APPLICATION FORM MATRIX STRUCTURED PRODUCTS LIMITED MATRIX ASCENSION CLOSED END Please return this form to: Matrix Structured Products Limited, c/o CACEIS Ireland Limited, One Custom House Plaza, IFSC, Dublin 1, Ireland. +353 1 672 1653 Facsimile: +353 1 790 0459 fb-reg-ireland1@caceis.com No repurchase proceeds can be paid out until the original application form has been received by the Administrator, at the address provided above, and all anti-money laundering checks have been completed. APPLICANT DETAILS (please complete Individual / Company or Joint details as appropriate) INDIVIDUAL / COMPANY Title (Mr, Mrs, Miss, Ms, other): JOINT (only complete this section if the holding is to be held in joint names) Title (Mr, Mrs, Miss, Ms, other): Surname: Surname: Forename: Forename: (or) Company / Nominee Name: Designation: Fax: Country of Tax Residency: Fax: Tax Indentification Number: Country of Tax Residency: Tax Indentification Number: We request you to register our Shares in our joint names and we hereby authorise you from time to time until we or any/either party give you written notice to the contrary to honour all orders for subsequent subscriptions, redemptions or exchanges when signed by: Any Joint Applicant All Joint Applicants SHARE TYPES I / We wish to invest in the following Shares in the Matrix Ascension Closed End: SHARE CLASS CURRENCY AMOUNT (in figures) Matrix Ascension Closed End Retail* Sterling Matrix Ascension Closed End Institutional Sterling *Please note that the Retail Share Classes are not available or suitable for UK retail investors, as they are not compliant with the FSA s requirements under the Retail Distribution Review. Minimum initial investment is 50,000. Minimum subsequent investment is 10,000. Please pay in the currency of the Share Class for which you are subscribing. Cleared funds, net of any bank charges, in the currency of the relevant Share Class are to be received by the Administrator no later than 5.00pm (Dublin time) 3 Business Days preceeding the relevant Dealing Day. AGENT / INTRODUCER DETAILS (to be completed by the applicant s agent / introducer, if applicable. e.g. IFA, Bond Provider, SIPP Provider, Nominee Banks, etc.) Contact Name: Commission required (%) (To be taken by Agent): Company Name: Discount (%) (To be applied to Client): Agent Number: Fax Number: Regulated By:
FOR COMMISSION PAYMENTS Name of Bank: Account Number: Name of Account Holder: IBAN Number: Name of Swift Code: Branch Number / Sort Code: REPURCHASE DETAILS All payments will be paid in the currency of the Share Class in which you invested. All payments will be made by Direct Credit to the bank account provided below. Please note the bank account MUST be in the name of the Applicant. Name of Bank / Building Society: Name of Account Holder: Account Number: Bank Swift Code: IBAN Number: Branch Number / Sort Code: PAYMENT INSTRUCTIONS FOR STERLING SHARES Correspondent Bank: HSBC Bank Plc International Correspondence Swift Code: MIDLGB22 Correspondence Sort Code: 40-05-15 IBAN: GB94MIDL40051535210915 Account No: 35210915 Beneficiary Bank: CACEIS Bank Luxembourg / Caceis Ireland Client Account Beneficiary Swift Code: BSUILULL Retail Share Ref: MSP ASC CE (61687)/Investor Name Institutional Share Ref: MSP ASC CE (61688)/Investor Name
FOREIGN ACCOUNT TAX COMPLIANCE ACT ( FATCA ) On March 18, 2010, the United States of America enacted provisions commonly known as the Foreign Account Tax Compliant Act (FATCA). According to the FATCA Rules, foreign financial institutions ( FFIs ), unless they can rely under ad-hoc lighter or exempted regimes, need to report to the IRS certain holdings by/and payments made to (i) certain US investors; (ii) ertain US controlled foreign entity investors; (iii) non US financial institution investors that do not comply with their obligations under FATCA; and (iv) investors that are not able to document clearly their FATCA status. Moreover, any account that it is not properly documented may l have to suffer a 30% withholding tax. On December 19th 2013 Bermuda and US governments entered into a Model 2 IGA which aims to coordinate and facilitate the reporting obligations under FATCA with other US reporting obligations of Bermudan financial institutions. According to the IGA, Bermudan FFIs will generally have to report directly to the IRS. In order to comply with its obligations, the Fund needs to gather from subscriber(s) a series of additional information and documents relating to subscriber(s) and potential beneficial owners. FATCA means the Foreign Account Tax Compliance Act such as enacted and adopted by the United States of America on March 18, 2010, requiring US individuals to report their financial accounts held outside of the United States and foreign financial institutions to report to the Internal Revenue Service about their US clients. CACEIS IRL, subject to the provisions of the transfer and registrar agency agreement, the Fund s constitutive documents and prospectus and any applicable laws may have the right to: (i) Withhold the payment of any dividend or redemption proceeds to a Unitholder/Shareholder of the Fund until the Fund holds sufficient information; (ii) Reject at its discretion any subscription for Units/Shares; (iii) Compulsorily redeem at any time the Units held by Unitholder/Shareholders who are excluded from purchasing or holding Units/Shares; and (iv) decline to register the transfer of Units to any person who is excluded from purchasing or holding Units. (v) take any additional measures authorized by the Fund s constitutive documents and prospectus/offering memorandum. FACTA DECLARATION (TO BE COMPLETED BY INDIVIDUALS) In this connection, the undersigned subscriber hereby declares, by ticking the correspondent box that, in accordance with the principles of FATCA, the regulations relating to Information reporting by Foreign Financial Institutions and Other Foreign Entities released by the IRS on 28th January 2013 (the FATCA Regulations ), all subsequently published FATCA announcements 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: I AM / WE ARE NOT US RESIDENT (For joint accounts, each subscriber shall provide the relevant confirmation) I AM / WE ARE US RESIDENT (For joint accounts, each subscriber shall provide the relevant confirmation) I/We undertake to provide CACEIS all relevant supporting documents duly filled and electronically signed in accordance with the principles of the US Tax laws. If I am / We are individuals: (Please tick as many boxes as relevant to your situation): 1) I / We have no US Bank account(s); My/Our primary address and/or mailing address are not within the US territory; I / We do not have a US phone or fax number; I / We do not have a power of attorney or signatory authority granted to an individual having a primary address and/or mailing address within US territory. 2) I / We have not a US place of birth If I / We ticked ALL the above boxes under 1) and 2), please note that you are not required to provide CACEIS BL with any further documentation for FATCA identification purposes. If I / We did not tick any box in section 1) above, I / We undertake to provide CACEIS BL with the relevant supporting documents duly filled and electronically signed in accordance with the principles of the US Tax laws. If I / We did tick certain but not all boxes in section 1) above, I / We undertake to provide CACEIS BL with the relevant supporting documents duly filled and electronically signed in accordance with the principles of the US Tax laws. If I / We did not tick the box in section 2) above, I / We undertake to provide CACEIS BL with the relevant supporting documents duly filled and electronically signed in accordance with the principles of the US Tax laws as well as a US nationality renunciation certificate. Should you not be in the capacity to provide a US nationality renunciation certificate, then you need to provide a W9 Form. For the completion of the foregoing US Tax forms, Individuals are herein requested to provide CACEIS with an email address which shall allow CACEIS BL to provide you with an internet link: E-mail: Under penalties of perjury, the subscriber herein declares that the information of this section of this application form is, to the best of its knowledge and belief, true, correct and complete. Signature:
FATCA DECLARATION (TO BE COMPLETED CORPORATE ENTITIES) If I am / We are corporate entities: (Please tick as manay boxes as relevant to your situation): The Corporate entity is a company having its headquarters registered office in the US; OR The Corporate entity is a company incorporated in the US (US corporation). We undertake to provide CACEIS with all relevant supporting documents duly filled and electronically signed in accordance with the principles of the US Tax laws. If the Corporate entity is a company NOT having its headquarter registered office in the US; OR If the Corporate entity is NOT a company incorporated in the US (US corporation). We undertake to provide CACEIS BL with the relevant supporting documents duly filled and electronically signed in accordance with the principles of the US Tax laws (Please note that you are requested to complete the BO Section of the W8 BEN E Form, when applicable, by indicating the exact US tax payer identification number (TIN). The undersigned subscriber further declares that: It has the following FATCA Status by ticking the appropriate box, adding its signature. Also, it undertakes to take the necessary actions to prepare on the Identity system of Thomson Reuters and send immediately to the Bank the appropriate related US tax Form. 1. Specified US Person; 2. US Person that is not a US Specified; 3. Bermudan FFI or FFI in a partner jurisdiction; 4. Participating FFI (other than case 3); 5. Deemed compliant FFI (other than case 3); 6. Exempt beneficial owner (other than case 3); 7. Active NFEE; 8. Passive NFEE; none of which controlling persons are US citizens or resident; which controlling persons are US citizens or resident; 9. Non participating FFI (including Bermudan Financial Institution or other Partner Jurisdiction Financial Institution treated by the IRS as a non participating Financial Institution). The undersigned deposit holder confirms, by ticking the corresponding box that: YES, it has registered on the IRS Portal its appropriate FATCA Status; Please confirm GIIN Code: NO, it has not registered on the IRS Portal due to its FATCA Status; It will register later and undertakes to send immediately to CACEIS its Fatca status and GIIN number. For Passive NFEE with a US controller person: Please provide US Taxpayer identification number (SSN or ITIN) for the ultimate relevant beneficial owner and the relevant supporting documents duly filled and electronically signed in accordance with the principles of the US Tax laws. Under penalties of perjury, the subscriber herein declares that the information of this section of this application form is, to the best of its knowledge and belief, true, correct and complete. Signature: Signature for a Corporation should be executed under seal or signed by a duly authorised signatory, and accompanied by a list of authorised signatories. If this application is signed under power of attorney, such power of attorney or a duly certified copy thereof must accompany this application.
GENERAL DECLARATION AND SIGNATURE OF APPLICANT(S) l/we am / are over 21 years of age and have the full right, power, authority and legal capacity to purchase Shares of the Segregated Account. I/We acknowledge and accept that this application is made solely upon the terms of the current Prospectus and Bye-laws of the Company. I/We hereby declare that I/we am/are making this investment on my/our own behalf and not on behalf of any other person or entity. I/We acknowledge that I/we will provide a certified copy of my/our Passport or a national identity card which must display a photograph and give details of my our date and place of birth. I/We will also provide details of my/our tax identification number if this does not appear on the Passport or other identity card provided. Documentary proof such as a certificate of tax residency from a relevant tax authority may also be required. These items are in addition to providing proof of my our permanent resident residential address which may be in the form of two utility bills which are no more than 3 months old. I/We agree undertake to ensure all such information is up to date and will notify the Administrator of any change in the information provided as soon as reasonably possible. I/We agree to indemnify and hold harmless the Administrator in its capacity as Paying Agent against any loss liability costs or expenses which may be incurred by the Administrator as a result of my/our failure to provide the information required. I/We also warrant and declare that the monies being invested pursuant to this agreement do not represent directly or indirectly the proceeds of any criminal activity and that the investment is not designed to conceal such proceeds so as to avoid prosecution for an offence or otherwise. I/We acknowledge that Shares may not be issued and repurchase proceeds may be frozen until all required information and documentation required by the Administrator pursuant to the EU Savings Directive is provided. l/we hereby confirm that the Segregated Account, the Directors and the Administrator are each authorised and instructed to accept and execute any instructions in respect of the Shares to which this application relates given by me/us by facsimile. If instructions are given by me/us by facsimile, I/we undertake to confirm them in writing. l/we hereby indemnify the Segregated Account, the Directors and the Administrator and agree to keep each of them indemnified, against any loss of any nature whatsoever arising to each of them as a result of any of them acting on facsimile instructions. The Segregated Account, the Directors and the Administrator may rely conclusively upon and shall incur no liability in respect of any action taken upon any notice, consent, request, instructions or other instrument believed, in good faith, to be genuine or to be signed by properly authorised persons. l/we acknowledge that due to anti-money laundering requirements, the Administrator may require further identification of the applicant(s) before the application can be processed or subscription monies accepted or redemptions requests processed. Both the Segregated Account and the Administrator shall be held harmless and indemnified against any loss arising due to the delay or failure to process this application if such information as has been requested has not been provided by me/us. I/We hereby represent that I/we and any persons we represent as agent or nominees or our beneficial owners or persons who control us or are controlled by us is/are not a prohibited country, territory, individual or entity listed on the US Department of Treasury s Office of Foreign Assets Control (OFAC) website at www. treas.gov/ofacoris/as described in the web site, a foreign shell bank or a senior foreign political figure or an immediate family member or close associate of a senior political figure and that, to the best of my/our knowledge, subscription monies are not directly or indirectly derived from activities that may contravene United States federal or state, or international, laws and regulations, including anti money laundering laws and regulations. l/we consent to details relating to my/our application and holding being disclosed to LGBR Capital LLP which performs marketing and investor servicing duties and acknowledge that I/we may be sent details of other investment products. l/we declare that I am/we are not a US Person as defined in the Prospectus and that I am/we are not applying as the nominee for or on behalf of a US Person. l/we will notify the Segregated Account immediately if I/we become aware that any person for whom I/we hold Shares has become a US Person. l/we agree to notify the Segregated Account immediately if I/we become aware that any of the representations is/are no longer accurate and complete in all respects. I/We further agree that the Administrator be fully indemnified and held harmless by me/us from and against any and all claims, liabilities, losses, damages, costs and expenses (including with limitation, attorney s fees) for acting or omitting to act upon instructions or inquiries believed genuine and/or arising as a result of any of the declarations made herein being untrue or as a result of my/our failure to notify the Segregated Account or Administrator of a change in status (relating to tax residency or otherwise) which would render any of the declarations contained herein untrue subsequent to the date of this application. If I/we am/are acting as trustee, agent, representative or nominee for a subscriber (a Beneficial Owner ), I/we understand and acknowledge that the representations, warranties and agreements made herein are made by me/us (a) with respect to myself/ourselves and (b) with respect to the Beneficial Owner. I/We further represent and warrant that I/we have all requisite power and authority from said Beneficial Owner to execute and perform the obligations under this Application Form. If we are a legal person we hereby declare that we are: (i) a legal person not being an individual and not acting in a representative capacity on behalf of an individual; or (ii) an entity liable to corporation tax in Ireland or an equivalent tax in Ireland or an equivalent tax in another country; or (iii) an undertaking for collective investment in transferable securities ( UCITS ) or have elected for the purpose of the EU Savings Directive to be treated as a UCITS. If the legal person is unable to make any of these declaration please contact the Administrator. Your personal information will be handled by the Administrator (as Data Processor on behalf of the Company) in accordance with the Data Protection Acts 1988 to 2003. Your information will be processed for the purposes of carrying out the services of Administrator, registrar and transfer agent of the Company and to comply with legal obligations including legal obligations under company law and anti-money laundering legislation. The Administrator or Company will disclose your information to third parties where necessary or for legitimate business interests. This may include disclosure to third parties where necessary or for legitimate business interests. This may include disclosure to third parties such as auditors, the Irish Revenue Authorities pursuant to the EU Savings Directive and the Irish Financial Services Regulatory Authority or agents of the Administrator who process the data for anti-money laundering purposes or for compliance with foreign regulatory requirements. The Applicant hereby consents to the processing of his/her information, which may include the recording of telephone calls with the Administrator for the purpose of confirming data, and the disclosure of his/her information as outlined above and to the Investment Manager and where necessary or in the Company s or the Administrator s and/or Investment Manager s group of companies or agents of the Administrator including companies situated in countries outside of the European Economic Area which may not have the same data protection laws as in Ireland. Signature of Applicant: Date: Signature (Joint Owner): Date: Signature for a Corporation should be executed under seal or signed by a duly authorised signatory, and accompanied by a list of authorised signatories. If this application is signed under power of attorney, such power of attorney or a duly certified copy thereof must accompany this application. Return this form to: Matrix Structured Products Limited c/o CACEIS Ireland Limited. One Custom House Plaza, IFSC, DUBLIN 1, Ireland. Telephone +353 1 672 1653 Facsimile +353 1 790 0459 Please ensure you have read and signed the Declaration