CANTOR FITZGERALD IRELAND Green Effects Fund INDIVIDUAL ACCOUNT Subscription / Redemption Form INFO LINE 1850 211 880 R
Green Effects Ethical Fund INDIVIDUAL ACCOUNT Subscription / Redemption Form R General Information (PLEASE USE BLOCK CAPITALS) Account Name: Cantor Account No: Northern Trust Account Number: Registered Address: Mailing Address: (if different from Registered Address): Telephone No: Fax No: Email: PPS Number Source of Wealth/Funds Please indicate your source of wealth (this refers to how you have accumulated your wealth), you may indicate more than one option: Salary/Bonus Inheritance Savings Sale of Shares Sale of Property Other (please specify): Please indicate your source of wealth (this refers to how you have accumulated your wealth), you may indicate more than one option: Maturing Deposit Savings Account Transfer from other investment provider Proceeds of asset sale Other (please specify): Please confirm the following: The country or countries where you are a tax resident: Whether you are a US citizen? Yes No A US citizen has been defined by the IRS as: an individual born in the United States; an individual born in Puerto Rico, Guam or the US Virgin Islands; a former alien who has been naturalised as a US citizen or an individual whose parent is a US citizen. For further information please visit www.irs.gov/individuals/international-taxpayers/foreign-persons Document CheckList Completed & Signed application form Certified copy of passport or drivers licence Two original utility bills as proof of address Cheque made payable to Pershing Securities International ltd or wire transfer Please invest/redeem on our behalf in the following shares or cash equivalent in THE GREEN EFFECTS FUND as follows: Fund Name Buy Sell Cash Amt Shares Payment Currency Green Effects Fund EURO I/We* confirm that I am/we are* 18 years of age or over. I/We confirm that I am/we are not a US person (as defined in the Prospectus) and am/are* not acquiring Units on behalf of, or for the benefit of, a US person, nor do I/we* intend transferring any Units which I/we* may purchase to any person who is a US person. I/We* having received and considered a copy of the Prospectus hereby confirm that this application is based solely on the Prospectus, together (where applicable) with the most recent accounts of the Fund and unaudited semi-annual report of the Company and I/We* hereby undertake to observe and be bound by the provisions of the Articles of Association of the Company (as amended from time to time). You (Green Effects Investment Plc), The Administrator (Northern Trust International Fund Administration Services Ireland Ltd) and the Investment Manager (Cantor Fitgerald Ireland Ltd) are hereby authorised and instructed to accept and execute any instructions in respect of the Shares to which this application relates given by me/us in written form or by facsimile. I/we hereby agree to indemnify you (Green Effects Investment Plc), The Administrator (Northern Trust International Fund Administration Services Ireland Ltd) and the Investment Manager (Cantor Fitgerald Ireland Ltd) against any loss of any nature whatsoever arising to the Administrator as a result of them acting upon facsimile instructions. You (Green Effects Investment Plc), The Administrator (Northern Trust International Fund Administration Services Ireland Ltd) and the Investment Manager (Cantor Fitgerald Ireland Ltd) may rely conclusively upon and shall incur no liability in respect of any action taken upon any notice, consent, request, instruction or other instrument believed in good faith to be genuine or to be signed by properly authorised persons. I/We* hereby accept such lesser number of Shares if any, than may be specified above in respect of which this application may be accepted. I/We* agree to provide on request such certifications, documents or other evidence as You (Green Effects Investment Plc), The Administrator (Northern Trust International Fund Administration Services Ireland Ltd) and the Investment Manager (Cantor Fitgerald Ireland Ltd) may reasonably require to substantiate any representations given by me/us and agree to notify You (Green Effects Investment Plc), The Administrator (Northern Trust International Fund Administration Services Ireland Ltd) and the Investment Manager (Cantor Fitgerald Ireland Ltd) immediately if I/we* become aware that any of the representations made is no longer accurate and complete in all respects and agree Please continue to next page 2015
Green Effects Ethical Fund INDIVIDUAL ACCOUNT Subscription / Redemption Form R immediately either to sell or to tender to You (Green Effects Investment Plc), The Administrator (Northern Trust International Fund Administration Services Ireland Ltd) and the Investment Manager (Cantor Fitgerald Ireland Ltd) for redemption a sufficient number of Shares to allow the representation to be made. I/We consent to the disclosure of details relating to my/our shareholding, or any details on this application form, to any of the Administrator, the Investment Manager or the Custodian. (In respect of joint applicants only) We direct that on the death of one of us the Shares for which we hereby apply be held in the name of and to the order of the survivor or survivors of us or the executor or administrator of the last of such survivor or survivors. I/We declare that the Key Investor Information Document (the KIID ) for the Fund has been provided to me/us in good time prior to making this application for Shares and that I/we have read and reviewed same. I/We hereby acknowledge and agree that the up-to-date KIID for the Fund is available at the Investment Manager s website at www.greeneffects.ie that I/we will read and review the most up-to-date version of the relevant KIID prior to making any subsequent applications for Shares in the Company. I/We acknowledge that by signing this subscription form that I/we give full consent to receiving the KIID by means of electronic communication. I/We am/are aware that I/we can also obtain upon request and free of charge paper copies of the Prospectus, latest annual and semi-annual reports, KIID and other information from Northern Trust International Fund Administration Services (Ireland) Limited, Georges Court, 54-62 Townsend Street, Dublin 2, Ireland or by telephoning +353 (1) 542 2000. Signature Joint Signature (where appropriate) Print Name Print Name Date Date 1. The completed application form must be sent: A. BY FAX or B. BY POST TO: Richard Power/Arthur Mehigan To: Client Services Department (01) 633 3856 Green Effects Fund Cantor Fitzgerald Ireland Ltd 75 St. Stephens Green Dublin 2 To arrive no later than 5:30 p.m. on Wednesday evening, for execution on Thursday. 2. A corporation should complete this form under seal or under the hand of a duly authorised official who should state his capacity and furnish a certified copy of the authority pursuant to which such official is authorised. 3. If this application form is signed under power of attorney, such power of attorney or a duly certified copy thereof must accompany this form. Bank Account Details for Payments: Name of Bank: Ulster Bank, 33 College Green, Dublin 2 SORT Code: 98-50-10 Account Number:31911845 IBAN Number: IE72 ULSB9850 1031 9118 45 Account Name: Pershing Securities International ltd s52 HUB a/c Reference: Green Effects Fund DS For International Transfer details, please contact Client Services on 1850 365 636 (Intl + 3531 6333 888) Unless otherwise provided for in this Application Form, all defined terms used herein shall have the meanings assigned to them in the Prospectus for the Fund. If you are currently not an Irish Resident as defined in the Prospectus for tax purposes or are otherwise an exempt Irish Investor kindly contact Cantor Fitgerald Ireland Ltd for the necessary additional documentation. Please include the following documents with any subscription application form: 1. Certified copy of passport or drivers licence. 2. Two original utility bills as proof of address (less than 6 months old). 3. Cheque made payable to Pershing Securities International ltd or wire transfer to the account detailed above with your account reference in the narrative. Should you require any assistance completing this application form contact your broker at our Dealing Desk on (01) 6333 800 R 75 St. Stephen s Green, Dublin 2, Ireland. Tel : +353 1 633 3800. Fax : +353 1 633 3856 email : ireland@cantor.com web : www.cantorfitzgerald.ie Cantor Fitzgerald Ireland Ltd is regulated by the Central Bank of Ireland. Cantor Fitzgerald Ireland Ltd is a member firm of the Irish Stock Exchange and the London Stock Exchange. 2015
Green Effects Ethical Fund GE Redemption - Payment Instruction Letter Sender: To: Green Effects Fund Dolmen Securities Limited. 75 St. Stephens Green, Dublin 2. Re: Green Effects Redemption Date: / / 2014 Dear Mary Please redeem all/ units of my holding of the Green Effects Fund and transfer the proceeds to the following account in my name: Account Name: Bank Name: Sort Code: Account Number: BIC Number: IBAN Number: I trust that this is in order and payment will be made in due course. Regards 2015
Instructions for completion Entity Self-Certification for FATCA and CRS We are obliged under Section 891E, Section 891F and Section 891G of the Taxes Consolidation Act 1997 (as amended) and regulations made pursuant to those sections to collect certain information about each investor s tax arrangements. Please complete the sections below as directed and provide any additional information that is requested. Please note that in certain circumstances we may be legally obliged to share this information, and other financial information with respect to an investor s interests in the Fund with relevant tax authorities.this form is intended to request information only where such request is not prohibited by Irish law. If you have any questions about this form or defining the investor s tax residency status, please refer to the OECD CRS Portal or speak to a tax adviser. For further information on FATCA or CRS please refer to Irish Revenue website at http://www.revenue.ie/en/business/aeoi/index.html or the following link: http://www.oecd.org/tax/automatic-exchange/ in the case of CRS only. If any of the information below about the investor s tax residence or FATCA/CRS classification changes in the future, please ensure that we are advised of these changes promptly. (Mandatory fields are marked with an *) Investors that are individuals should not complete this form and should complete the form entitled Individual Self-Certification for FATCA and CRS. Section 1: Investor Identification Investor Name*: (the "Entity ) Country of Incorporation or Organisation: Current Registered Address*: Number: Street: City, town, State, Province or County: Postal/ZIP Code: Country: Mailing address (if different from above): Number: Street: City, town, State, Province or County: Postal/ZIP Code: Country: Section 2: FATCA Declaration Specified U.S. Person: Please tick either (a), (b) or (c) below and complete as appropriate. a) The Entity is a Specified U.S. Person and the Entity s U.S. Federal Taxpayer Identifying number (U.S. TIN) is as follows: U.S. TIN: Or b) The Entity is not a Specified U.S. Person (please also complete Sections 3, 4 and 5) Or c) The Entity is a US person but not a Specified U.S. Person (please also complete Sections 3, 4 and 5)
. Section 3: Entity s FATCA Classification* (the information provided in this section is for FATCA, please note your classification may differ from your CRS classification in Section 5): 3.1 Financial Institutions under FATCA: If the Entity is a Financial Institution, please tick one of the below categories and provide the Entity s GIIN at 3.2 I. Irish Financial Institution or a Partner Jurisdiction Financial Institution II. Registered Deemed Compliant Foreign Financial Institution III. Participating Foreign Financial Institution 3.2 Please provide the Entity s Global Intermediary Identification number (GIIN) 3.3 If the Entity is a Financial Institution but unable to provide a GIIN, please tick one of the below reasons: I. The Entity has not yet obtained a GIIN but is sponsored by another entity which does have a GIIN Please provide the sponsor s name and sponsor s GIIN : Sponsor s Name: Sponsor s GIIN: II. Exempt Beneficial Owner III. Certified Deemed Compliant Foreign Financial Institution (including a deemed compliant Financial Institution under Annex II of the Agreement) IV. Non-Participating Foreign Financial Institution V. Excepted Foreign Financial Institution 3.4 Non-Financial Institutions under FATCA: If the Entity is not a Financial Institution, please tick one of the below categories I. Active Non-Financial Foreign Entity II. Passive Non-Financial Foreign Entity (If this box is ticked, please include self-certification forms for each of your Controlling Persons) III. Excepted Non-Financial Foreign Entity Section 4: CRS Declaration of Tax Residency (please note that you may choose more than one country)* Please indicate the Entity s country of tax residence for CRS purposes, (if resident in more than one country please detail all countries of tax residence and associated tax identification numbers ( TIN )). NOTE: Provision of a Tax ID number (TIN) is required unless you are tax resident in a Jurisdiction that does not issue a (TIN). If the Entity is not tax resident in any jurisdiction (e.g., because it is fiscally transparent), please indicate that below and provide its place of effective management or country in which its principal office is located. Country of Tax Residency Tax ID Number
. Section 5: Entity s CRS Classification*(The information provided in this section is for CRS. Please note an Entity's CRS classification may differ from its FATCA classification in Section 3): For more information please see the CRS Standard and associated commentary. http://www.oecd.org/tax/automatic-exchange/common-reporting-standard/common-reporting-standard-and-related-com mentaries/#d.en.345314 5.1 Financial Institutions under CRS: If the Entity is a Financial Institution, please tick one of the below categories I. Financial Institution under CRS(other than (II) below) II. An Investment Entity located in a Non-Participating Jurisdiction and managed by another Financial Institution (If this box is ticked, please indicate the name of any Controlling Person(s) of the Entity and complete a separate individual self-certification forms for each of your Controlling Persons **) 5.2 Non Financial Institutions under CRS: If the Entity is a Non Financial Institution, please tick one of the below categories I. Active Non-Financial Entity a corporation the stock of which is regularly traded on an established securities market or a corporation which is a related entity of such a corporation II. Active Non-Financial Entity a Government Entity or Central Bank III. Active Non-Financial Entity an International Organisation IV. Active Non-Financial Entity other than (I)-(III) (for example a start-up NFE or a non-profit NFE) V. Passive Non-Financial Entity (If this box is ticked, please complete a separate Individual Self-Certification Form for each of your Controlling Person(s) ) **Controlling Person s: NB: Please note that each Controlling Person must complete a Separate Individual Self-Certification form. If there are no natural person(s) who exercise control of the Entity then the Controlling Person will be the natural person(s) who hold the position of senior managing official of the Entity. For further information on Identification requirements under CRS for Controlling Persons, see the Commentary to Section VIII of the CRS Standard. http://www.oecd.org/tax/automatic-exchange/common-reporting-standard/common-reporting-standard-and-related-commenta ries/#d.en.345314
. Section 6: Declarations 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 acknowledge that the information contained in this form and information regarding the Account Holder may be reported to the tax authorities of the country in which this account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the Account Holder may be tax resident where those countries (or tax authorities in those countries) have entered into Agreements to exchange financial account information. I/We undertake to advise the recipient promptly and provide an updated Self-Certification where any change in circumstance occurs which causes any of the information contained in this form to be incorrect. Authorised Signature(s)*: Print Name(s)*: Capacity in which declaration is made*: Date: (dd/mm/yyyy):*