Governments around the world have concluded agreements requiring financial institutions to gather and report information on their clients tax residencies and related financial account information. This new requirement is referred to as the Common Reporting Standard or CRS and follows on intergovernmental agreements entered into between the United States of America and various other jurisdictions under the Foreign Account Tax Compliance Act of 2010 ( FATCA ). In terms of the CRS and FATCA, we are required to collect certain information to determine the tax residency of all equity and debt interest holders of companies and trusts being administered by Guardian Trust Company Limited / Guardian Corporate Services Limited / Paladin Corporate Services Limited / Paladin Trust Company S.A. and Patron (PTC) Limited ( Guardian ). Please therefore complete the information that is requested in this form. Please note that, in certain circumstances, we may be required to share with the relevant tax authorities the information set out in this form, along with certain financial information relating to the equity or debt interests (including the value of the interests at the end of, and amounts paid or credited during, a reportable period). Such tax authorities may then share this information with other countries tax authorities, including the tax authority/ies where the equity and/or debt interest holder(s) is/are tax resident. By signing this form, you consent, to the extent required, to the reporting of the necessary information to the relevant tax authorities. This form will remain valid unless there is a change of circumstance relating to the information provided. If any of the information below changes in the future, please ensure that you promptly advise us of these changes. If you have any questions about how to complete the form, please contact your tax advisor or seek qualified professional assistance. Please complete this form in BLOCK CAPITALS and please provide full legal names where names are required. SECTION 1: DETAILS OF THE ENTITY OR TRUST Name of Entity or Trust: Country of Incorporation/Organisation Permanent Residence Address of Entity or Trustee: Mailing Address (if different from above) Please indicate the country or countries in which the Entity or Trust is resident for tax purposes and its tax identification number ( TIN ) or equivalent in such country or countries: 1 2 3 Country(ies) of Tax Residence Tax Reference Number If TIN is unavailable please select an appropriate reason for non-availability: Reason A: The country where the entity or trust is liable to pay tax does not issue TIN s to its residents Reason B: The authorities of country of tax residence do not require a TIN to collected / reported under CRS Reason C: The controlling person is unable to obtain a TIN or equivalent number (Please explain why the entity or trust is unable to obtain a TIN): 1
SECTION 2: US PERSONS Are you a US Person for US federal tax purposes? If you are a US Person, please also complete and return an IRS W-9 Form. SECTION 3: FATCA STATUS (please tick where appropriate) [ ] Participating FFI [ ] Reporting Model 1 FFI [ ] Reporting Model 2 FFI [ ] Registered Deemed Compliant FFI [ ] Sponsored FFI [ ] Sponsored Investment Vehicle [ ] Sponsored Investment Vehicle [ ] Nonreporting IGA FFI [ ] Certified Deemed Compliant FFI (eg [ ] Exempt retirement plans [ ] Exempt Beneficial Owner [ ] Excepted FFI [ ] Owner Documented FFI [ ] Trustee Documented Trust [ ] Non-participating FFI [ ] Non-Profit Organisation [ ] Direct Reporting NFFE [ ] Sponsored Direct Reporting NFFE [ ] Active NFFE [ ] Passive NFFE (PLEASE COMPLETE SECTION 5 BELOW) GIIN Number of Entity or Trust: GIIN Number of Sponsor: Sponsor Name: Reason for lack of GIIN or Sponsoring GIIN: SECTION 4: CRS STATUS (please tick where appropriate) [ ] Reporting Financial Institution [ ] Non-Reporting Financial Institution [ ] Investment Entity located in Non-Participating Jurisdiction and managed by another Financial Institution (PLEASE COMPLETE SECTION 5 BELOW) [ ] Active NFE [ ] Passive NFE (PLEASE COMPLETE SECTION 5 BELOW) 2
SECTION 5: CONTROLLING PERSONS 1 (IF YOU HAVE MORE THAN FOUR CONTROLLING PERSON PLEASE USE AN ADDITIONAL PAGE TO COMPLETE INFORMATION) Controlling Person 1 Controlling Person 2 Controlling Person 3 3
Controlling Person 4 1 CRS Definition of Controlling Person : The natural person(s) who exercise control over an entity. In the case of a trust, the Controlling Person(s) are the settlor(s), the trustee(s), the protector(s) (if any), the beneficiary(ies) or class(es) of beneficiaries, or any other natural person(s) exercising ultimate effective control over the trust (including through a chain of control or ownership). Under the CRS the settlor(s), the trustee(s), the protector(s) (if any), and the beneficiary(ies) or class(es) of beneficiaries, are always treated as Controlling Persons of a trust, regardless of whether or not any of them exercises control over the activities of the trust. Where that entity is treated as a Passive Non-Financial Entity ( Passive NFE ) then a Financial Institution is required to determine whether or not these Controlling Persons are Reportable Persons. This definition corresponds to the term beneficial owner described in Recommendation 10 and the Interpretative Note on Recommendation 10 of the Financial Action Task Force Recommendations (as adopted in February 2012). In the case of a legal arrangement other than a trust, Controlling Person(s) means persons in equivalent or similar positions FATF Recommendations on Controlling Persons: Identify the beneficial owners of the customer and take reasonable measures to verify the identity of such persons, through the following information. For legal persons: a) The identity of the natural persons (if any as ownership interests can be so diversified that there are no natural persons (whether acting alone or together) exercising control of the legal person or arrangement through ownership) who ultimately have a controlling ownership interest in a legal person; and b) to the extent that there is doubt under (a) as to whether the person(s) with the controlling ownership interest are the beneficial owner(s) or where no natural person exerts control through ownership interests, the identity of the natural persons (if any) exercising control of the legal person or arrangement through other means. c) Where no natural person is identified under (a) or (b) above, financial institutions should identify and take reasonable measures to verify the identity of the relevant natural person who holds the position of senior managing official. Measures (a) to (b) are not alternative options, but are cascading measures, with each to be used where the previous measure has been applied and has not identified a beneficial owner. A controlling ownership interest depends on the ownership structure of the company. It may be based on a threshold, e.g. any person owning more than a certain percentage of the company (e.g. 25%). 2 Types of Controlling Persons: For example Settlor, Protector, Trustee, Beneficiary, Shareholder, Director, Senior Managing Officer, Partner in a partnership 3 If TIN is unavailable please provide appropriate defined as follows: Reason A: The country where the Controlling Person is liable to pay tax does not issue TIN s to its residents Reason B: The authorities of the country of tax residence do not require the TIN to collected and reported under Common Reporting rules Reason C: The controlling person is unable to obtain a TIN or equivalent number (Please explain why the Controlling Person is unable to obtain a TIN) 4
SECTION 6: DECLARATION AND SIGNATURE 1. I/We declare that all statements made in this declaration are, to the best of my/our knowledge and belief, correct and complete. 2. I/We hereby acknowledge that the information contained in this form, along with certain financial information relating to the equity or debt interests in the company/trust administered by Guardian (including the value of the interests at the end of, and amounts paid or credited during, a reportable period) may be reported by Guardian to the relevant tax authorities to the extent that Guardian is legally obliged to do so, and may be exchanged by such tax authorities with other relevant tax authorities, and, to the extent required, I/we hereby consent thereto. 3. I/We undertake to advise Guardian Corporate Services Limited within 30 days of any change in circumstances which causes the information contained herein to become incorrect or incomplete (including any changes to the information on controlling persons) and promptly to provide Guardian Corporate Services Limited with a suitably updated self-certification form, together with any applicable documentary evidence that may be required. 4. I/We certify that I am/we are authorised to sign for the Entity or Trust to which this form relates. 5. I/We certify that where I/we have provided information regarding any other person (such as any controlling person(s)) that I/we will, within 30 days of signing this form, notify each of those persons that information has been provided to Guardian and that such information may be provided by Guardian to the relevant tax authorities to the extent that Guardian is legally obliged to do so, and may be exchanged by such tax authorities with other relevant tax authorities. Name of Entity/Trust: Signed on behalf of Entity or Trust by: (insert signature) (print name) (indicate capacity of signatory) (date of signature) 5