Individual Form - Tax Information by BVCA

PLEASE READ BEFORE COMPLETING THIS FORM:

Tax authorities require us to collect and report certain information about an Account Holder's tax residency status 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 the Account Holder's tax residence or 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 person or persons identified as the holder(s) of a Financial Account. On this form these persons are cumulatively referred to as the "Account Holder(s)".

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

BVCA Individual

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 acting as an intermediary, agent, custodian, nominee, signatory, investment advisor or legal guardian on behalf of another individual who is the account holder, this form must be completed by or on behalf of that other person who is referred to as the Account Holder.

Name: ___________________________________________________

Address: _________________________________________________

City/Town: _______________________________________________

State/Province/County: _____________________________________

Postal Code/Zip Code: ______________________________________

Country (do not abbreviate): _________________________________

Date of birth (DD/MM/YY): __________________________________

Place of birth (Town/City/Country): ___________________________

Part 2 - Tax Residence

Please provide details for all jurisdictions in which the Account Holder is resident for tax purposes*.

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 individual 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, a person's TIN is generally their National Insurance Number.

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 - 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 I/or the Account Holder am/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 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

____________________________________________________________