FOR USE IN MAURITIUS COMPANY DETAILS FORM IMPORTANT: ALL SECTIONS MUST BE COMPLETED Name of proposed new entity: (if known) Name of applicant company: Company type: (please tick one box) Quoted on a stock exchange Subsidiary of a quoted company Regulated financial service business (in an equivalent** jurisdiction) Private company State-owned company Other (please provide details) Date of incorporation Company number Jurisdiction of incorporation VAT number or equivalent: (if applicable) Registered office address Mailing address (if different from the registered office address) Principal place of business (if different from the registered office address)
2 Telephone numbers (including country codes) Website address (if applicable) Nature of business activities (including the jurisdictions these are undertaken) Details of any existing relationship(s) with Ocorian Countries where tax returns are required (if more than one, list all) Tax reference numbers ENTITY SELF-CERTIFICATION FOR FOREIGN TAX COMPLIANCE Following the introduction of the Foreign Account Tax Compliance Act (FATCA) and the Common Reporting Standard (CRS) regulations we are required to collect certain information about each client for the purpose of identifying reportable accounts and ensuring, where necessary, that reporting is undertaken on a timely basis to the relevant tax authority. Please note that we will have to treat you as reportable if you do not complete, sign and return the selfcertification form. PART 1 - FATCA CLASSIFICATION If you are a Registered Financial Institution, please tick one of the boxes below: Participating Foreign Financial Institution Registered Deemed Compliant Foreign Financial Institution Reporting Model 1 Foreign Financial Institution Reporting Model 2 Foreign Financial Institution Please provide your Global Identification Number (GIIN): If you are a Financial Institution but unable to provide a GIIN, please tick one of the boxes below: The entity is a Model 1 FI and has not yet obtained a GIIN but intends to do so The entity is a Sponsored FI and has not yet obtained a GIIN but is sponsored by another entity that has registered Sponsoring Entity's name GIIN The entity is a Documented Trust 's name: GIIN:
3 Certified Deemed Compliant Foreign Financial Institution Owner Documented Foreign Financial Institution Exempt Beneficial Owner If you are not a Financial Institution, please confirm your status below: Passive Non Financial Foreign Entity Active Non Financial Foreign Entity US Institution Other: If you have confirmed that the Entity is a Passive Non-Financial Foreign Entity please provide details of the Controlling Persons by completing Part 3 of this form. PART 2 - CRS CLASSIFICATION Please provide your CRS classification by ticking the corresponding box(es) below. Please note, an Entity's CRS classification may not necessarily be the same as its classification for US FATCA purposes. If the Entity is a Financial Institution please tick this box and specify the type of Financial Institution below: Depository Institution Custodial Institution Investment Entity - within the meaning of Section VIII, A.6(a) of the CRS 'Managed' Investment Entity - within the meaning of Section VIII, A.6(b) of the CRS Specified Insurance Company If you have ticked the box for 'Managed' Investment Entity and the entity is resident in a Non-Participating Jurisdiction the Entity will be treated as a Passive Non-Financial Institution therefore please provide details of the Controlling Persons by completing Part 3 of this form. Non-Reporting CRS Financial Institution. Please specify the type below: Governmental Entity International Organisation Central Bank Broad Participation Retirement Fund Narrow Participation Retirement Fund Pension Fund of a Governmental Entity, International Organisation or Central Bank Exempt Collective Investment Vehicle Documented Trust Qualified Credit Card Issuer Other Entity defined under domestic law as low risk of being used to evade tax. Please specify the type: If the Entity is an Active Non-Financial Entity please tick this box If the Entity is a Passive Non-Financial Entity please tick this box If you have confirmed that the Entity is a Passive Non-Financial Entity please provide details of the Controlling Persons by completing Part 3 of this form (copy this page as required for further entries) PART 3 - CONTROLLING PERSONS Entities that are Passive NFFEs must complete this section to set out all their Controlling Persons 1
4 1 The term Controlling Person means the natural persons who exercise control over an entity. For companies and similar legal persons, it depends on the ownership of the structure of the company and will include any person owning 20 per cent or more of the company (or legal person).
5 VERIFICATION DOCUMENTS Please note that the documents listed are required by Ocorian to verify the identity of the company. To meet regulatory requirements and/or to fully understand any relationship or transaction Ocorian may need to request further information or documentation. If documents are not in a language easily understood in the Ocorian jurisdiction provide certified true translations. Ocorian can provide details on request. Please tick beside each required document to confirm that you have attached a copy: Company quoted on a stock exchange or a subsidiary of such evidence of the company being quoted on a stock exchange (please contact Ocorian for details of a list of exchanges which are deemed to be acceptable) or details of where this can be obtained online Stock Exchange identification number: A link to relevant stock exchange website where the audited financial statements and annual reports are located: Percentage of shares listed: In the case of any unlisted shares provide a certified* copy of the Registers of Shareholders completed "Individual Details Form" or an appropriate Details Form for each shareholder holding an interest in any unlisted shares (over 20% of total shares) If the company is a subsidiary - please provide a structure chart, a copy of the parent company's latest report and accounts or written confirmation of the relationship from the holding or parent company a structure chart dated and signed by an officer of the company certified* copy of the authorised signatory list Company which is a regulated financial service business in Mauritius or within an equivalent** jurisdiction: certified* evidence of regulatory licence or details of where this can be obtained online. certified* copy of the authorised signatory list Private companies: Please note that equivalent documents, extracts from registers or details of where the information can be sourced online are also acceptable. copy of the company's latest report and accounts (if available) certified* copy of the Certificate of Incorporation and any Certificate of Name Change(s) (if applicable) certified* copy of the Memorandum and Articles of Association/Incorporation certified* copy of the Registers of Shareholders, Directors and Secretary certified* copy of the authorised signatory list completed "Individual Details Form" for two directors with control over the capital/assets of the company list of the ultimate beneficial owner(s) of the company. If ownership is not direct, please provide details of the ownership from the company up to the ultimate beneficial owner(s). completed "Individual Details Form" or an appropriate Details Form for each shareholder holding an interest of 20% or more. If the Company has a UK jurisdiction, please provide appropriate details of any individual holding 25% or more of the voting rights, and/or details of any persons with significant influence or control (or lower where you believe it to be a controlling interest) in the capital or net assets of the company completed "Confirmation of Source of Funds Form" for each person providing funds a structure chart dated and signed by an officer of the company Other than the parties mentioned above, will any other person natural or otherwise have a material controlling interest in the new entity or in the relationship with Ocorian, i.e. bank signatories, proxy holders? If 'yes' provide details of the names, means of control below and complete a Details Form for each. Yes No
6 CERTIFICATION FOR FOREIGN TAX COMPLIANCE I/We declare that the information provided on this form, to the best of my/our knowledge and belief, is correct and complete. I/We agree to submit a new form within 30 days if any certification made on this form becomes incorrect. Where legally obliged to do so, I/We hereby consent to the recipient sharing this information with the relevant tax authority. GENERAL DECLARATION The information given in this form and that contained in any attachments and supporting documents supplied is complete and accurate and we confirm that in completing this form we are acting as a principal and not as an agent or intermediary on behalf of others and are properly authorised to complete and sign this form on behalf of the Company. The Company has never been declared bankrupt or similar in any part of the world, nor has it been involved with a company that has been the subject of a compulsory or insolvent liquidation or a judicial enquiry; it has never been convicted of an offence, censured, disciplined, publicly criticised or adversely commented upon or subject to any ongoing regulatory or legal action which may have an adverse impact on its reputation, character, financial integrity and reliability. The Company has never been involved in any activities connected directly or indirectly with drugs trafficking, terrorism, tax fraud or money laundering. The Company is compliant with its tax filing and reporting obligations. In addition, we consent to the disclosure of this information and any cover letter and attachments to Ocorian Limited and other service companies owned by Ocorian and to third party intermediaries who are engaged to provide any services, government departments and regulatory authorities (including those relating to taxation laws and regulations of relevant jurisdictions). We will inform Ocorian as soon as possible of any changes provided in this form and of any changes to the circumstances that impact on this declaration. Authorised Signatory: Authorised Signatory: Date: Date: *CERTIFICATION REQUIREMENTS When providing copy documents these must be certified by a third party who is subject to professional rules of conduct. Suitable certifiers are determined by local legislators and can therefore vary from country to country. Examples of suitable certifiers include: a lawyer, notary public, actuary or accountant who is a member of a relevant professional body a member of the judiciary or a senior civil servant a serving police or customs officer an officer of an embassy, consulate or high commission of the country or territory of issue of documentary evidence of identity an individual who is a member of a professional body that sets and enforces ethical standards a director, officer or manager of a regulated financial services business in an equivalent** jurisdiction. Please ensure the required wording for the certification is copied onto the photocopy that is certified as follows; "I certify that I have seen the original document and that this extract of that document is an accurate copy. [Signature of certifier] [Name in block capitals] [Professional capacity] [Organisation] [Address] [Telephone number] [Date]"
**EQUIVALENT JURISDICTIONS BY OCORIAN OFFICE Argentina 1 Cayman Islands 6 Hong Kong Aruba 2 China 1 Hungary 5 Australia Croatia 13 Iceland Austria Cyprus 7 India 9 Bahamas 3 Czech Republic 8 Ireland Bahrain 4 Denmark Isle of Man 12 Barbados 4 Estonia 5 Israel 4 Bermuda 3 Finland Italy Belgium France Japan Brazil 1 Germany Jersey Bulgaria 5 Gibraltar 12 Latvia 5 BVI 4 Greece Liechtenstein 10 Canada Guernsey 12 Lithuania 5 *Excluding Aruba, Bonaire, Curaçao, Saba, Sint Eustatius & Sint Maarten 1 status in UK, Ireland, Singapore & Cayman 2 status in UK, Ireland & Singapore 3 status in Mauritius & Cayman only 4 status in Cayman only 5 Does not have equivalent status in Mauritius & Cayman 6 status in Jersey, Mauritius & Cayman only 7 Does not have equivalent status in Cayman 8 status in Jersey, UK, Ireland, Singapore & Lux only 9 Does not have equivalent status in Jersey, Cayman & Lux 10 Does not have equivalent status in Mauritius 11 status in Mauritius only 12 Does not have equivalent status in Lux 13 status in Lux only 14 Does not have equivalent status in Cayman or Lux 15 status in UK, Ireland, Singapore & Lux 16 status in UK, Ireland, Cayman, Singapore & Lux Luxembourg Malta Mexico 16 Netherlands* New Zealand Norway Panama 4 Poland 8 Portugal Republic of Korea 15 Romania 8 Russia 11 Singapore 7 Slovakia 8 Slovenia 8 South Africa 14 Spain Sweden Switzerland Turkey 16 United Arab Emirates 4 United Kingdom United States ADDITIONAL INFORMATION: