Entity Form - Tax Information by BVCA

PLEASE READ BEFORE COMPLETING THIS FORM: Tax authorities require us to collect and report certain information about the tax residency status of certain Account Holders in order to comply with legal requirements based on the OECD Common Reporting Standard for Automatic Exchange of Financial Account Information "CRS". If you have any questions regarding how to complete this form, please consult your tax adviser.

To enable us to comply with our obligation to report to the relevant tax authorities, you are required to state the residency for tax purposes of the entity which is the Account Holder for the relevant account(s).

When completing this form, please refer to the separate Key Definitions section.

BVCA Entity

Part 1 - Account Holder Information

Account Holder - The person listed or identified as the holder of a Financial Account. The name of the Account Holder should be provided. If the person opening the account is not a Financial Institution and is acting as an intermediary, agent, custodian, nominee, signatory, investment advisor or legal guardian on behalf of another entity that is the account holder, this form must be completed by or on behalf of that other entity which is referred to as the Account Holder.

Entity Name: _____________________________________________

Address: _________________________________________________

City/Town: _______________________________________________

State/Province/County: _____________________________________

GIIN (if any): ______________________________________________

Country of Incorporation or Organisation: _________________________________________________________

Postal Code/Zip Code: ______________________________________

Country (do not abbreviate): _________________________________

Part 2 - Tax Residence

Please provide details for all jurisdictions in which the Account Holder is resident for tax purposes*. If the entity has no residence for tax purposes, enter the country in which its principal office is located.

Taxpayer Identification Number (TIN) – A TIN or functional equivalent should be provided for each country of residence for tax purposes identified. A TIN is a unique combination of letters and/or numbers assigned to the entity by a government, or its tax authorities, which is used to identify the account holder for the purposes of administering taxes. In some countries this may be a number that is specifically referred to as a TIN, while other countries may use other numbers (such as a social insurance number) to identify their residents for tax purposes. In the UK, an entity's TIN is their Unique Taxpayer Reference (UTR).

Country of Tax Residence 1: ________________________________

Taxpayer Identification Number 1: __________________________

TIN Unavailable - [ ]

Country of Tax Residence 2: ________________________________

Taxpayer Identification Number 2: __________________________

TIN Unavailable - [ ]

Country of Tax Residence 3: ________________________________

Taxpayer Identification Number 3: __________________________

TIN Unavailable - [ ]

[ ] I certify the countries listed above (and in any attached statement) represent any and all countries in which the Account Holder is considered a tax resident.

Part 3 - CRS Status

Please note that your status under CRS may differ from your status under FATCA. See Key Definitions section for definitions.

Is the Account Holder a Financial Institution?*

[ ] Yes

Financial Institution (FI)
Is the entity an Investment Entity resident in a Non-Participating Jurisdiction and is an Investment Entity by virtue of being managed by an FI?

[ ] Yes
[ ] No

[ ] No

Non-Financial Entity (NFE)
Select the category of NFE which applies to the entity. Select only a single category.

Active NFE

[ ] Governmental Entity, International Organisation, or Central Bank
[ ] An entity the stock of which is regularly traded on an established securities market (or entity related to such an entity) \ Name of securities market: _________________________________ If a Related Entity, name of the entity the stock of which is regularly traded and the securities market : __________________________________________________________

[ ] A start-up company formed in the past 24 months Provide the date that the entity was organised: ________________

[ ] Other Active NFE Please specify which paragraph of the definition of Active Non-Financial Entity which applies to the entity: __________________________________________________________

Passive NFE

Complete Controlling Persons Form [ ]

Part 4 - FATCA Status

Please note that your status under CRS may differ from your status under FATCA. This section of the form should be used by requestors resident in a jurisdiction that has a Model 1 Intergovernmental Agreement (IGA) with the United States. See Key Definition section for definitions.

Is the Account Holder a U.S. Person?

[ ] Yes

U.S. Persons
Is the entity a specified U.S. Person?

[ ] Yes Provide a U.S. TIN below.
[ ] No

U.S. TIN: _________________________

[ ] No

Is the Account Holder an FFI or a NFFE?

[ ] FFI*

[ ] NFFE

If you are a NFFE, are you active or passive?

[ ] Active NFFE

[ ] Passive NFFE

If you are a Passive NFFE, do you have Controlling Persons that are U.S. Persons?

[ ] Yes Complete Controlling Persons form for each Controlling Person that is a U.S. Person.

[ ] No

Part 5 - Declarations and Signature

[I understand that the information supplied by me in this certification (including any attachments hereto) is covered by the full provisions of the terms and conditions governing my/the Account Holder's relationship with [FI name] setting out how [FI name] may use and share the information supplied by me to [FI name].]

I acknowledge and agree that information contained in this certification (including any attachments hereto) may be reported to the tax authorities of the country in which the account is maintained or otherwise as required by CRS or FATCA, and that those tax authorities may provide the information to the country or countries in which the Account Holder is resident for tax purposes.

I undertake to advise [FI name] promptly of any change in circumstances which causes the information contained herein to become incorrect and to provide [FI name] with a suitably updated certification and/or attachment within 30 days of such change in circumstances.

I certify that I am authorised to sign for the Account Holder to which this form relates.

I declare that all statements made in this certification (including any attachments hereto) are, to the best of my knowledge and belief, true, correct and complete.

Name ____________________________________________________________

Capacity in which signing ____________________________________________________________

Date ____________________________________________________________

Signature

____________________________________________________________