Long Tail Partners No.1 Fund Long Tail Asset Management Pty Ltd ABN: 34 136 795 170 Australian Financial Services Licence Number: 341474 APPLICATION FORM FOR REGULATED AUSTRALIAN TRUSTS GUIDE TO COMPLETING THIS FORM This form is only for Australian Regulated Trusts. Australian Regulated Trusts include selfmanaged super funds, registered and unregistered managed investment schemes (AFS Licensees), government superannuation funds or other Trusts subject to the regulatory oversight of an Australian regulator. For unregulated Trusts (not subject to the oversight of an Australian statutory regulator), please complete the Unregulated Trusts Application Form. Please note that this application must also include a fully completed form for the Trustee so it too can also be verified for legislative purposes. Complete information about the trustee(s) must be provided. o If the trustee is an individual(s), please also complete the Application Form for Individuals. If there are multiple individuals as trustees, then one form must be completed for each person (trustee). o If the trustee is an Australian company, please also complete the Application Form for Australian companies. o If the Trustee is both an individual and a company, then one form must be completed for each person that is trustee and also the Australian company acting in that role. ALL sections must be completed. Please contact us if you have any queries completing the form. If you are a current investor in the Long Tail Partners No.1 Fund, please state your existing investor / unitholder number: Page 1
SECTION 1 TRUST DETAILS Full name of the Trust Country where Trust established Full name of the Trustee (Please ALSO complete application form(s) for the trustee separately and attach to this application) Type of Trust Self-Managed Superannuation Fund Provide the SMSF s ABN Registered managed investment scheme Provide Australian Registered Scheme Number (ARSN) or Australian Financial Services Licence Number (AFSL) Government superannuation fund Provide name of the legislation establishing the fund Other regulated Trust (A trust that is subject to the regulatory oversight of a Commonwealth, State or Territory statutory regulator such as an approved deposit fund, a pooled superannuation trust or an APRA-regulated superannuation fund). Provide name of the regulator (e.g. ASIC, APRA, ATO) Provide the Trust s ABN or registration/licensing details For other types of Trusts (e.g. family, unit, charitable, estate) or Trusts regulated by a foreign regulatory body, do not use this form but rather complete the Unregulated Trusts Application Form. Primary Contact Information Full name Telephone no. (business hours) Mobile no. Email address Mailing Address PO Box no. Unit no. Street no. Street name Suburb State Postcode Tax File Number Provide TFN or exemption Page 2
Settlor provide FULL details of the Settlor of the Trust* * This section of the form only needs to be completed for trusts where the material asset contribution to the trust by the settlor at the time the trust was established was $10,000 or more, AND the settler is not deceased. In brief, a settlor of a trust invites a person to act as the first trustee, settles some property on the trust and determines the terms of the trust deed. A settlor may also be referred to as a trustor, or occasionally, a grantor or donor. Settlor Type Individual Company Trust Provide FULL details of the settlor (Individuals name, address, date of birth. Company full name, type of company, ACN. Trust Full name.) Amount by which the trust was settled for: $10 $100 Other. Insert details: $ Page 3
SECTION 2 FATCA INFORMATION FOR THE APPLICANT (United States - Foreign Account Tax Compliance Act - must be completed in full) Regulated super funds (Self-Managed Superannuation Funds, APRA regulated super funds, government super funds or pooled superannuation trusts) are not required to complete this section 2 and can proceed to section 3. If you are a registered managed investment scheme or other regulated Australian Trust: Provide the Trust or Trustee s Global Intermediary Identification Number (GIIN), if applicable: If neither the Trust nor the Trustee has a GIIN, please provide the Trust s FATCA status: Page 4
SECTION 3 CUSTOMER VERIFICATION To comply with legislative requirements and in particular the Anti-Money Laundering and Counter- Terrorism Financing Act 2006, we need to collect documents to verify: (1) the full name of the trust; AND (2) that the Trust is a Self-Managed super fund, registered or unregistered managed investment scheme (i.e. subject to ASIC oversight), government superannuation fund or other regulated Trust, as applicable (3) ONE of the trustees: (i) Trustee is an individual we need to verify: (a) your full name; AND (b) Either: (i) your date of birth; OR (ii) your residential address; OR (iii) both (i.e. your residential address and date of birth). To do this we require either: 1. a primary photographic identification document this must include a clear picture of the person; or 2. a primary non-photographic identification document AND a secondary identification document. (ii) Trustee is an Australian Company we need to verify: (a) the full name of the company as registered by ASIC; (b) whether the company is registered as a proprietary or a public company; AND (c) the Australian Company Number (ACN) issued to the company. To do this we require documents setting out this information. All documents must be certified. 1. Acceptable identification documents for the Trust: Tick You only need to select ONE document from the list below An extract from a suitable website e.g. ASIC, ATO or relevant regulator s website (e.g. Super Fund Lookup at www.abn.business.gov.au) A copy of an offer document of the managed investments scheme (e.g. a copy of a Product Disclosure Statement or Information Memorandum) A copy of the AFS Licence to confirm the licensee has the authority to operate a managed investment scheme (registered or unregistered) A copy or relevant extract of the legislation establishing the government superannuation fund sourced from a government website. 2. Acceptable identification documents for the Trustee that is an individual: Part 1 acceptable primary photographic identification documents Tick You only need to select ONE document from the list below A valid drivers licence or permit which includes a photograph An Australian passport, which has not expired OR expired within the preceding two years A passport or international travel document, that: (a) has a photograph and the signature of the customer; and (b) is issued by a foreign government, the UN or a UN agency and, if it is not in English, is accompanied by an English translation prepared by an accredited translator. Page 5
A proof of age card which includes a photograph A national identity card that: (a) has a photograph and the signature of the customer; and (b) is issued by a foreign government, the UN or its agency and, if it is not in English, is accompanied by an English translation prepared by an accredited translator. Part 2 acceptable secondary identification documents (Only complete if you did not provide a document set out in Part 1 above) Tick Select one document from this section Australian birth certificate Australian citizenship certificate Pension card issued by Department of Human Services (previously known as Centrelink) A citizenship certificate issued by a foreign government that, if not in English, is accompanied by an English translation prepared by an accredited translator A birth certificate issued by a foreign government, the UN or a UN agency that, if it not in English, is accompanied by an English translation prepared by an accredited translator AND another document from this section - must contain your name and residential address A utility bill i.e. a notice issued to the customer by a local government body (e.g. local council) or utilities provider (e.g. electricity bill) which is not less than 3 months old A statement issued by an Authorised Deposit Taking Institution (i.e. bank) which is not less than 3 months old A document issued by the Commonwealth or a State or Territory within the preceding 12 months An ATO Notice of Assessment issued to the customer which is less than 12 months old 3. Acceptable identification documents for the Trustee that is an Australian company: Tick You only need to select ONE document from the list below ASIC company extract which is less than 3 months old Certificate of Incorporation Company Constitution An ATO Notice of Assessment issued to the company which is less than 12 months old Page 6
SECTION 4 INFORMATION FOR THE PURPOSES OF COMPLIANCE WITH THE ANTI-MONEY LAUNDERING AND COUNTER-TERRORISM FINANCING ACT 2006 1. Does the trustee have any links to a Politically Exposed Person ( PEP ) 1 this includes any director or a beneficial owner (if trustee is a company) OR any beneficiaries (including beneficial owners)? No Yes (insert details: ) 2. Is the trustee related to a PEP this includes any director or a beneficial owner (if trustee is a company) OR any beneficiaries (including beneficial owners)? No Yes (insert details: ) 3. What is the reason for the trust s investment in the Long Tail Partners No.1 Fund? Diversification Part of an investment strategy To generate positive absolute returns over a rolling 3 to 5 year period Speculative 4. What is the level of experience by the trust or trustee in investing? Novice Experienced Very experienced Professional Other (insert details: ) 5. What was the annual revenue of the trust in the last financial year? Less than $250,000 Between $250,000 and $750,000 Greater than $750,000 6. What is the net asset value of the trust as stated in its last financial accounts? Less than $500,000 Between $500,000 and $2,500,000 Greater than $2,500,000 1 PEPs are individuals who are, or have been, entrusted with prominent public positions or functions in a government body or an international organisation such as head of a country or government, government minister or other senior politician, senior government official, judge, governor of a central bank, senior foreign representative, ambassador, or high commissioner, high-ranking member of the armed forces, board chair, chief executive, or chief financial officer of, or other position that has comparable influence in, any State enterprise or international organisation. Page 7
7. Explain the control structure of the trust: Trustee is an individual Trustee is a joint account (two individuals) Trustee is a partnership Trustee is a wholly owned subsidiary of another company Trustee is a company that is partially owned by another entity (greater than 25% equity) Trustee is a company that is partially owned by another entity (less than 25% equity) Trustee is a company where the company only has individual beneficiaries (no other entities that are shareholders) 8. Method of delivery of our services to the trust: Direct Phone or email contact Through AFSL registered financial adviser / intermediary Through non-afsl financial advisor / intermediary Insert details: 9. In which country will funds be sourced for the investment in the Long Tail Partners No.1 Fund? Australia Abroad (Insert details: ) Please note that due to legislative requirements funds will only be returned to the named investor (no third party payments allowed) and in the manner in which they are received. Page 8
SECTION 5 WHOLESALE CLIENT Long Tail Asset Management Pty Ltd ( Long Tail ) only provides financial services to wholesale clients. Under the Corporations Act, all clients are treated as retail clients unless they meet one of the criteria listed in Sections 761G or 761GA, the definitions in the Corporations Act and/or the Corporation Regulations. Please advise which criteria you meet to satisfy us that you meet the definition of a Wholesale investor: Price or value test - the price or value of the product/service exceeds AUD $500,000. Size of Business Test - the financial product or service is provided for use in connection with a business that is not a small business. Small business means a business employing less than 20 people (or if the business is or includes the manufacture of goods then less than 100 employees). Wealth Test - the product/service is not provided in connection with a business, but for the last 2 years you earned more than $250,000 per annum (gross) or have net assets greater than $2.5 million. This requires a certificate from an Accountant. Extended Wealth Test - the financial product or service is acquired by a company controlled by a person who meets the Wealth Test (i.e. the Trustee). A Professional Investor as defined in the definitions in Section 9 of the Corporations Act. Please advise on what basis you believe you are a Professional Investor (as defined). Page 9
SECTION 6 - INVESTMENT DETAILS If payment is by cheque: Make cheque payable to: Long Tail Partners No.1 Client Account Please send the cheque and the completed application form to: Apex Fund Services (Australia) Pty Ltd Suite 801, Level 8 100 William Street Woolloomooloo NSW 2011 Note: Cheques should be crossed Not Negotiable and be drawn from an Australian bank account in the name of the investor(s). Units will only be issued once the cheque has been cleared and may be subject to timing delays. The Manager has the discretion to reject applications. Applications will not be processed from non-australian bank accounts or if the name of the investor differs from the name of the bank account. Application monies must be in Australian dollars. If payment is by Electronic Funds Transfer: please send the application amount to: Bank: UBS Cash Management Branch: 8 Exhibition Street, Melbourne Account Name: Long Tail Partners No.1 Client Account BSB: 033 808 Account Number: 558239 Please ensure that you include the applicant details in the bank transfer information. Initial Investment Amount (Initial minimum $500,000) $,, Distribution Instructions You can elect to have your distributions directly deposited into your nominated bank account, or receive additional units in the Fund. Please specify below. If you wish to have your distributions directly credited to your bank account please provide full bank details below. How do you want to receive distributions? (Please tick box) Reinvest To nominated bank account below If no selection is made, distributions will be reinvested. Distributions will be paid by direct credit to your nominated Australian Bank Account only. Cheques will not be issued for distribution payments. Page 10
SECTION 7 - BANK ACCOUNT DETAILS Please nominate the bank account into which you would like distributions or withdrawals to be paid. Name of financial institution (must be an Australian authorised deposit taking institution) Branch location BSB number Account number Account name (Must be in the name of the investor) Page 11
SECTION 8 REMINDERS, DECLARATION AND SIGNATURE (a) Reminders (please tick): I/We have completed ALL sections above. I/We have attached CERTIFIED documents to verify the identity of the trust (refer appendix for certification requirements). I/We have attached CERTIFIED documents to verify the identity of the trustee (refer appendix for certification requirements). I/We have provided confirmation that the applicant meets the definition of a wholesale client. (b) Declaration (please tick each box): I/We, the above named applicant, declare that the details given in this application are true and correct. I/We understand that if I/we fail to provide any information requested in this application form, the application may not be accepted. I/We confirm that we meet the definition of a wholesale client as defined in Section 5 above. I/We agree to be bound by the provisions of the Constitution governing the Long Tail Partners No.1 Fund. I/We acknowledge that neither Long Tail Asset Management Pty Ltd nor any of its related entities, shareholders, directors or officers makes any representation as to the performance or success or the rate of income or capital return from, or any distribution, or recovery of money invested in the Long Tail Partners No.1 Fund. I/We confirm having read and understood the Information Memorandum provided and the risks associated when investing in the Long Tail Partners No.1 Fund. I/We understand that Long Tail Asset Management Pty Ltd (or its agent) may provide disclosures / statements (as determined by the Manager) to the applicant in an electronic form, including to the email address provided. Signature If the Trustee is a company then two (2) directors or a director and secretary must sign this application form, unless the company is a sole director company, in which case the sole director only must sign. If signed under power of attorney, the attorney encloses a certified copy of the Power of Attorney and declares that s/he has not received notice of revocation of that power. Company/Corporate Trustee (at least two to sign unless a sole director) Name and title (e.g. Director, secretary or sole director/secretary) Signature Date Name and title (e.g. Director, secretary or sole director/secretary) Signature Date Page 12
APPENDIX 1 WEALTH TEST CERTIFICATE FROM ACCOUNTANT PRACTICING IN AUSTRALIA CERTIFICATE UNDER SECTION 761G(7)(C) OF THE CORPORATIONS ACT TO: Long Tail Asset Management Pty Ltd PO Box R1777 ROYAL EXCHANGE NSW 1225 [Name of person or entity of investor. If investor is a Trustee, then insert the full name e.g. ABC Pty Ltd ATF XYZ trust]... [Address of investor]...... I certify that: 1. the financial service or product will not be used in connection with a business; and 2. the [person or entity] whose details are set out above: has net assets of at least $2.5million; or has a gross income for each of the last 2 financial years of at least $250,000. I belong to [name of my professional body*]... My membership designation from this professional body is... I comply with this body's continuing professional education requirements. Signature of accountant... Date certificate issued... *NOTE: A qualified accountant in Australia must belong to one of the following professional bodies at the declared membership classification: Professional Body The Institute of Chartered Accountants in Australia CPA Australia National Institute of Accountants in Australia Declared Membership Classifications CA, ACA and FCA CPA and FCPA PNA, FPNA, MINA and FINA Page 13
EXTENDED WEALTH TEST CERTIFICATE FROM ACCOUNTANT PRACTICING IN AUSTRALIA CERTIFICATE UNDER SECTION 761G(7)(CA) OF THE CORPORATIONS ACT AND REGULATION 7.6.02AB TO: Long Tail Asset Management Pty Ltd PO Box R1777 ROYAL EXCHANGE NSW 1225 A. [Name of company or trust i.e. name of investor. If investor is a Trustee, then insert the full name e.g. ABC Pty Ltd ATF XYZ trust]... [Address of investor]...... B. Name of person or entity who controls the company or trust which is the investor.... I certify that the [person or entity] whose details are set out immediately above at point B: has net assets of at least $2.5million; or has a gross income for each of the last 2 financial years of at least $250,000. In addition, I certify that the [person or entity] whose details are set out above at point B, controls (within the meaning of section 50AA of the Corporations Act 2001) the company or trust (where applicable) whose details are set out above at point A. I belong to [name of my professional body*]... My membership designation from this professional body is... I comply with this body's continuing professional education requirements. Signature of accountant... Date certificate issued... *NOTE: A qualified accountant in Australia must belong to one of the following professional bodies at the declared membership classification: Professional Body The Institute of Chartered Accountants in Australia CPA Australia National Institute of Accountants in Australia Declared Membership Classifications CA, ACA and FCA CPA and FCPA PNA, FPNA, MINA and FINA Page 14
APPENDIX 2 CERTIFICATION OF DOCUMENTS Each document provided with this form must be certified by an acceptable certifier. We will not accept photocopies or faxes of a certification. Please ask the certifier to include the following certification on the front page of the document: first and last name, phone number and category of certifier (refer to list below). The statement by the certifier should include: I certify that this is a true and correct copy of the original document provided to me. OR I certify that this page and the following pages are true and correct copies of the original document provided to me. Signature of the Certifier and Date (dd/mm/yyyy) Acceptable certifiers: a legal practitioner enrolled in a Supreme Court of a State, or Territory or the High Court of Australia a judge of a court a magistrate a chief executive officer of a Commonwealth court a registrar or deputy registrar of a court a Justice of the Peace a notary public a police officer an agent of the Australian Postal Corporation who is in charge of an office supplying postal services a permanent employee of the Australian Postal Corporation who supplies postal services an Australian consular officer or Australian diplomatic officer an officer with 2 or more continuous years service with one or more financial institutions a finance company officer with 2 or more continuous years service with one or more finance companies an officer with, or authorised representative of, a holder of an Australian financial services licence, having 2 or more years continuous service with one or more licensees (note that Long Tail Asset Management will not certify documents) a member of the Institute of Chartered Accountants in Australia, CPA Australia, or the National Institute of Accountants with 2 or more years continuous membership. Page 15