APPLICATION FORM MATRIX STRUCTURED PRODUCTS LIMITED ASCENSION CLOSED END (the Fund ) Please 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 Email: fb-reg-ireland1@caceis.com 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: Date of Birth: Date of Birth: Place / Country of Birth: Place / Country of Birth: Passport / ID Card Number: Passport / ID Card Number: Nationality: Nationality: (or) Company / Nominee Name: Address: Country of Incorporation: Designation: Postcode: Address: Telephone: Fax: Email: Postcode: Telephone: Email: SHARE TYPES Fax: 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 I / We wish to invest in the following Shares in the Fund: SHARE CLASS CURRENCY AMOUNT (in figures) Ascension Closed End Retail* Sterling 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 FCA s requirements under the Retail Distribution Review. Minimum initial investment is 50,000 for Sterling Shares. Minimum subsequent investment is 10,000 for Sterling Shares. 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: Regulated By: Company Name: Commission required (%) (To be taken by Agent): Address: Discount (%) (To be applied to Client): Agent Number: Postcode: Email: Telephone: Fax Number: FOR COMMISSION PAYMENTS Name of Bank: Account Number: Name of Account Holder: IBAN Number: Name of Swift Code: Branch Number / Sort Code: REDEMPTION DETAILS No redemption proceeds can be paid out until the original application form has been received by the Administrator, at the address provided in the APPLICANT DETAILS section above, and all anti-money laundering checks have been completed. 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: Address: 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: GB94MIDL40051576888255 Account No: 76888255 Beneficiary Bank: CACEIS Bank Luxembourg / Dublin Branch Beneficiary Swift Code: ISAEIE2D 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 certain US investors; 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: Withhold the payment of any dividend or redemption proceeds to a Unitholder/Shareholder of the Fund until the Fund holds sufficient information; 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) DECLARATION OF US CITIZENSHIP OR US RESIDENCE FOR TAX PURPOSES Please tick either or or (iii) and complete as appropriate. I confirm that I am a US citizen and/or resident in the US for tax purposes (green card holder or resident under the substantial presence test) and my US federal taxpayer identifying number (US TIN) is as follows: (iii) I confirm that I was born in the US (or US territory) but am no longer a US citizen as I have voluntarily surrendered my citizenship as evidenced by the attached documents. I confirm that I am not a US citizen or resident in the US for tax purposes. Complete the section below if you have non-us tax residences. DECLARATION OF TAX RESIDENCY (OTHER THAN US) I hereby confirm that I am, for tax purposes, resident in the following countries (indicate the tax reference number type and number applicable in each country): COUNTR(Y/IES) OF TAX RESIDENCY TAX REFERENCE NUMBER TYPE TAX REFERENCE NUMBER Please indicate not applicable if jurisdiction does not issue or you are unable to procure a tax reference number or functional equivalent. If applicable, please specify the reason for non-availability of a tax reference number. DECLARATION AND UNDERTAKINGS I declare that the information provided in this form is, to the best of my knowledge and belief, accurate and complete. I undertake to advise the recipient promptly and provide an updated Self-Certification form within 30 days where any change in circumstances occurs which cuases any of the information contained within this form to be inaccurate or incomplete. Where legally obliged to do so, I hereby consent to the recipient sharing this information with the relevant tax authorities. Signature: Date (dd/mm/yyyy):
FATCA DECLARATION (TO BE COMPLETED CORPORATE ENTITIES) SECTION 1: US PERSONS Please tick and complete as appropriate: The entity is a Specified US Person and the entity s US federal taxpayer identifying number (US TIN) is as follows: The entity is a US Person that is not a Specified US Person. Indicate exemption: If the entity is not a US person, please complete section 2. SECTION 2: US FATCA CLASSIFICATION FOR ALL NON UNITED STATES ENTITIES Please complete this section id the entity is not a US Tax Resident: 2.1 If the entity is a Registered Financial Institution, please tick one of the below categories, and provide the entity s FATCA GIIN: Bermudan or IGA Partner Jurisdiction Financial Institution Registered Deemed Compliant Foreign Financial Institution (iii) Participating Foreign Financial Institution Please provide you Global Intermediary Identification Number (GIIN) (if registration in progress indicate so): 2.2 If the entity is a Financial Institution but unable to provide a GIIN, please tick one of the reasons below: The Entity is a Sponsored Financial Institution and has not yet obtained a GIIN but is sponsored by another entity that has registered as a Sponsoring Entity. Please provide the Sponsoring Entity s name and GIIN. Sponsoring Entity s Name: Sponsoring Entity s GIIN: The Entity is a Trustee Documented Trust. Please provide your Trustee s name and GIIN. Trustee s Name: Trustee s GIIN: (iii) The Entity is a Certified Deemed Compliant, or otherwise Non-Reporting, Foregin Financial Institution (including a Foregin Financial Institution deemed compliant under Annex II of an IGA, except for a Trustee Documented Trust or Sponsored Financial Institution. Indicate exemption: (iv ) The Entity is a Non-Participating Foreigh Financial Institution. 2.3 If the Entity is not a Foreign Financial Institution, please confirm the Entity s FATCA staus below: The Entity is an Exempted Beneficial Owner Exempt Beneficial Owner means any of the entities listed as such in Annex 2.1 of the US IGA or section 1.1471-6 or 1.1471-6T of the US Treasury Regulations. Indicate status: The Entity is an Active Non-Financial Foreign Entity: If the Entity is a Direct Reporting NFFE, please provide the Entity s GIIN: If the Entity is a Sponsored Direct Reporting NFFE, please provide the Sponsoring Entity s name and GIIN: Sponsoring Entity s Name: Sponsoring Entity s GIIN: (iii) The Entity is a Passive Non-Financial Foreign Entity. If you have ticked 2.3(iii) (Passive Non-Financial Foreign Entity), please add the Full Name(s) of any Controlling Person(s): Please complete Section 7 below providing further details of any ultimate Controlling Persons who are natural persons. SECTION 3: UK IGA - UNITED KINGDOM PERSONS The Entity is a Specifed United Kingdom Person and the Entity s United Kingdom indentifying tax number is as follows: The Entity is a United Kingdom Person that is not a Speficied United Kingdom Person Indicate exemption: If the Entity is not a UK person, please complete Section 4.
FATCA DECLARATION (TO BE COMPLETED CORPORATE ENTITIES) SECTION 4: UK FATCA CLASSIFICATION FOR ALL NON UNITED KINGDOM RESIDENT ENTITIES Please complete this section if the entity is not a UK Tax Resident. If you are a Financial Institution please tick this box. If you are not a Financial Institution please confirm the Entity s status below by ticking either (a), (b) or (c): (a) The Entity is an Exempted Beneficial Owner. Indicate status: (b) (c) The Entity is an Active Non-Financial Foreign Entity. The Entity is a Passive Non-Financial Foreign Entity. If you have ticked 4(c) (Passive Non-Financial Foreign Entity), please add the Full Name(s) of any Controlling Person(s): Please complete Section 7 below providing further details of any ultimate Controlling Persons who are natural persons. SECTION 5: COMMON REPORTING STANDARD DECLARATION OF ALL TAX RESIDENCY (REPEAT ANY RESIDENCES INDICATED IN SECTION 2 (US) OR SECTION 3 (UK) Please indicate the Entity s place of tax residence (if resident in more than one jurisdiction please detail all jurisdictions and associated tax reference number type and number). Please indicate not applicable if the jurisdiction does not issue, or you are unable to procure, a tax reference number or functional equivalent. JURISDICTION(S) OF TAX RESIDENCY TAX REFERENCE NUMBER TYPE TAX REFERENCE NUMBER If applicable, please specify the reason for non-availabilty of a tax reference number. SECTION 6: CRS CLASSIFICATION Please provide your CRS classification by checking the corresponding box(es). Note that CRS classification does not necessarily coincide with your classification for US or UK FATCA purposes. 6.1 If the Entity is a Financial Institution please tick one of the boxes below: Non-Reporting Financial Institution under CRS: 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 Trust whose trustee reports all required information with respect to all CRS Reportable Accounts Qualified Credit Card Issuer Other Entity defined under the domestic law as low risk of being used to evade tax. Specify the type: Financial Insitution resident in a Non-Participating Jurisdiction under CRS. Specifiy the type of Financial Institution resident in a Non-participating Jurisdiction below: (a) Investment Entity and managed by another Financial Insitution. If you have ticked this box, please add the Full Name(s) of any Controlling Person(s): (b) (c) Other Investment Entity. Other Financial Institution, including a Depository Financial Institution, Custodial Institution, or Specified Insurance Company.
FATCA DECLARATION (TO BE COMPLETED CORPORATE ENTITIES) 6.2 If the Entity is an Active Non-Financial Entity ( NFE ), please tick this box and specify the type of NFE below: (a) Corporation that is regularly traded or a related entity of a regularly traded corporation. Provide the name of the stock exchange where traded: If you are a related entity of a regularly traded corporation, provide the name of the regularly traded corporation: (b) (c) Governmental Entity, International Organisation, a Central Bank or an Entity wholly owned by one or more of the foregoing. Other Active Non-Financial Entity. 6.3 If the Entity is a Passive Non-Financial Entity. If you have ticked this box, please add the Full Name(s) of any Controlling Person(s): Please complete Section 7 below providing further details of any ultimate Controlling Persons who are natural persons. ENTITY DECLARATION AND UNDERTAKINGS I/We declare (as an authorised signatory of the Entity) that the information provided in this form is, to the best of my/our knowledge and belief, accurate and complete. I/We undertake to advise the recipient promptly and provide an updated Self-Certification form within 30 days where any change in circumstances occures, which causes any of the information contained in this form to be inaccurate or incomplete. Where legally obliged to do so, I/We hereby consent to the recipient sharing this information with the relevant tax information authorities. Authorised Signature: Authorised Signature: Position / Title: Position / Title: Date (dd/mm/yyyy): Date (dd/mm/yyyy): SECTION 7: IDENTIFICATION OF A CONTROLLING PERSON (please complete for each Controlling Person) 7.1 Name of Controlling Person Surname: Forename: Middle name(s): 7.2 Current Residential Address: Country: Postcode / ZIP Code: 7.3 Mailing Address (if different to Residential Address): Country: Postcode / ZIP Code: 7.4 Date of Birth: 7.5 Place of Birth: City / Town of Birth: Country of Birth:
FATCA DECLARATION (TO BE COMPLETED CORPORATE ENTITIES) 7.6 Please enter the legal name of the relevant Entity Account Holder(s) of which you are the Controlling Person Legal name of Entity 1: Legal name of Entity 2: Legal name of Entity 3: Please complete the following table indicating where the Controlling Person is a tax resident; the Controlling Person s TIN for each jurisdiction indicated; and (iii) if the Controlling Person is a tax resident in a jurisdiction that is a Reportable Jurisdiction(s) then please also complete Section 8 Type of Controlling Person. If the Controlling Person is tax resident in more than five jurisdictions, please use a seperate sheet. JURISDICTION(S) OF TAX RESIDENCY TAX REFERENCE NUMBER TYPE TAX REFERENCE NUMBER If applicable, please specify the reason for non-availability of a tax reference number. SECTION 8: TYPE OF CONTROLLING PERSON (please complete this section if you are a tax resident in one or more Reportable Jurisdictions) Please provide the Controlling Person s Status by ticking the appropriate box: ENTITY 1 ENTITY 2 ENTITY 3 Controlling Person of a legal person - control by ownership Controlling Person of a legal person - control by other means Controlling Person of a legal person - senior managing official Controlling Person of a legal person - settlor Controlling Person of a legal person - trustee Controlling Person of a legal person - protector Controlling Person of a legal person - beneficiary Controlling Person of a legal person - other Controlling Person of a legal arrangement (non-trust) - settlor-equivalent Controlling Person of a legal arrangement (non-trust) - trustee-equivalent Controlling Person of a legal arrangement (non-trust) - protector-equivalent Controlling Person of a legal arrangement (non-trust) - beneficiary-equivalent Controlling Person of a legal arrangement (non-trust) - other equivalent CONTROLLING PERSON DECLARATION AND UNDERTAKINGS I acknowledge that I acknowledge that the information contained in this form and information regarding the Controlling Person and any Reportable Account(s) may be reported to the tax authorities of the jurisdiction in which this account(s) is/are maintained and exchnaged with tax authorities of another jurisdction(s) in which [I/the Controlling Person] may be tax resident pursuant to internatonal agreement to exchnage financial account information. I certify that I am the Controlling Person, or am authorised to sign for the Controlling Person, of all the account(s) held by the entity Account Holder to which this form relates. I declare that all statements made in this declaration are, ot the best of my knowledge and belief, correct and complete. I undertake to advise the recipient within 30 days of any change in circumstances which affects the tax residency status of the individual identified in Part 1 of this form or causes the information contained herein to become incorrect, and to provide the recipient with a suitably updated self-certification and Declaration within 30 dayes of such change in circumstances. Signature: Date (dd/mm/yyyy): Print Name: Capacity: Note: If you are not the Controlling Person, please indicate the capacity in which you are signing the form. If signing under power of attorney please also attach a certified copy of the power of attorney.
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: a legal person not being an individual and not acting in a representative capacity on behalf of an individual; or 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