CRS Self-Certification Form for Partnerships Part 1 Identification of Account Holder Legal name of Entity/Branch: Country of Incorporation or Residence: Current Residence Address: Mailing Address: (please only complete if different from the current residence address): Part 2 Tax Residence for CRS purposes Please indicate in the table below your tax residence country/countries (also when it is Poland): Country of Tax Residence* Taxpayer Identification Number (TIN) 1 The country of tax residence did not issue TIN 1 1 2 3 *If there is no tax residence, please provide the country of the place of effective management of the entity. Part 3 Classification of non-financial entities for CRS purposes NOTE: If you are a financial institution, do not complete this part, but go straight to Parts 4, 5 and 6. If you are a non-financial institution, select your CRS status. I declare that pursuant to the CRS Act I am: 1. Active NFE a corporation the stock of which is regularly traded on an established securities market 2. Active NFE a corporation which is a related entity of a corporation the stock of which is regularly traded on an established securities market 3. Active NFE a Government Entity or Central Bank 4. Active NFE an International Organisation 5. Active NFE other than the categories listed above 6. Passive NFE If you have ticked 1, please provide the name of the securities market on which the stock of NFE is regularly traded: ----------------------------------------------------------------------------------------------------------------------------------------------------------- If you are a Passive NFE, please also complete Part 5. ----------------------------------------------------------------------------------------------------------------------------------------------------------- If you are a Passive NFE, please also complete Part 5. 1 Not required, if the country of tax residence is Poland. Page 1 z 5
Part 4 Classification of financial institutions for CRS purposes NOTE: If you are a financial institution, complete only Part 4. and 6. If you are a non-financial institution and you have already completed Part 3, go straight to Parts 5 I declare that pursuant to the CRS Act my status is: 1. Financial Institution Investment Entity i. An Investment Entity located in a Non-Participating Jurisdiction and managed by another Financial Institution. ii. Other Investment Entity 2. Financial Institution Custodial Institution, Depository Institution or Specified Insurance Company NOTE: If you have ticked YES in 1(i) above, please also complete Part 5. Part 5 Controlling Persons of a Passive Non-Financial Entity or an Investment Entity not being a financial institution from a Participating Jurisdiction NOTE: Complete Part 5 only if you have selected Passive NFE in Part 3 or An Investment Entity located in a Non-Participating Jurisdiction and managed by another Financial Institution in Part 4. In the table please indicate the names of all Controlling Persons, except for those being residents for tax purposes only in Poland or the United States. Full Name Country of Tax Residence Address TIN/SSN ID number and series Date and place of birth The country of tax residence did not issue TIN 1 2 3 4 Page 2 z 5
Declaration I declare that I have notified the Controlling Persons that I provided their details to Bank Handlowy w Warszawie S.A. with its registered office in Warsaw, ul. Senatorska 16 (hereinafter referred to as the Bank) and the information regarding the Bank as the administrator of personal data: - within the scope covering the data provided in the contents of this form in Part 5, - in order for the Bank to comply with the obligation of performing Customer identification process in line with the rules of the Act of 9 March 2017 on exchange of tax information with other countries (CRS Act). The obligation to provide data is required under Article 43 of the CRS Act. Data recipients may be Polish tax administration authorities that are entitled to further disclose data to tax administration authorities of other countries, - about the right to access and correct my data Part 6 Declarations and Signature I declare on behalf of the above-mentioned entity that: 1. The entity is a beneficial owner of the balances and revenues related to the accounts kept by the Bank. 2. I undertake to advise Bank Handlowy w Warszawie S.A. of any change in circumstances which affects the tax residence status or causes the information contained herein to become invalid and to provide a suitably updated declaration within 30 days of such change in circumstances. 3. I am authorized to sign declarations on behalf of the Entity identified at the beginning of this declaration. 4. I declare that all statements made on this form are, to the best of my knowledge and belief, correct and reliable. Full name: Signature: Page 3 z 5
Part 7 Definitions CRS 1. NFE means any Entity that is not a Financial Institution, subject to paragraph 7(b); 2. Active NFE an NFE that meets any of the criteria listed below: a) less than 50% of the NFE s gross income for the preceding calendar year is passive income, which is understood as income from dividend and other income from participation in profits of legal entities, income from sale of stock (shares), debt claims, interest and benefits from any type of loan, surety and guarantee, as well as income from copyright, industrial property rights, also from disposal of these rights, as well as from disposal and execution of rights in financial instruments, and less than 50% of the assets held by the NFE during the preceding calendar year are assets that produce or are held for the production of passive income; b) the stock of the NFE is regularly traded on an established securities market or the NFE is a Related Entity of an Entity the stock of which is regularly traded on an established securities market; c) the NFE is a Governmental Entity, an International Organisation, a Central Bank, or an Entity wholly owned by one or more of the foregoing; d) substantially all of the activities of the NFE consist of holding (in whole or in part) the outstanding stock of, or providing financing and services to, one or more subsidiaries that engage in trades or businesses other than the business of a Financial Institution; The NFE does not meet this criterion, if it operates as a private equity fund, venture capital fund, leveraged buyout fund (LBO) or any other investment instrument, the purpose of each is an acquisition or financing of corporations, and then holding stock in these corporations as fixed assets for the purposes of investments; e) the NFE is not yet operating a business and has no prior operating history, but is investing capital into assets with the intent to operate a business other than that of a Financial Institution; The NFE does not meet this criteria, if 24 months have passed from the date of the initial organisation of the NFE; f) the NFE was not a Financial Institution in the past five years, and is in the process of liquidating its assets or is reorganising with the intent to continue or resume operations in a business other than that of a Financial Institution; g) the NFE primarily engages in financing and hedging transactions with, or for, Related Entities that are not Financial Institutions, and does not provide financing or hedging services to any Entity that is not a Related Entity, provided that the group of any such Related Entities is primarily engaged in a business other than that of a Financial Institution; h) the NFE meets all of the following criteria: i. is established and operated in its jurisdiction of residence exclusively for religious, charitable, scientific, artistic, cultural, athletic, or educational purposes; or it is established and operated in its jurisdiction of residence as a professional organisation, business league, chamber of commerce, labour organisation, agricultural or horticultural organisation, civic league or an organisation operated exclusively for the promotion of social welfare; ii. is exempt from income tax in its jurisdiction of residence; iii. has no shareholders or members who have a proprietary or beneficial interest in its income or assets; iv. the applicable laws of the NFE s jurisdiction of residence or the NFE s formation documents do not permit any income or assets of the NFE to be distributed to, or applied for the benefit of, a private person or non-charitable Entity other than pursuant to the conduct of the NFE s charitable activities, or as payment of reasonable compensation for services rendered, or as payment representing the fair market value of property which the NFE has purchased; v. the applicable laws of the NFE s jurisdiction of residence or the NFE s formation documents require that, upon the NFE s liquidation or dissolution, all of its assets be distributed to a Governmental Entity or other non-profit organisation, or escheat to the government of the NFE s jurisdiction of residence or any political subdivision; 3. Passive NFE means: a. NFE that is not an Active NFE; b. Investment Entity referred to in paragraph 7(b) located in a Non-Participating Jurisdiction; 4. Financial Institution means a Custodial Institution, a Depository Institution, an Investment Entity, or a Specified Insurance Company; 5. Depository Institution means any Entity that accepts deposits in the ordinary course of a banking or similar business, including: a. a domestic bank, foreign bank, foreign branch of a domestic bank and a branch of a foreign bank within the meaning of the Act of 29 August 1997 Banking Law (Journal of Laws of 2016, items 1988, 1948, 1997 and 2260, and of 2017, item 85), b. a credit institution and a branch of a credit institution, within the meaning of the Act of 29 August 1997 Banking Law; c. cooperative savings and credit union and the National Cooperative Savings and Credit Union; 6. Custodial Institution means any Entity that holds, as a substantial portion of its business, Financial Assets for the account of other persons. Custodial Institution means the Entity, which accepts financial assets on the account of others as an important part of its business activity. It is considered that accepting financial assets on the account of others is an important part of an entity s business activity if the gross revenue of this entity from keeping financial assets in custody and related financial services equals or exceeds 20% of the Entity s gross revenues during the shorter of: a. the three-year period that ends on 31 December of the year preceding the year in which the calculation of share is made or the last day of the financial year, if they are not identical; b. the period during which the Entity has been in existence; Page 4 z 5
7. Investment Entity means: a. an Entity that primarily conducts as a business one or more of the following activities or operations for or on behalf of other persons: i. trading in money market instruments, cheques, promissory notes, certificates of deposit, derivatives; ii. foreign exchange; iii. trading in FX derivatives, interest rate and index derivatives; iv. trading in transferable securities; or commodity futures; v. individual and collective portfolio management; vi. otherwise investing, administering, or managing Financial Assets or cash on behalf of other persons, or b. the gross income of which is primarily attributable to investing, reinvesting, or trading in Financial Assets where the entity is managed by another entity that is a Depository Institution, a Custodial Institution, a Specified Insurance Company or an Investment Entity referred to in a); 8. Controlling Person means the beneficial owner referred to in Article 2(1a) of the Act of 16 November 2000 on the Counteracting of Money Laundering and Terrorist Financing (Journal of Laws of 2016, items 299, 615 and 1948); 9. Entity means a legal person or an organisational unit without legal personality, and a legal arrangement, particularly a partnership, under with the contracting parties intend to jointly accomplish the objectives or tasks specified therein; 10. Government Entity this term covers: a. state government; b. political subdivisions of a state; c. entities owned by the given state or the subdivision mentioned in b); d. authorities or institutions exercising power in the jurisdiction, provided that their net income is collected on their own account or another account kept in that jurisdiction and do not bring benefits to any individual; e. a state-controlled entity, which means a legal entity independent from the state, provided that: i. such an entity is owned by another government entity and is controlled directly or through an entity controlled by another government entity; ii. net income of such an entity is collected on its own account or on accounts of another government entity and do not bring benefits to any individual; iii. after the dissolution of the said entity, its assets are entrusted to one or more of the Polish government entities. 11. TIN means Taxpayer Identification Number or a functional equivalent in the absence of a TIN, used for the country of residence to identify the individual or Entity for tax purposes, including the Tax Identification Number (NIP) or the General Electronic Civic Registration System (PESEL No.); 12. Established Securities Market means a securities market that in the country of its principal office is supervised by the competent regulator of the financial market, on which the average annual value of stock trading as at the end of each of 3 calendar years preceding the calendar year, in which the calculation is made, amounts to at least 1,000,000,000 USD. If within the specific securities market other markets are distinguished, only the market on which the stocks of the given corporation are listed shall be taken into account; Page 5 z 5