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.

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