. 4

5 4. Non-Reporting IGA FFI Pursuant to the FATCA Regulations, I/we certify that the Account Holder is a Financial Institution and is treated as a Non-Reporting IGA FFI and does not require a GIIN and accordingly is (please tick or complete the appropriate classification): a. A Trustee Documented Trust; or b. Other (please specify) Please provide the: - Name of the trustee or Sponsor and - The GIIN of the trustee or Sponsor below: Registered Deemed Compliant Financial Institutions Pursuant to the FATCA Regulations, I/we certify that the Account Holder is a Financial Institution and is treated as a Registered Deemed Compliant Financial Institution and accordingly is (please select or complete the appropriate classification and provide the GIIN below): a. A Local FFI; or b. A Non-Reporting Member of a Participating FFI Group; or c. A Qualified Collective Investment Vehicle; or d. A Restricted Fund; or e. A Qualified Credit Card Issuer; or f. A Sponsored Investment Entity; or g. A Sponsored Controlled Foreign Corporation; or h. Other (please specify) Please provide the GIIN of the Account Holder below:... In the case of (f) and (g) above (and if applicable (h)), if no GIIN is available, please provide the: - Name of the Sponsor and 5

6 - The GIIN of the Sponsor below Exempt Retirement Funds Pursuant to the FATCA Regulations, I/we certify that the Account Holder is a Financial Institution that qualifies as an Exempt Retirement Fund and does not require a GIIN and accordingly is (please select or complete the appropriate classification): a. A Treaty Qualified Retirement Fund; or b. A Broad Participation Retirement Fund; or c. A Narrow Participation Retirement Fund; or d. Is a Pension Fund of an Exempt Beneficial Owner; or e. Other (please specify) 7. Investment Entity wholly owned by Exempt Beneficial Owners I/We certify that the Account Holder is a Financial Institution and is an Investment Entity wholly owned by Exempt Beneficial Owners and accordingly does not require a GIIN. 8. Certified Deemed Compliant FFI Pursuant to the FATCA Regulations, I/we certify that the Account Holder is a Financial Institution and is treated as a Certified Deemed Compliant FFI and does not require a GIIN and accordingly is (please select or complete the appropriate classification): a. A Local Bank; or b. A Financial Institution with only Low Value Accounts; or c. A Sponsored Closely Held Investment Vehicle; or d. A Limited Life Debt Investment Entity; or e. An Owner Documented FFI; or f. Other (please specify) 6

7 Part 4 - Declaration and signature On behalf of the Account Holder, I/we acknowledge that the information contained in this Form, and other information that the Bank and its Subsidiaries hold, in relation to the Account Holder, may be provided by the Bank and its Subsidiaries to the Maltese tax authorities pursuant to the FATCA Regulations for onward transmission to the U.S. tax authorities. I/We hereby grant my/our consent, on behalf of and as duly authorised by the Account Holder, that the information which I/we have provided in this Form, and any updates that the Account Holder may forward in the future, may be shared by the Bank and its Subsidiaries, for purposes of compliance by the Bank and its Subsidiaries with the FATCA Regulations. On behalf of the Account Holder, I/we undertake that the Bank will be provided with a duly updated and signed Form within 90 days of any change in circumstances of the Account Holder, which causes any of the information contained herein, in relation to the Account Holder, to become incorrect or incomplete. I/We declare that all statements made herein are, to the best of my/our knowledge and belief, correct and complete. Signature/s and designation/s of individual/s authorised to sign on behalf of the Account Holder. (Please attach relevant mandate/s/ resolution/s) Full name/s of the above signer/s in BLOCK LETTERS Date 7

8 APPENDIX 1 Definitions The following are selected definitions which are being provided to assist you with the completion of this Form. You should refer to the FATCA Regulations for further details. The Bank makes no guarantee of the accuracy and completeness of these selected definitions and is not responsible for any errors nor shall the Bank be liable for any loss that results from reliance upon these definitions provided. Account Holder means the person listed or identified as the holder of a Financial Account with BOV and (where applicable) with any of its Subsidiaries; Entity means a legal person or a legal arrangement, such as a corporation, organisation, partnership, trust or foundation. This term covers any person other than an individual (i.e. a natural person); Entity Account Holder means an Entity that maintains Financial Accounts with the Bank or its Subsidiaries; Financial Account means an account maintained by a Financial Institution and includes: Depository Accounts; Custodial Accounts; Equity and debt interest in certain Investment Entities; Cash Value Insurance Contracts; and Annuity Contracts (as these terms are defined in the FATCA Regulations); Financial Institution means a Custodial Institution, a Depository Institution, an Investment Entity, or a Specified Insurance Company as more fully explained in the FATCA Regulations; GIIN means Global Intermediary Identification Number; Malta Financial Institution means: (i) any Financial Institution that is resident in Malta, but excludes any branch of that Financial Institution that is located outside Malta; and (ii) any branch of a Financial Institution that is not resident in Malta, if that branch is located in Malta; Non-Participating FFI means a Financial Institution that has been identified as having committed significant non-compliance vis-à-vis FATCA and such non-compliance was not, within the 18 month period allowed under FATCA, duly resolved; Non-Reporting Malta Financial Institution means any Malta Financial Institution, or other Entity resident in Malta that is described under FATCA as a Non-Reporting Malta Financial Institution or that otherwise qualifies as a Deemed-Compliant FFI or an Exempt Beneficial Owner; Non-U.S. Person means any person that is not a U.S. Person; Reporting Malta Financial Institution means any Malta Financial Institution that is not a Non-Reporting Malta Financial Institution; Residency for Tax Purposes generally means resident for tax purposes in a jurisdiction if, under the laws of that jurisdiction (including tax conventions), it pays or should be paying tax therein by reason of his domicile, residence, place of management or incorporation, or any other criterion of a similar nature, and not only from sources in that jurisdiction. Dual resident Entities may rely on the tiebreaker rules contained in tax conventions (if applicable) to solve cases of double residence for determining their residence for tax purposes; Specified U.S. Person means a U.S. Person, other than: i. A corporation, the stock of which is regularly traded on one or more established securities markets as described in section (c)(1)(i) of the U.S. Internal Revenue Code; or ii. A corporation that is a member of the same expanded affiliated group as a corporation described in section 1471(e)(2) of the U.S. Internal Revenue Code; or iii. An organization exempt from tax under section 501(a) of the U.S. Internal Revenue Code or an individual retirement plan as defined in section 7701(a)(37) of the U.S. Internal Revenue Code; or 8

9 iv. A bank as defined in section 581 of the U.S. Internal Revenue Code; or v. A real estate investment trust as defined in section 856 of the U.S. Internal Revenue Code; or vi. A regulated investment company as defined in section 851 of the U.S. Internal Revenue Code or any Entity registered at all times during the tax year under the Investment Company Act of 1940; vii. A common trust fund as defined in section 584(a) of the U.S. Internal Revenue Code; or viii. A trust that is exempt from tax under section 664(c) of the U.S. Internal Revenue Code or that is described in section 4947(a)(1) of the U.S. Internal Revenue Code; or ix. A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any U.S. State; or x. A broker as defined in section 6045(c) of the U.S. Internal Revenue Code; or xi. A tax-exempt trust under a plan that is described in section 403(b) of the U.S. Internal Revenue Code or section 457(b) of the U.S. Internal Revenue Code; or xii. The United States or any of its wholly owned agencies or instrumentalities thereof; or xiii. A U.S. State, a U.S. Territory or Possession, any political subdivision of any of the foregoing, or any wholly owned agency or instrumentality thereof; Subsidiaries means BOV Asset Management Limited (Reg. no. C18603) and BOV Fund Services Limited (Reg. no. C39623); U.S. Internal Revenue Code formally known as the Internal Revenue Code of 1986, is the domestic portion of federal statutory tax law in the U.S; U.S. Person means a U.S. citizen or U.S. resident alien; a partnership created or organised in the United States or under the laws of the United States; a corporation created or organised in the United States or under the laws of the United States; a company created or organised in the United States or under the laws of the United States; an association created or organised in the United States or under the laws of the United States; a trust as defined in the U.S. Internal Revenue Code regulations section ; an estate of a decedent (deceased person) who was a U.S. citizen or U.S. resident alien; U.S. Territory means American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, the Commonwealth of Puerto Rico, or the U.S. Virgin Islands; U.S. TIN means U.S. tax identification number. U.S. TINs include a Social Security Number (SSN), which is issued to individuals, and an Employer Identification Number (EIN), which is issued to individuals or Entities. In addition, an Individual Taxpayer Identification Number (ITIN) is issued to individuals who are required to have a U.S. taxpayer identification number but who do not have and are not eligible to obtain an SSN. 9