SUBSCRIPTION FORM FOR TRADITIONAL AND ALTERNATIVE SUBFUNDS

Transcription

1 SUBSCRIPTION FORM FOR TRADITIONAL AND ALTERNATIVE SUBFUNDS EDMOND DE ROTHSCHILD PRIFUND (the Fund f sht) is an undertaking f collective investment with multiple subfunds registered in Luxembourg. The subfunds with in their name represent a special investment risk due to their investment in alternative management funds and/ investments in transferable securities linked with the property sect. F these subfunds, the nature and degree of risk pertaining to this type of investment are not the same as those typically linked with an investment in transferable securities issued by companies listed on the wld s leading financial markets. There is no guarantee that these subfunds will achieve their investment targets. The return on any investment in these subfunds may vary significantly over time. Invests may lose all some of the capital they invest in these subfunds. Investing in these subfunds is not designed to be a complete investment solution f all invests. Potential invests are invited to consider carefully whether an investment in these subfunds is right f them in view of their personal circumstances (see Comments on the risks of alternative management subfunds, in Chapter 31.3 of the Prospectus, and Comments on the risks of subfunds linked with the property sect, in Chapter of the Prospectus). However, the Board of Directs of EDMOND DE ROTHSCHILD PRIFUND will use its best effts to monit these risks based on a due diligence procedure applied to a selection of investments in these subfunds (see the section on Due Diligence procedure in Chapters 31.4 and of the Prospectus). In der to make the invest s task easier, special guidelines and fact sheets f these special risk subfunds can be found in Chapters 31 and 32 of the Prospectus. It is strictly fbidden to sell and/ promote shares of Edmond de Rothschild Prifund in the United States of America, including its territies and possessions ans regions submitted to its authity, and/ to US Persons as defined under the US Securities Act of

2 SUBSCRIPTION FORM To be returned to the Agent: EDMOND DE ROTHSCHILD (EUROPE) 20 Boulevard Emmanuel Servais, L-2535 Luxembourg Tel: (352) Swift: PRIBLULL fax: (352) Invest s details (to be used in all crespondence) 1. Full name company name: 2. Full name company name (*): (*) In the case of joint invests, all invests must sign this subscription fm. The Fund will only recognise one person as being authised to exercise the rights relating to shares in the Fund. Unless otherwise decided by the Board of Directs, the person authised to exercise these rights will be the person whose name appears first on this subscription fm. Agent s customer identification number, as given in the subscription confirmation, f invests who have previously subscribed with the Agent: 2. Official address Address: Postcode: Town/city: Country: Telephone: Fax:

3 3. Subfund selection 3.1. Selection DELIVERY NAME OF SUBFUND and CLASS OPEN FOR SUBSCRIPTION ISIN CURRENCY NUMBER OF WHOLE SHARES SUBSCRIBED AMOUNTS SUBSCRIBED (see point 3.2. below) N: Registered shares C: Shares delivered via a clearing system N. C. MONEY MARKET SUBFUNDS BOND SUBFUNDS EQUITY SUBFUNDS - 3 -

4 STRATEGY SUBFUNDS GLOBAL MANAGEMENT SUBFUNDS - 4 -

5 NAME OF SUBFUND and CLASS OPEN FOR SUBSCRIPTION ISIN CURRENCY SPECIAL RISK ALTERNATIVE MANAGEMENT a SUBFUNDS AMOUNTS SUBSCRIBED DELIVERY (see point 3.2 below) N: Registered shares C: Shares delivered via a clearing system N. C. SPECIAL RISK a SUBFUNDS LINKED WITH THE PROPERTY SECTOR - 5 -

6 3.2. Delivery a) Delivery of registered shares By ticking box N. in the table above, I/We recognise that no registered share certificate will be issued; instead, the Agent will send confirmation of the entry in the share register kept at the Agent s head office. Confirmation of the entry in the share register will be sent to the shareholder accding to the timetable indicated in the prospectus. b) Delivery via the clearing system By ticking box C. in the table above, I/We recognise that the shares will be delivered via the clearing system. The subscription will be registered in the name of the clearing system its custodian using the following details: Name of the clearing institution: Country: Account name: Account number: In this case, the shareholder s name will not appear in the register

7 4. Invest s bank details Details of the bank to which subscriptions are to be paid. Income from redemptions and any dividends will be paid into the same account. Account name: Account number: Bank name: Swift code: Address: Postcode: Town/city: Country: Crespondent bank f payment: Swift code: Country: 5. Bank details of the Fund s custodian bank Depending on the currency, the total amount due in respect of subscriptions must be transferred to Edmond de Rothschild (Europe) via its crespondent bank indicated below. Any crespondence sent by the invest s bank to the crespondent bank of Edmond de Rothschild (Europe) must include the invest s name and the name of the fund concerned. Payment by cheque will not be accepted. Please find attached our Cash Crespondent Banks (Wiring Instructions) in an annex - 7 -

8 Declarations and signature As the invest, I/we hereby declare and expressly accept the following: 1) I/We have read the latest Fund Prospectus and have received a copy of the Fund s latest available financial statements. I/We am fully aware of the extent of the financial risks linked with any Fund subscription and that I/we could lose all some of my capital as a result of market fluctuations. Despite this, I/we confirm that this investment is suitable f me. 2) This subscription request is binding. However, I/we understand that the Fund its Agent may decline this subscription request wholly in part without explanation, and that they are entitled to request infmation, documents similar f the purposes of identifying the beneficiary, as well as any other document that the Fund may consider necessary to enable it to fulfil its legal and regulaty obligations and to establish trust. Specifically, I/we can confirm that I/we meet the eligibility criteria. The Fund is permitted to seek a fced redemption at the price applicable on the redemption date. If needed, the Fund its Agent will infm me/us of the reason of the fced redemption. I/we have an obligation to indemnify the Fund f any losses incurred. If needed, the Fund its Agent will provide me/us with the detail of the incurred losses. The subscription request may be deferred until the next valuation date following the date on which the Fund its Agent has received all of the infmation they require in a fm acceptable to them. Any payment made pri to the acceptance of the subscription may be deposited in a non-interest-bearing account. 3) I/We agree to transfer the subscription amount in the appropriate currency on the proper value date. I/we understand that in case of non-payment of the subscription amount on the proper value date, the subscription may be cancelled and the Fund will bear the financial impact of this cancellation. The Fund may then institute any legal other proceedings against me any representative f said non-payment. 4) This subscription fm may be sent by post fax and subscription requests may be made by Swift. The Fund its Agent shall not be responsible f any subscription requests sent by fax. I/We hereby undertake, at my own expense, to immediately send the iginal subscription fm to the Fund its Agent by priity express mail. The Fund its Agent may decline any subscription request received cancel any subscription request accepted by fax if they do not receive the iginal subscription fm within five wking days of the relevant valuation date. The absence of the iginal may not be used against the Fund its Agent. I/We agree to indemnify the Fund f any losses resulting from the cancellation of the subscription. 5) The Fund its Agent shall send me all crespondence by standard post, if required by the laws and regulations in Luxembourg, by registered mail sent to the address indicated in this subscription fm ( to such other address that I/we may subsequently indicate to the Fund its Agent) at my own risk. I/We agree that any crespondence from the Fund its Agent shall be considered valid if sent to this address, the presumed date of posting being the date shown on the duplicate ( dispatch list) kept by the Fund its Agent. 6) All requests and complaints made by me in relation to any Fund transaction shall be submitted in writing to the Fund its Agent. 7) The Fund its Agent shall compare the signatures given to them with the specimens held on file without being obliged to carry out any further checks. In the absence of any binding legal and regulaty provisions, the Fund and its Agent shall only be required to exercise due care and shall only be liable in the event of gross negligence. 8) Provided that the signature matches, at first sight, the specimens deposited with them, the Fund its Agent shall not be liable f any losses caused by the fact that signatures on instructions given to the Fund its Agent are not authentic. The Fund its Agent may rely on the signature below without being required to carry out further investigation. The Fund and its Agent decline all responsibility f any losses that might result from any lack of valid documentary proof any undetected fgery. 9) Without prejudice to the fegoing, the Fund and its Agent shall not be liable f any losses caused directly indirectly by the lack of authenticity invalidity of authisation that I/we rely on relied on by third parties authised to act on my behalf. 10) The Fund its Agent reserve the right to refuse to act on instructions issued by any person whose identity and powers are not sufficiently established in the opinion of the Fund its Agent

9 11) The Fund its Agent shall not be liable f losses resulting from my legal incapacity from the incapacity of a third party authised to act on my behalf if the Fund its Agent has not received pri, written notification of same in writing. 12) I/We shall indemnify and hold the Funds its Agent harmless against all complaints, claims, action, costs, expenses, prejudice, losses other amounts paid responsibilities incurred by the Fund its Agent when acting on my instructions. If needed, the Fund its Agent will provide me/us with infmations on the incurred harms. 13) The Fund its Agent is authised to recd telephone conversations with them, to be used as evidence in case of a dispute. The absence of recdings the failure to keep recdings may not be used against the Fund its Agent. 14) This subscription fm and all instructions arising herefrom shall be exclusively subject to Luxembourg law and any dispute shall come under the exclusive jurisdiction of the competent Luxembourg court. Nevertheless, I/we recognise that the Fund its Agent may bring legal action befe any other tribunal which would have been competent in the absence of the afementioned election of jurisdiction, and specifically the courts in the jurisdiction in which I/we am domiciled that of the Agent authised broker. 15) I/We note that the personal data requested above must be sent in der to proceed with the subscription. In the event that I/we refuse to send this infmation, the Fund its Agent shall decline the subscription. I/We hereby consent to my personal data, consisting of certain personal infmation (particularly concerning my identity, address, personal and marital status) and infmation about my assets and transactions perfmed on my behalf being sted in one me of the Fund s the Agent s computer files in accdance with the applicable legislation. Pursuant to this legislation, the Fund its Agent may entrust the processing of this infmation to a third party. I/We expressly authise the Fund its Agent to collect and process personal data about me as described in this clause. I/We understand that on written request I/We am entitled to consult the data held about me and to have any mistakes crected. The Fund its Agent may recd and process my personal data f the purposes of managing investment fund recds, handling transactions instructed by me, managing contractual relations and, in general, f the purposes of fulfilling its obligations in particular regarding the identification of the invests as provided f under FATCA regulation and providing me with its services. 16) I undertake to provide the Fund and/ its Agent, upon request, with all documents, fms and infmation in der f them to comply with their respective legal regulaty obligations 17) I/We are not U.S. Persons; 18) The Shares are not being acquired f the benefit of, directly indirectly, any U.S. Person; 19) I/We will not sell transfer Shares any interest therein to a U.S. Person in the U.S.A.; 20) I/We did not acquire, and will not transfer, any Shares within the U.S.A.; 21) None of the funds used by us to effect the purchase of the Shares have been obtained from U.S. Person; 22) I/We will notify the Fund and its Agent immediately if I/we should become at any time U.S. Persons; 23) I/We were not solicited to purchase Shares while present in the U.S.A.; and 24) I/We understand that the Fund has not been registered under the U.S. Investment Company Act of 1940, as amended, that the Shares have not been registered and will not be registered under the U.S. Securities Act of 1933, as amended, and that the Shares have not been qualified under the securities laws of any state of the United States any other jurisdiction and may not be offered sold in the U.S.A. to f the benefit of, directly indirectly, any U.S. Person Date: Signature Full name (in capitals) of the invest representative of the company and his/her position - 9 -

10 By signing this fm, the invest expressly and specially accepts the limitations of liability of the Fund stipulated in the paragraph entitled Declarations and Signature. Signature Full name (in capitals) of the invest representative of the company and his/her position

11 FOREIGN ACCOUNT TAX COMPLIANT ACT ( FATCA ) 1 C/o Agent: EDMOND DE ROTHSCHILD ASSET MANAGEMENT (Luxembourg) 20 Boulevard Emmanuel Servais - L-2535 Luxembourg - Swift: PRIBLULB Fax: (352) Contact details f individual invests: EDRAM: Tel (352) / CSM-TA@bpere.eu Otherwise, please contact: CACEIS: Tel (352) / EDRAM-TA@caceis.com On March 18, 2010, the United States of America enacted provisions commonly known as the Feign Account Tax Compliant (FATCA). Accding to the FATCA Rules, FFIs, unless they can rely under ad-hoc lighter exempted regimes, need to rept to the IRS certain holdings by / and payments made to a/ certain U.S. invests b/ certain U.S. controlled feign entity invests, c/ non U.S. financial institution invests that do not comply with their obligations under FATCA and d/ invests that are not able to document clearly their FATCA status. Meover, any account that is not properly documented may have to suffer a 30% WHT. On March 24 th, 2014, Luxembourg and U.S. governments entered into a Model I IGA which aims to codinate and facilitate the repting obligations under FATCA with other U.S. repting obligations of Luxembourg financial institutions. Accding to the IGA, Luxembourg FFIs will generally have to rept to the Luxembourg tax authities instead of directly to the IRS. Infmation will be communicated onward by the Luxembourg authities to the IRS under the general infmation exchange provisions of the U.S. Luxembourg income tax treaty. In der to comply with its obligations, the Fund needs to gather from subscriber(s) a series of additional infmation and documents relating to subscriber(s) and potential beneficial owners. The Fund, subject to the Fund s constitutive documents and prospectus / offering memandum and any applicable laws may: (i) (ii) (iii) (iv) Withhold the payment of any dividend redemption proceeds to a Unitholder / Shareholder of the Fund until the Fund holds sufficient infmation; Reject at its discretion any subscription f Units / Shares; Compulsily redeem at any time the Units held by Unitholder / Shareholders who are excluded from purchasing holding Units / Shares; and decline to register the transfer of Units to any person who is excluded from purchasing holding Units. (v) take any additional measures authized by the Fund s constitutive documents and prospectus / offering memandum. A. In this connection, the undersigned subscriber hereby declares and certifies, by ticking the crespondent box that, in accdance with the principles of FATCA, the regulations relating to Infmation Repting by Feign Financial Institutions and Other Feign Entities released by the IRS on 28 th January 2013 (the FATCA Regulations ), all subsequently published FATCA announcements 1 FATCA means the Feign Account Tax Compliance Act such as enacted and adopted by the United States of America on March 18, 2010, requiring US individuals to rept their financial accounts held outside of the United States and feign financial institutions to rept to the Internal Revenue Service about their US clients

12 and as the case may be, the provisions of the intergovernmental agreement (IGA) entered between the country of residence of the subscriber and the United States of America to improve International Tax Compliance and with respect to FATCA, as well as relevant national Laws: Name and address registered office of the invest 1. I AM / WE ARE US RESIDENT (F further details please refer to definition below 2. F joint accounts, each subscriber shall provide the relevant confirmation). a) If I am / we are individual(s): We undertake to provide the Fund and/ its Agent a W9 Fm duly filled and electronically signed in accdance with the principles of the US Tax laws. b) If I am / we are Cpate entities: The Cpate entity is a company having its headquarter registered office in the U.S.; OR The Cpate entity is a company incpated in the U.S. (U.S. cpation) 2 Within the meaning of the U.S. Internal Revenue Code and subject to any amendments to the legal definition which may be from time to time adopted, shall qualify as US Person the following: US Person (Cpate entity): (i) any company incpated in the US (US cpation); (ii) any US partnership (domestic partnership); (iii) any trust if a US court is able to control the trust administration and one several US persons are entitled to control any substantial decisions of the trust; (iv) any states of the United States; (v) any company that has a bank account located in the US; (vi) any company having its headquarter registered office in the US; (vii) any company having its headquarter registered office located outside the US but having one me US beneficial owner(s). US Person (Individual): (i) US citizen (including double multiple nationality and US place of birth); (ii) US residents owner of a permanent residence title ( Green Card ); (iii) Individual having resided in the USA f a substantial period of time in the course of the year N and / the two years befe. Example of substantial period of time: (a) Residence in the US f me than 183 days in the course of the year N; (b) Stay of me than 31 days in the course of the year N in the US, if the total of a) this period, plus b) the number of days of residence in N-1 divided by 3, plus c) the number of days of residence in N-2 divided by six, exceeds 183 days; (iv) If the issuer country of the ID passpt is a US territy; (v) If the primary address and / the mailing address (as set fth in part IV d) above) are within US territy (vi) if at least one of the subscribers is a US Citizen (joint account, as set fth in part IV a) above. In case of doubt with respect to their situation re FATCA Regulation, subscribers should consult with their legal tax advis

13 We undertake to provide the Fund and/ its Agent a W9 Fm duly filed and electronically signed in accdance with the principles of the US Tax laws. 2. I AM / WE ARE NOT US RESIDENT (F joint accounts, each subscriber shall provide the relevant confirmation) AND a) If I am / We are individuals: (Please tick as much cases as relevant to your own situation) (aa) I / We have no US Bank account(s); My / our primary address and / mailing address are not within the U.S. territy; I / We do not have a U.S. phone fax number; I / We do not have a power of attney signaty authity granted to an individual having a primary address and / mailing address within the U.S. territy. (bb) I / We have not a US place of birth If I / we ticked ALL the above boxes under (A.2.a.aa.) and (A.2.a.bb.), I am / we are not required to provide the Fund and/ its Agent with any further documentation f FATCA identification purposes; If I /we ticked the above box under (A.2.a.bb.) but did not tick any box in section (A.2.a.aa.) above, I / we undertake to provide the Fund and/ its Agent with a W8-BEN fm duly filled and electronically signed in accdance with the principles of the US Tax laws; If I / we ticked the above box under (A.2.a.bb) but did tick certain but not all boxes in section (A.2.a.aa.) above, I / we undertake to provide the Fund and/ its Agent with a W8-BEN fm duly filled and electronically signed in accdance with the principles of the US Tax laws; If I / we did not tick the box in section (A.2.a.bb.) above, I / we undertake to provide the Fund and/ its Agent with a W8-BEN fm duly filled and electronically signed in accdance with the principles of the US Tax laws as well as a US nationality renunciation certificate. Should I / we not be in the capacity to provide a US nationality renunciation certificate, then I / we undertake to provide a W9 Fm. F the completion of the fegoing US Tax fms, Individuals are herein requested to provide the Fund and/ its Agent with an address which shall allow the Fund and/ its Agent to provide you with an internet link, as the case may be: b) If I am / We are Cpate entities: If the Cpate entity is a company NOT having its headquarter registered office in the U.S; AND/OR If the Cpate entity is NOT a company incpated in the U.S. (U.S. cpation)

14 we undertake to provide the Fund and/ its Agent with a W8-BEN-E Fm duly filled and electronically signed in accdance with the principles of the US Tax laws (Please note that you are requested to complete the BO Section of the W8-BEN-E Fm, when applicable, by indicating the exact US tax payer identification number (TIN)). B. The undersigned subscriber further declares that: 1. Subscriber (cpate entities) a. It has the following FATCA Status by ticking the appropriate box, adding its signature. Also, it undertakes the necessary actions to answer to any other request to confirm its status and send immediately to the Fund and/ its Agent the appropriate related US tax Fm. Specified US Person US Person that is not a Specified US Person Luxembourg FI FI in a jurisdiction having signed an IGA (Registered and repting FI under an IGA 1 IGA 2 model) Participating FFI (other than case 3) in a jurisdiction not having signed an IGA Deemed compliant FFI (other than case 3) (Non registered and non repting FFI compliant with FATCA under Final Regulations IGA jurisdictions) Exempt beneficial owner (other than case 3) Active NFFE Passive NFFE non of which controlling persons are US citizens resident; which controlling persons are US citizens resident Non participating FFI (including a Luxembourg Financial Institution other Partner Jurisdiction Financial Institutions treated by the IRS as non participating Financial Institutions) b. The undersigned deposit holder confirms, by ticking the cresponding box that: YES, it has registered on the IRS Ptal its appropriate FATCA Status. Please confirm GIIN Code: NO, it has not registered on the IRS Ptal due to its FATCA Status It will register later and undertakes to send immediately to the Fund and/ its Agent its FATCA status and GIIN number

15 2. F Passive NFFE with U.S. controlling person(s): In case you selected under B.1.a. above Passive NFFE with U.S. controlling person(s), please provide U.S. Taxpayer identification number (SSN ITIN) f the ultimate relevant beneficial owner and a W9 Fm duly filled and electronically signed in accdance with the principles of the US Tax laws. The subscriber herein declares that the infmation of Section IV of this application fm is, to the best of its knowledge and belief, true, crect and complete. Subscriber undertakes to infm the Fund and/ its Agent without delay of any change in his / her / its situation that would make above declaration no longer valid. Signed by: Name [and Title: F and on behalf of] Dated:

16 ENTITY S TAX RESIDENCE SELF CERTIFICATION FOR AEI - CRS Instructions to complete this fm. (Mandaty fields are marked by an *). The AEoI-CRS (Automatic Exchange of Infmation Common Repting Standard) provides f tax authities to require the financial institutions under their supervision to collect certain infmation on their register account s holders and, where appropriate, to use such infmation to satisfy repting requirements. Pursuant to this standard, please complete the sections below as indicated and provide all additional infmation requested concerning your entity. Please note that in some circumstances we will be required to rept this infmation (as well as the register account balance and the amount of revenues and sale proceeds paid credited to the register account) to our supervisy tax authity, which will in turn send it to the tax authity of each state in which the entity that you represent is resident f tax purposes. If you have any questions about the identification of your status as entity (section 2) your Tax Identification Number (TIN), please contact your tax adviser your local tax authity. You must rept the residence of register account s holder f tax purposes. The register account s holder is the legal person(s) that benefit(s) from the revenue and/ assets associated with a register account. Please refer to the definitions provided in the appendix "Definitions to help you to complete this fm. If the register account s holder is a Passive NFE (non-financial entity) a professionally managed investment entity in a country not participating in the AEoI - CRS (Automatic Exchange of Infmation - Common Repting Standard), then you must also provide infmation on the individuals who exercise control over the entity ("Controlling Person") by completing section 6 "Identification of Controlling Persons ( beneficial owners)" f each person exercising an effective control over the entity. Please note: If you are not the register account s holder and you complete and sign the fm on behalf of the register account s holder, you must specify in which capacity you are authised to sign section 7. Do not use this fm if the register account s holder is an individual. In such case, please use and complete the "Individual's tax residence self-certification" fm. If any of the infmation below is amended following a change in circumstances, your must immediately provide the Financial Institution with a new self-certification fm, updated showing this change in circumstances. You can send us this completed and signed self-certification fm either electronically ( , fax) by post

17 Section 1 Identification of the register account s holder A. Name of the entity * B. Place of ganisation * C. Effective place of activity * D. Address of permanent residence Line 1 (name of street, number, etc.) Line 2 (town) COUNTRY * POSTCODE E. Country of residence f tax purposes * Section 2 Entity / Legal person's status 1. Please tick the appropriate box f the entity/legal person's status * Please refer to the definitions provided in the appendix "Definitions" to help you to complete this section and identify your status. (a) Financial Institution Professionally managed investment entity (b) Financial Institution - Other (c) Active NFE Cpation that is publicly traded an affiliate of a publicly traded (d) Active NFE Government entity (e) Active NFE International ganisation (f) Active NFE Categy of entity other than those listed in (c) to (e) (g) Passive NFE (see definition in the appendix "Definitions" to this fm). If you are a passive NFE (g) OR a professionally managed investment entity that is resident in a country that is NOT a signaty to the AEoI-CRS agreement, you must complete section 6 "Identification of Controlling Persons ( beneficial owners)"

18 Section 3 Tax Identification Number (TIN) A. Tax identification number recognised by the tax authity:* B. The country of residence f tax purposes does not provide a TIN to its residents (tick the box if appropriate) Section 4 Confirmation of your tax residence (Complete section 4 if the register account s holder has tax residence in just one country, section 5 if the register account s holder has tax residence in me than one country, then read and sign the statement in section 7) We certify that the register account s holder is not a resident f tax purposes in a country other than the country indicated in section 1 above (tick the box). Section 5 Additional countries of residence f tax purposes (if any) We certify that, in addition to the country indicated in section 1, the register account s holder is resident f tax purposes in the following countries, that the TIN attached to each additional country is shown below that we have ticked the box to indicate that the TIN is not issued by one of these countries any other situation substantiated below (please use a separate sheet if resident f tax purposes in me than two additional countries): COUNTRY* TIN* TIN not issued Other; explain COUNTRY* TIN* TIN not issued Other; explain Section 6 Identification of Controlling Persons ( beneficial owners) Please note the following: You must complete this section ONLY if you have selected the status of passive NFE OR professionally managed investment entity that is resident in a country that is NOT a signaty to the AEoI-CRS agreement in section 2. Complete the infmation below if your entity has one me Controlling Persons. If any of the infmation below is amended following a change in circumstances, your must immediately provide the Financial Institution with a new self-certification fm, updated showing this change in circumstances. The definitions of "controlling person" and "changes in circumstances" are shown in the appendix "Definitions". Please refer to it to complete section

19 A. Controlling Person No.1 Type of Controlling Person*: - Directly indirectly owning the control of an entity through the ownership of the entity's shares, units voting rights - Or, where no person owns such an interest, exercising effective control over the entity - Or, where there is no effective control, holding the position of company direct. Last name * First name(s) * Place of birth Town of birth * Country of birth* Date of birth (dd/mm/yyyy) * Address of permanent residence: Line 1 (name of street, number, etc.) * Line 2 (town)* Postcode * COUNTRY * Country of residence f tax purposes * TIN * We certify that, in addition to the country indicated below, the Controlling Person No.1 is resident f tax purposes in the following countries, that the TIN attached to each additional country is shown below that we have ticked the box to indicate that the TIN is not issued by one of these countries any other situation substantiated below (please use a separate sheet of paper if the Controlling Person No.1 is resident f tax purposes in me than two additional countries). COUNTRY* TIN* TIN not issued Other; explain COUNTRY* TIN* TIN not issued Other; explain B. Controlling Person No.2 Type of Controlling Person*: - Directly indirectly owning the control of an entity through the ownership of the entity's shares, units voting rights - Or, where no person owns such an interest, exercising effective control over an entity - Or, where there is no effective control, holding the position of company direct

20 Last name * First name(s) * Place of birth Town of birth * Country of birth* Date of birth (dd/mm/yyyy) * Address of permanent residence: Line 1 (name of street, number, etc.) * Line 2 (town)* Postcode* COUNTRY * Country of residence f tax purposes * TIN * We certify that, in addition to the country indicated below, the Controlling Person No.2 is resident f tax purposes in the following countries, that the TIN attached to each additional country is shown below that we have ticked the box to indicate that the TIN is not issued by one of these countries any other situation that we justify (please use a separate sheet of paper if the Controlling Person No.2 is resident f tax purposes in me than two additional countries). COUNTRY* TIN* TIN not issued Other; explain COUNTRY* TIN* TIN not issued Other; explain

21 C. Controlling Person No.3 Type of Controlling Person*: - Directly indirectly owning the control of an entity through the ownership of the entity's shares, units voting rights - Or, where no person owns such an interest, exercising effective control over the entity - Or, where there is no effective control, holding the position of company direct. Last name * First name(s) * Place of birth Town of birth * Country of birth* Date of birth (dd/mm/yyyy) * Address of permanent residence Line 1 (name of street, number, etc.) * Line 2 (town)* Postcode * COUNTRY * Country of residence f tax purposes * TIN * We certify that, in addition to the country indicated below, the Controlling Person No.3 is resident f tax purposes in the following countries, that the TIN attached to each additional country is shown below that we have ticked the box to indicate that the TIN is not issued by one of these countries any other situation that we justify (please use a separate sheet if the No.3 Controlling Person is resident f tax purposes in me than two additional countries). COUNTRY* TIN* TIN not issued Other; explain COUNTRY* TIN* TIN not issued Other; explain If there are me than three Controlling Persons, please use a separate sheet of paper and sign it

22 Section 7 Statement and signature We acknowledge and accept that the infmation concerning our register account(s) and the infmation contained in this fm can be sent to exchanged with the tax authities of the country(ies) in which this(these) register account(s) is(are) held and exchanged with the competent tax authities of a country countries in which we may be resident f tax purposes and which have signed electronic infmation exchange agreements. We undertake to immediately infm our Financial Institution and its transfer agent of any change in circumstances and to provide it with a new self-certification fm, updated and highlighting such change in circumstances. We certify that we are the holders of the register account accounts f which this fm has been completed, are authised to sign f the holder of such account(s). We certify that all the statements made in this fm are accurate and complete. We agree to complete a new self-certification fm if one me elements of this self-certification fm is(are) no longer crect. Signature of the person(s) authised to sign on behalf of the entity holder of the register account : Authised person No.1: Last name and first name*: Date *: Capacity *: Signature *: Authised person No.2 (if different from authised person No.1): Last name and first name *: Date *: Capacity *: Signature *: In accdance with the provisions of the Luxembourg applicable data protection law on the protection of persons with regard to the processing of personal data (the Data Protection Law ), you benefit from a right of access and amendment of your personal data. Any complaint relating to your rights under the Data Protection Law shall be addressed to the Transfer agent acting on behalf of the financial institution. F your infmation, the Transfer agent acting on behalf of the financial institution will recd and process your personal data in der to carry on the relevant requirements vis-à-vis the relevant tax administration f the purpose of the AEOI-CRS Regulations. In case of circumstances changes, thank you to highlight infmation you have changed

23 INDIVIDUAL S TAX RESIDENCE SELF-CERTIFICATION FOR AEI-CRS Instructions to complete this fm (Mandaty fields are marked by an *) The AEoI-CRS (Automatic Exchange of Infmation Common Repting Standard) provides that tax authities require the financial institutions under their supervision to collect certain infmation on their invests and, where appropriate, to use such infmation to satisfy repting requirements. Pursuant to this standard, please complete the sections below as indicated and provide all additional infmation requested. Please note that in some circumstances your Financial Institution will be required to rept this infmation (as well as the register account balance and the amount of revenues and sale proceeds paid credited to the register account) to its supervisy tax authity, which will in turn send it to the tax authity of each country in which you are resident f tax purposes. In der to comply with the requirements placed on you as holder of a register account (person entitled to the revenue and/ assets associated with a financial account), you are required to disclose the country(ies) in which you are resident f tax purposes. Please complete the sections below as indicated and provide all additional infmation requested. The definitions in the appendix will help you to identify the holder of the register account and to complete this fm. If you have any questions concerning your Tax Identification Number (TIN), please contact your tax adviser your local tax authity. You can send us this self-certification fm completed and signed either electronically ( , fax) by post. Please note: If you are not the holder of a register account and you complete and sign the fm on behalf of the holder of a register account, you must specify in which capacity you are authised to sign section 5, and attach a copy of your power of attney. Do not use this fm if the holder of a register account is not an individual. If the holder of a register account in not an individual, please use and complete the "Entity's tax residence self-certification" fm. If any of the infmation below is amended following a change in circumstances, you must immediately provide the Financial Institution with a new self-certification fm, updated showing this change in circumstances. Section 1 Identification of the Individual register account s holder D. Name of the register account s holder: Last name* Title: First name(s): * E. Date of birth*

24 F. Place of birth Town of birth* Country of birth* G. Address of permanent residence Line 1 (name of street, number, etc.) Line 2 (town) Country:* Postcode: H. Country of residence f tax purposes*: Section 2 Tax Identification Number TIN * Complete A B A. Tax Identification Number in the country of residence f tax purposes:* B. The country of residence f tax purposes does not provide a TIN to its residents (tick the box if appropriate) Section 3 Confirmation of your residence f tax purposes (Complete section 3 if the holder of a register account has residence f tax purposes in just one country, OR section 4 if the holder of a register account has residence f tax purposes in me than one country, then read and sign the statement in section 5) I certify that the register account s holder is NOT a resident f tax purposes in a country other than the country indicated in section 1 above (tick the box). Section 4 Additional countries of residence f tax purposes (if any) I certify that, in addition to the country indicated in section 1, the holder of a register account is resident f tax purposes in the following countries and that the TIN attached to each additional country is shown below that I have ticked the box to indicate that the TIN of one of these countries is unavailable (please use a separate sheet of paper if you are resident f tax purposes in me than three additional countries): Country: TIN:* * TIN unavailable:

25 Country: * Country: * TIN:* TIN:* TIN unavailable: TIN unavailable: Part 5 Statement and signature I acknowledge and accept that the infmation concerning my register account(s) and the infmation contained in this fm can be sent to the tax authities of the country in which this(these) register account(s) is(are) held. Such infmation can also be exchanged with the tax authities of another country countries in which I am resident f tax purposes and which have concluded electronic infmation exchange agreements. I undertake to immediately infm the financial institution of any change in circumstances and to provide it with a new self-certification fm, updated highlighting such change in circumstances. I certify that all the statements made in this fm are accurate and complete. Signature of the register account s holder ( of the authised person): Last name, first name*: Date * *Please indicate the capacity in which you have signed, and attach a copy of your power of attney. Capacity*: In accdance with the provisions of the Luxembourg applicable data protection law on the protection of persons with regard to the processing of personal data (the Data Protection Law ), you benefit from a right of access and amendment of your personal data. Any complaint relating to your rights under the Data Protection Law shall be addressed to the Transfer agent acting on behalf of the financial institution. F your infmation, the Transfer agent acting on behalf of the financial institution will recd and process your personal data in der to carry on the relevant requirements vis-àvis the relevant tax administration f the purpose of the AEOI-CRS Regulations. In case of circumstances changes, thank you to highlight infmation you have changed

26 APPENDIX Definitions These definitions are those provided as part of the OECD's Common Repting Standard (CRS) f the Automatic Exchange of Infmation. If you have any questions about these definitions, if you would like me details, please contact your tax adviser your local tax authity. "Account Holder" The term "account holder" means the person listed identified as the holder of a financial account. A person who is the holder of a financial account f the benefit of another person as agent, custodian, nominee, signaty, investment adviser, intermediary legal guardian is not treated as holding the account. Such other person is treated as holding the account. F example, in the case of a parent/child relationship where the parent acts as legal guardian, the child is treated as holding the account. In the case of a jointly held account, each joint holder is treated as an account holder. "Financial Account" A financial account is an account maintained by a financial institution and includes: deposit accounts; securities accounts (custodian accounts); equity securities debt issued by investment entities; life insurance policies with a cash surrender value; and annuity contracts. "Change in Circumstances" Generally speaking, a "change in circumstances" means any change that results in the addition of infmation relevant to a person's status (tax residence) otherwise conflicts with such person's previously declared status. A change in circumstances also means any change addition of infmation to the account holder's account (including the addition of a new holder, change of country, etc.) OR any change addition of infmation to any account associated with such account if such change addition of infmation affects the account holder's status

27 EDMOND DE ROTHSCHILD (EUROPE) standard settlement instructions f cash payments Please note that the payments have to be made f the benefit of CACEIS Bank Luxembourg (Swift Code: BSUILULL).

28 SSI CASH LAST UPDATE OCT CUR CASH CORRESPONDENT CITY SWIFT CODE ACCOUNT NUMBER AED HSBC Bank Middle East Dubai BBMEAEAD IBAN : AE AUD Westpac Banking Cpation Intl Div. Sydney WPACAU2S AIS BGN UniCredit Bulbank Sofia UNCRBGSF IBAN : BG68UNCR CAD Canadian Imperial Bank of Commerce Tonto CIBCCATT CHF UBS, Zurich Zurich UBSWCHZH80A Z IBAN : CH Z CNH HSBC Hong Kong Limited Hong Kong HSBCHKHH CZK Unicredit Bank Czech Republic, a.s. Prague BACXCZPP IBAN : CZ DKK Den Danske Bank Aktieselskab Copenhagen DABADKKK EUR via TARGET II (MT202) BSUILULL EUR via TARGET II (MT103) BSUILULL LU83007J EUR GBP HSBC Bank Plc Intl. London MIDLGB St Code : IBAN : GB63MIDL HKD Standard Chartered Bank Hong Kong SCBLHKHH HRK* Zagrebacka Banka d.d. Zagreb ZABAHR2X IBAN : HR EDMOND DE ROTHSCHILD (EUROPE) 28/30

29 SSI CASH LAST UPDATE OCT CUR CASH CORRESPONDENT CITY SWIFT CODE ACCOUNT NUMBER HUF Unicredit Bank Hungary ZRT Budapest BACXHUHB IBAN : HU ILS Bank Hapoalim Tel Aviv POALILITCBS IBAN : IL ISK Verdis HF Reykjavik ESJAISRE IBAN IS JPY The Bank of Tokyo-Mitsubishi UFJ Tokyo BOTKJPJT MAD Attijariwafa Bank Casablanca BCMAMAMC IBAN : MXN Banco Santander (Mexico), S.A. Mexico BMSXMXMMSSS NOK Ndea Bank Nge Oslo NDEANOKK Iban : NO NZD Westpac Institutional Bank Wellington WPACNZ2W RET001188NZD OMR HSBC Bank Middle East Limited Ruwi BBMEOMRX PEN Banco Credito Del Peru Lima BCPLPEPL PLN Bank Pekao SA Warsaw PKOPPLPW IBAN : PL QAR HSBC Bank Middle East Limited Doha BBMEQAQX IBAN: QA83BBME RON* UniCredit Tiriac Bank SA Bucharest BACXROBU IBAN RO12 BACX RSD* Unicredit Bank Serbia JSC Belgrade BACXRSBG IBAN RS EDMOND DE ROTHSCHILD (EUROPE) 29/30

30 SSI CASH LAST UPDATE OCT CUR CASH CORRESPONDENT CITY SWIFT CODE ACCOUNT NUMBER RUB ZAO UniCredit Bank Moscow IMBKRUMM Final Bank : Russian Central Bank a/c n : BIK / Bank beneficiary :ZAO UniCredit Bank (IMBKRUMM) a/c n : INN Number : SEK Skandinaviska Enskilda Banken Stockholm ESSESESS IBAN : SE SGD Standard Chartered Bank, Singape Singape SCBLSGSG THB Hongkong Shanghai Bank Bangkok HSBCTHBK TRY Deutsche Bank A.S Istanbul DEUTTRISCUS IBAN : TR USD JP Mgan Chase New Yk CHASUS Chips number : 0002 ABA number : ZAR The Standard Bank of South Africa Ltd Johannesburg SBZAZAJJ * F these currencies, please execute the payments f further credit of UniCredit Bank Austria AG (Swift Code : BKAUATWW) f the benefit of CACEIS Bank Luxembourg (Swift Code : BSUILULL, account AT f HRK, account AT f RON, account AT f RSD). Please seek professional confirmation befe taking any action based on infmation contained in this document. Please do not hesitate to contact your client services manager. EDMOND DE ROTHSCHILD (EUROPE) 30/30