EEA Life Settlements Fund

Transcription

1 EEA Fund Management (Guernsey) Limited EEA Life Settlements Fund Application Form

2 EEA LIFE SETTLEMENTS FUND PCC LIMITED APPLICATION FORM This application form should be completed and sent to International Administration (Guernsey) Limited, P.O. Box 282, Regency Court, Glategny Esplanade, St. Peter Port, Guernsey, Channel Islands GY1 3RH and marked Attn: EEA Life Settlements Fund PCC Limited or fax to +44 (0) To: the Directors of EEA Life Settlements Fund PCC Limited I/We, the applicant(s) named in Section 1 below, hereby offer irrevocably to subscribe in the Cells of the Company, as stated in Section 2 below on the terms of this application form and the latest Offering Memorandum and supplements and subject to the Memorandum and Articles of Incorporation of the Company and to the laws of Guernsey. Section 1 investor(s) Existing Shareholder(s) Yes No Designation Holder 1 Name INDIVIDUAL APPLICANTS ONLY Occupation Date of Birth Previous names (if any)* Holder 2 Name INDIVIDUAL APPLICANTS ONLY Occupation Date of Birth Previous names (if any)* Holder 3 Name INDIVIDUAL APPLICANTS ONLY Occupation Date of Birth Previous names (if any)* Holder 4 Name INDIVIDUAL APPLICANTS ONLY Occupation Date of Birth Previous names (if any)* * Includes Maiden name or any other names used in the past or currently.

3 Registered address: Postcode: Correspondence address (if different from above): Postcode: Section 2 Deal Instruction umulating/distributing Investment Amount USD Fund Class A Cell Euro Fund Class A Cell GBP Fund Class A Cell GBP Fund Class Dist Cell USD Fund Class Dist Cell Euro Fund Class Dist Cell GBP Fund Class Cell USD Fund Class Cell EUR Fund Class Cell Dist Dist Dist $ C $ C $ C The Sterling and USD Classes will apply for distributor status (see supplement) Section 3 - Distributions Distributions may be made from time to time to the bank account you nominate below. Your distributions in the Dist Cells will be einvested r in Shares of the Cell to which you subscribe, unless you tick this box. Your instruction will remain valid unless you otherwise advise the Company in writing. Section 4 Bank ount Details (ount for receipt of distribution and redemption proceeds. ount must be in the name of the registered holder.) Bank Name Bank Address SWIFT/Sort Code ount Name ount No. Section 5 Declaration I/We enclose payment crossed not negotiable or I/We confirm that payment has been made by telegraphic transfer to the above account, for the sum set out above. I/We understand that the completion of this Application Form accompanied by a cheque or bank draft or confirmation that monies have been remitted by telegraphic transfer constitutes a warranty that the cheque or bank draft will be honoured on first presentation and constitutes an acceptance of the other terms and conditions of application set out in the Offering Memorandum and supplements. I/We understand that no application will be accepted unless and until payment in full for the Shares has been made. Signed in the order as in Section 1: Holder 1 Holder 2 Holder 3 Holder 4 PLEASE COMPLETE SHAREHOLDER NAME(S), REGISTERED ADDRESS (INCLUDING COUNTRY), TYPE OF OWNER AND SIGNATURE (USUALLY HOLDER 1) ON THE ATTACHED W-8BEN FORM. EXAMPLES ATTACHED.

4 Section 6 Introducing agent Name of introducing agent Introducing agent s registered address Postcode Introducing agent s correspondence address Postcode Contact Name Telephone Agent Special Instruction MONEY LAUNDERING DECLARATIONS The Criminal Justice (Proceeds of Crime) (Financial Services Businesses) (Bailiwick of Guernsey) Regulations, 2007 require the Company to establish the identity of the person by whom or on whose behalf an Application Form is lodged with payment. The applicant or agent lodging an Application Form shall be deemed to agree to provide the Company with such information and other evidence as the Company may require to satisfy the verification of identity requirements. Shares will not be allotted to the applicant until the verification of identity requirements has been complied with to the satisfaction of the Company. The documentation required to comply with such requirements will vary depending on the type of applicant, the nature of the relationship between the Company and the applicant, and whether the applicant is in a Recognised Jurisdiction as defined under Criminal Justice (Proceeds of Crime) (Financial Services Business) (Bailiwick of Guernsey) Regulations, In all cases, the applicants should provide the following documents on application. INDIVIDUAL APPLICANTS: The Company will require the following due diligence documents to accompany the Application Form: a) A certified copy passport, driving licence or national identity card which must contain the identity of the applicant, the number of the document, a clear photograph of the applicant, the signature of the applicant as well as the date and place of issue of the document and expiry date. b) An original telephone, water, electricity or similar invoice addressed to the residential address(es) for review and return. The invoice should not be more than three months old. The Company will be pleased to return the original document if requested to do. c) Should any other party retain signing authority over the investment (e.g. financial advisor) then due diligence documentation will also be required by the Company. CORPORATE APPLICANTS OTHER THAN NOMINEE COMPANIES: The Company will require the following due diligence documents to accompany the Application Form: a) A certified copy of the applicant s statutory documents. This will include the Certificate of Incorporation, Change of Name Certificate (if applicable), the Memorandum and Articles of Association and the authorised signatory list. b) Due diligence documentation as for individual applicants will be taken on the beneficial owner and a maximum of four principal directors (or the authorised signatories if the Directors and signatories are not the same). c) Where the applicant is a public company quoted on the stock exchange of the jurisdiction of the applicant then it will be sufficient to supply a copy of the latest set of audited annual accounts and the authorised signatory list. CORPORATE APPLICANTS NOMINEE COMPANIES: The Company will require the following due diligence documents to accompany the Application Form: a) A certified copy of the applicant s statutory documents. This will include the Certificate of Incorporation, Change of Name Certificate (if applicable), the Memorandum and Articles of Association and the authorised signatory list. b) Due diligence documentation as above on the underlying beneficial investor. Certification can be effected by the following individuals: A member of the judiciary, a senior civil servant, or a serving police or customs officer; or An officer of an embassy, consulate or high commission of thecountry or territory of issue of the documentary evidence of identity; or A lawyer or notary public who is a member of a recognized professional body; or An actuary or an accountant who is a member of a recognized professional body; or A member of the Institute of Chartered Secretaries and Administrators; or A director or officer of a financial services business regulated or authorized by the FSA; or A director or officer of financial services businesses regulated in certain other countries (please check with the Administrator to ensure that your business is regulated in a recognised jurisdiction). The suitable certifier must certify that he has seen the original documentation verifying identity or residential address. The certifier must also sign and date the copy documentation and provide adequate information so that contact can be made with the certifier in the event of a query.

5 PROCEDURE FOR APPLICATION If you wish to apply for Shares you must complete the Application Form in accordance with the instructions printed thereon and send it together with payment in full by cheque, bank draft or telegraphic transfer. Applications sent by post should be addressed to INTERNATIONAL ADMINISTRATION (GUERNSEY) LIMITED, P.O. BOX 282, REGENCY COURT, GLATEGNY ESPLANADE, ST. PETER PORT, GUERNSEY, CHANNEL ISLANDS GY1 3RH and marked ATTN: EEA LIFE SETTLEMENTS FUND PCC LIMITED. Applications sent by facsimile transmission should be sent to INTERNATIONAL ADMINISTRATION (GUERNSEY) LIMITED, FAX NO +44 (0) Applications must arrive no later than the day specified in the relevant supplements to the Offering Memorandum with cleared funds 3 days before the Subscription Day. Payment shall be made in the denominated currency of the Cell. Cheques and bank drafts should be made payable to IAG re EEA Life Settlements Fund Client ount and crossed Not Negotiable. Monies sent by telegraphic transfer should be sent to: Remittance in USD HSBC Bank plc St Peter Port, Guernsey SWIFT: MIDLGB22 a/c IBAN GB67MIDL a/c name: IAG re EEA Life Settlements Fund PCC Limited Clients ount Correspondent Bank HSBC Bank USA ABA: SWIFT: MRMDUS33 IMPORTANT CHEQUES MUST ARRIVE 1 WEEK BEFORE DEALING DEADLINE Remittance in EURO HSBC Bank plc St Peter Port, Guernsey BIC: MIDLGB22 IBAN: GB75MIDL a/c name: IAG re EEA Life Settlements Fund PCC Limited Clients ount Remittance in GBP HSBC Bank plc Guernsey Branch Sort code a/c a/c name: IAG re EEA Life Settlements Fund PCC Limited Clients ount IBAN: GB64MIDL If the monies remitted are not in the denominated currency of the Cell applied for, the applicants on signing the Application Form agree that the Administrator or Custodian may convert the remittances into the respective Cell currency at the prevailing market rate. If the correctly completed Application Form, or associated cleared funds and satisfactory anti-money laundering documentation are not received as required, then the Application may be rejected or held over until the next Subscription Day, at the discretion of the Administrator. In the event that an application is rejected, application monies will be returned without interest by cheque through the post or telegraphic transfer at the risk and expense of the applicant. No applications may be withdrawn once received by the Administrator and any interest accruing upon monies received prior to the relevant Subscription Day will be for the account of the Manager. EEA Fund Management (Guernsey) Limited

6 INTRODUCING AGENT CHECKLIST Please ensure the following: Cleared Funds should arrive before dealing deadline (3 full Business Days before the first of the month) Cheques should arrive in Guernsey 1 week before the cut off date The application form is fully completed and signed The deal instruction is fully completed Original money laundering documentation should arrive in Guernsey before deal deadline OR Regulated advisers in approved jurisdictions can sign a Letter of Understanding and provide an Introducer Certificate for each new account before the deal deadline A W8-BEN has been completed by the investor. In the case of joint holders please write all holder names on the same form, along with the registered address of the account. Applicant s undertakings and consents By completing and delivering an Application Form together with payment each applicant undertakes to the Company as follows: (a) the applicant acknowledges the right of the Company to scale down applications and to reject applications in whole or in part. In such case application monies will be returned to applicants by cheque sent through the post at the applicant s own risk; (b) any application shall be irrevocable and any cheque or bank draft presented for payment will be honoured on first presentation; (c) the application and any issue of Shares made on and subject to the terms and conditions of the latest Offering Memorandum and supplements, the Application Form and the Articles; (d) the application for Shares is based solely upon the information in this document and no other information or representation has been relied upon; (e) the applicant acknowledges a copy of the latest annual accounts, if any, has been made available to him before the application; (f) the applicant agrees that if monies remitted are not in the denominated currency of the Cell applied for, the Administrator or the Custodian may convert the remittance into the relevant Cell currency at the prevailing market rate; and (g) any monies returned will not include any interest, if any, earned while being held in a client account, and the applicant consents that the interest shall be for the benefit of the Manager. (h) The applicant acknowledges that the Administrator (amongst other methods) may use and/or fax transmissions to communicate with him, and/or with such third parties as the Administrator may consider necessary in connection with his affairs and generally in connection with his investment in the Fund or as the Guernsey Data Protection Legislation may require. The applicant is aware that /fax is not a secure or error-free medium of communication and he is aware of the possible risks involved in connection with the transmission of information via /fax. Therefore, the Administrator does not accept liability for any errors or omissions in the content of the faxes/ messages and their attachments. He undertakes to keep the Administrator indemnified at all times against, and to hold the Administrator harmless from all actions, proceedings, claims, loss, damage, costs and expenses including consequential losses and damages which may be brought against the Administrator and which shall have arisen either directly or indirectly out of or in connection with the sending or receiving of communications as described above via or fax Personal information contained in the Application Form will be handled by the Administrator acting as Data Processor on behalf of the Company in accordance with Guernsey Data Protection Legislation. The applicant hereby consents to the processing of his information and disclosure of his information to any relevant Guernsey or overseas agency, the Manager, the Investment Adviser and where necessary or in the Company's or Administrator's legitimate interests to any company in the Administrator's or Manager's group of companies or agents of the Administrator including companies situated in countries which may not have the same data protection laws as Guernsey. The Administrator may disclose information about the account to any Introducing Agent. If you do not wish to have information disclosed to the Introducing Agent please tick this box EEA Fund Management (Guernsey) Limited

7 Form W-8BEN (Rev. February 2006) Department of the Treasury Internal Revenue Service 1 Name of individual or organization that is the beneficial owner 2 Country of incorporation or organization 3 Type of beneficial owner: Individual Corporation Disregarded entity Partnership Simple trust Grant or trust Complex trust Estate Government International organization Central bank or issue tax-exempt organization Private Foundation 4 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address. 5 Mailing address (if different from above) 6 U.S. taxpayer identification number, if required (see instructions) 7 Foreign tax identifying number, if any (optional) 8 Reference number(s) (see instructions) EXAMPLE OF AN INDIVIDUAL Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding Section references are to the Internal Revenue Code. See separate instructions. Give this form to the withholding agent or payer. Do not send to the IRS. OMB No Do not use this form for: Instead, use Form: A U.S. citizen or other U.S. person, including a resident alien individual...w-9 A person claiming that income is effectively connected with the conduct of a trade or business in the United States... W-8ECI A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions)...w-8eci or W-8IMY A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession that received effectively connected income or that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions)...w-8eci or W-8EXP Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a foreign person exempt from backup withholding. A person acting as an intermediary...w-8imy Note: See instructions for additional exceptions. Part I Part II Identification of Beneficial Owner (See instructions.) 9 I certify that (check all that apply): a The beneficial owner is a resident of... within the meaning of the income tax treaty between the United States and that country. b c d e ANDREW SAMPLE 123 THE STREET ANYTOWN, AB12 3CD Claim of Tax Treaty Benefits (if applicable) If required, the U.S. taxpayer identification number is stated on line 6 (see instructions). The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits (see instructions). The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions). The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500, Special rates and conditions (if applicable - see instructions): The beneficial owner is claiming the provisions of Article... of the treaty identified on line 9a above to claim a... % rate of withholding on (specify type of income):... Explain the reasons the beneficial owner meets the terms of the treaty article: Part III Notional Principal Contracts 11 I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required. Part IV Certification SSN or ITIN EXAMPLE Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that: I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates, The beneficial owner is not a U.S. person, The income to which this form relates is (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax under an income tax treaty, or (c) the partner s share of the partnership s effectively connected income, and For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. PLEASE NOTE DATE IN US FORMAT A Sample Sign Here 12/30/ EIN Signature of beneficial owner (or individual authorized to sign for beneficial owner) UNITED KINGDOM Date (MM-DD-YYYY) Capacity in which acting DO NOT DETACH For Paperwork Reduction Act Notice, see separate instructions. Cat. No Z Form W-8BEN (Rev )

8 Form W-8BEN (Rev. February 2006) Department of the Treasury Internal Revenue Service 1 Name of individual or organization that is the beneficial owner 2 Country of incorporation or organization 3 Type of beneficial owner: Individual Corporation Disregarded entity Partnership Simple trust Grant or trust Complex trust Estate Government International organization Central bank or issue tax-exempt organization Private Foundation PLEASE SELECT THE APPROPRIATE STRUCTURE 4 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address. 5 Mailing address (if different from above) 6 U.S. taxpayer identification number, if required (see instructions) 7 Foreign tax identifying number, if any (optional) 8 Reference number(s) (see instructions) EXAMPLE OF AN ORGANISATION Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding Section references are to the Internal Revenue Code. See separate instructions. Give this form to the withholding agent or payer. Do not send to the IRS. OMB No Do not use this form for: Instead, use Form: A U.S. citizen or other U.S. person, including a resident alien individual...w-9 A person claiming that income is effectively connected with the conduct of a trade or business in the United States... W-8ECI A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions)...w-8eci or W-8IMY A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession that received effectively connected income or that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions)...w-8eci or W-8EXP Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a foreign person exempt from backup withholding. A person acting as an intermediary...w-8imy Note: See instructions for additional exceptions. Part I Part II Identification of Beneficial Owner (See instructions.) 9 I certify that (check all that apply): a The beneficial owner is a resident of... within the meaning of the income tax treaty between the United States and that country. b c d e ANYCO LIMITED THE TOWER, 94 THE AVENUE LONDON, W1 2XY Claim of Tax Treaty Benefits (if applicable) If required, the U.S. taxpayer identification number is stated on line 6 (see instructions). The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits (see instructions). The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions). The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500, Special rates and conditions (if applicable - see instructions): The beneficial owner is claiming the provisions of Article... of the treaty identified on line 9a above to claim a... % rate of withholding on (specify type of income):... Explain the reasons the beneficial owner meets the terms of the treaty article: Part III Notional Principal Contracts 11 I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required. Part IV Certification SSN or ITIN EXAMPLE Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that: I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates, The beneficial owner is not a U.S. person, The income to which this form relates is (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax under an income tax treaty, or (c) the partner s share of the partnership s effectively connected income, and For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. PLEASE NOTE DATE IN US FORMAT A Sample Sign Here 12/30/2009 DIRECTOR EIN Signature of beneficial owner (or individual authorized to sign for beneficial owner) UNITED KINGDOM UNITED KINGDOM Date (MM-DD-YYYY) Capacity in which acting For Paperwork Reduction Act Notice, see separate instructions. Cat. No Z Form W-8BEN (Rev )

9 Form W-8BEN (Rev. February 2006) Department of the Treasury Internal Revenue Service Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding Section references are to the Internal Revenue Code. See separate instructions. Give this form to the withholding agent or payer. Do not send to the IRS. OMB No Do not use this form for: Instead, use Form: A U.S. citizen or other U.S. person, including a resident alien individual...w-9 A person claiming that income is effectively connected with the conduct of a trade or business in the United States... W-8ECI A foreign partnership, a foreign simple trust, or a foreign grantor trust (see instructions for exceptions)...w-8eci or W-8IMY A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession that received effectively connected income or that is claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b) (see instructions)...w-8eci or W-8EXP Note: These entities should use Form W-8BEN if they are claiming treaty benefits or are providing the form only to claim they are a foreign person exempt from backup withholding. A person acting as an intermediary...w-8imy Note: See instructions for additional exceptions. Part I Identification of Beneficial Owner (See instructions.) 1 Name of individual or organization that is the beneficial owner 2 Country of incorporation or organization 3 Type of beneficial owner: Individual Corporation Disregarded entity Partnership Simple trust Grant or trust Complex trust Estate Government International organization Central bank or issue tax-exempt organization Private Foundation 4 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address. 5 Mailing address (if different from above) 6 U.S. taxpayer identification number, if required (see instructions) 7 Foreign tax identifying number, if any (optional) SSN or ITIN EIN 8 Reference number(s) (see instructions) Part II 9 I certify that (check all that apply): a The beneficial owner is a resident of... within the meaning of the income tax treaty between the United States and that country. b c d e Claim of Tax Treaty Benefits (if applicable) If required, the U.S. taxpayer identification number is stated on line 6 (see instructions). The beneficial owner is not an individual, derives the item (or items) of income for which the treaty benefits are claimed, and, if applicable, meets the requirements of the treaty provision dealing with limitation on benefits (see instructions). The beneficial owner is not an individual, is claiming treaty benefits for dividends received from a foreign corporation or interest from a U.S. trade or business of a foreign corporation, and meets qualified resident status (see instructions). The beneficial owner is related to the person obligated to pay the income within the meaning of section 267(b) or 707(b), and will file Form 8833 if the amount subject to withholding received during a calendar year exceeds, in the aggregate, $500, Special rates and conditions (if applicable - see instructions): The beneficial owner is claiming the provisions of Article... of the treaty identified on line 9a above to claim a... % rate of withholding on (specify type of income):... Explain the reasons the beneficial owner meets the terms of the treaty article: Part III Notional Principal Contracts 11 I have provided or will provide a statement that identifies those notional principal contracts from which the income is not effectively connected with the conduct of a trade or business in the United States. I agree to update this statement as required. Part IV Certification Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that: I am the beneficial owner (or am authorized to sign for the beneficial owner) of all the income to which this form relates, The beneficial owner is not a U.S. person, The income to which this form relates is (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax under an income tax treaty, or (c) the partner s share of the partnership s effectively connected income, and For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions. Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. Sign Here Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY) Capacity in which acting For Paperwork Reduction Act Notice, see separate instructions. Cat. No Z Form W-8BEN (Rev )