Blenheim Fiduciary Group Limited

BLENHEIM FIDUCIARY GROUP LIMITED

Trust Formation Questionnaire

Blenheim Fiduciary Group Limited and such other intermediate, subsidiary or associated companies of it as have been issued fiduciary licences (whether lead or joint) by the Guernsey Financial Services Commission under The Regulation of Fiduciaries, Administration Businesses and Company Directors, etc (Bailiwick of Guernsey) Law, 2000 and regulations made under it (“BFGL”)

The establishment of an offshore structure can be a complex process and have legal, tax and other consequences which can extend to those connected, or involved or associated with the structure. Anyone contemplating establishing such a structure or becoming connected, or involved or associated with such a structure should take professional independent legal and tax advice before proceeding. Please note that BFGL does not provide legal or tax advice and nothing in this document should be construed as such.

Section A: TRUST FORMATION QUESTIONNAIRE

1. Proposed Trust Name

2. Preferred jurisdiction (e.g. Guernsey)

3. Revocability by settlor

4. Proposed structure required, purpose, objectives and intended nature of the Trust (please provide a basic outline of the Trust’s structure, purpose, objects and nature)

5. Please detail:

5.1 Geographical area of activities

5.2 Number of transactions expected per annum

5.3 Expected value of transactions per annum

6. Please detail the type of activity that can be expected in respect of the proposed Trust

B1513-0203/1235025/1 1 7. Rationale for establishing the Trust (please give detailed reasons for setting up the Trust (eg tax or estate planning))

8. Initial Capital:

8.1 Anticipated initial settled capital (cash) (or description of other assets and current value)

8.2 Anticipated additional settled capital (cash) (or description of other assets and current value)

8.3 Anticipated regular contributions

8.4 Currency of cash

9. Please state the method(s) by which funding and assets will be introduced, for example, bank/share transfer, trading activity surplus etc

10. Please detail the source of initial funds and/or assets to be settled into the Trust (please note that documentary evidence confirming the origin or source of funding may be required)

11. Please detail, to the extent known, the anticipated source of any future sums to be settled in to the Trust (whether by way of regular contributions or otherwise)

12. What services are you expecting BFGL to provide?

Services (tick if yes)

Acting as: Sole trustee

Joint trustee

(to include all

usual administrative usual administrative

functions unless

B1513-0203/1235025/1 2 otherwise stated) otherwise stated)

Sole protector

Joint protector

Sole enforcer

Joint enforcer

Other (please specify)

Section B: EXISTING TRUST QUESTIONNAIRE

Name of Trust

Date Trust was established

3. Jurisdiction of establishment of Trust

4. Structure, purpose, objectives and nature of the Trust (please provide an outline of the Trust’s structure purpose, objectives and nature)

5. Please detail:

5.1 Geographical area of activities

5.2 Number of transactions expected per annum

5.3 Expected value of transactions per annum

6. Please detail the type, volume and value of activity that can be expected in relation to the Trust

B1513-0203/1235025/1 3 7. What was the rationale for establishing the Trust (please give detailed reasons as to why the Trust was set up (eg tax or estate planning))?

Please also indicate if these reasons have changed and, if so, please give the reasons why and what the new or revised rationale is.

8. Capital:

8.1 Amount of the Trust’s capital (cash) (or description of other assets and current value)

8.2 Anticipated additional capital (cash) (or description of other assets and current value)

8.3 Details of regular contributions made to the Trust (what and when)

8.4 Details of regular contributions

8.5 Currency of cash

9. Please detail the source of funds and/or assets currently held by the Trust (please note that documentary evidence confirming origin or source of funding may be required)

10. Please detail, the extent known, the anticipated source of any future sums to be settled into the Trust (whether by way of regular contribution or otherwise)

11. What services or actions are you expecting BFGL to provide?

Services (tick if yes)

Acting as: Sole trustee Joint trustee (to include all

(to include all

usual administrative B1513-0203/1235025/1 4 usual administrative

functions unless

otherwise stated) otherwise stated)

Sole protector

Joint protector

Sole enforcer

Joint enforcer

Actions (tick if yes)

Change of proper law

Amendments

Change of trustee

documentation

Section C: KEY PERSONS QUESTIONNAIRE

C1.1 INDIVIDUALS

Each of the following persons who is an individual must complete the following section and the declaration at section F. If there is more than one person in a particular category, this section and section F must be filled out by each person. Additional section C and F forms are in the Appendix.

Please indicate in what capacity you are providing the following information:

Settlor (the person(s) who is/are instigating or who has/have instigated the establishment of the

B1513-0203/1235025/1 5 Trust and, if different, who will be providing/ provided the initial capital or any subsequent capital)

Beneficiary

Trustee (if not to be provided by BFGL)

Protector (if not to be provided by BFGL)

Enforcer (if not to be provided by BFGL)

Individual that comes within C1.2.2

Details of persons listed in C1.2.2 not needed if Company is subject to the Guernsey Financial Services Commission’s Handbook for Financial Services Businesses on Countering Financial Crime and Terrorist Financing as revised from time to time (the “Handbook”) or is an Appendix C Business as defined in the Handbook.

C.1.1.1 IDENTIFICATION

1. Full lawful name

2. Former names (such as maiden name) or other name(s) known by

3. Principal residential address including postcode NB Please do not use PO Box address Postcode

4. Other addresses

Postcode

5. Telephone number(s)

6. Email address(es)

7. Date of birth

8. Place and country of birth B1513-0203/1235025/1 6 9. Nationality (individuals with dual or multi-country nationalities should state each country of which they are a citizen)

10. Relationship with settlor NB This only needs to be answered by beneficiaries

11. Number of dependants (if any) NB This only needs to be answered by beneficiaries

C1.1.2 TAXATION INFORMATION

NB This only needs to be completed by the beneficiaries

1. Please list all countries in which you are a resident for tax purposes and detail the associated Tax Reference Numbers

2. If you are a citizen of or resident in the United States of America (US) what is your US Tax Identification Number

3. If you are not resident in any country for tax purposes please give details

4. Please confirm domicile for tax purposes

C1.1.3 BUSINESS ACTIVITIES AND SOURCE OF WEALTH

NB This only needs to be completed by the settlor and beneficiaries

1. Name of current employer

2. Address of current employer including postcode NB Please do not use PO Box address Postcode

3. Current occupation including job title

4. Business activities other than employment

B1513-0203/1235025/1 7 5. Details of any public position(s) you have held at any time

6. Details of your source of wealth [NB only the Settlor(s) or other persons introducing assets to the Trust need to provide details.] Please provide a description of the geographical sphere of activity that has generated the source of wealth.

7. Details of the source of the funds or assets to be transferred to the Trust [NB Only the Settlor(s) or other persons introducing assets to the Trust need to provide details.] Please provide a description of the geographical sphere of activity that has generated the funds.

8. Have you or any member of your family ever held a prominent public function or position of significant local or national influence, or ever been appointed to such a function or position in a country or territory other than Guernsey?

Please tick Yes No

9. Details of the position including length of service in it (from ______to ______)

10. If not you, what is that person’s relationship to you?

11. Do you consider yourself to be commercially exposed (for example, because of your position as senior executive of a well-known commercial enterprise) or otherwise high profile?

Please tick Yes No

12. If ‘yes’ to 11. above, please provide details

C1.1.4 DOCUMENTATION

Please provide to BFGL the following documentation:

B1513-0203/1235025/1 8 1. Certified copy proof of identity

2. Certified copy proof of principal residential address

3. Documents evidencing your:

3.1 Source of wealth

3.2 Source of funds

4. Due diligence declaration (NB this is only required from the settlor and any protector or enforcer.

It is possible that BFGL may need to conduct further investigations into the above, in which case you shall be contacted and may be requested to provide a letter of authorisation authorising a third party to release details to BFGL or a letter requesting a third party to provide a reference to BFGL.

C.1.2 COMPANIES

Each of the following persons who is a company must complete the following section and the declaration at Appendix F. If there is more than one person in a particular category, this section and section F must be filled out by each such person. Additional section C and F forms are in the Appendix.

Please indicate in what capacity the following information is being provided:

Settlor (the person(s) who is/are instigating or who has/have instigated the establishment of the Trust and, if different, who will be providing/provided the initial capital (or any subsequent capital)

Beneficiary

Corporate entity that comes within C1.2.2

C1.2.1 GENERAL INFORMATION

B1513-0203/1235025/1 9 1. Full registered name

2. Trading and/or former name or any alias

3. Full registered address including postcode NB Please do not use PO Box address Postcode

4. Full principal business/trading address (if different from 3. above) NB Please do not use PO Box address Postcode

5. Telephone number(s) and name or job title of individual contact Postcode

6. Website address

7. Email address of individual contact

8. Date of incorporation (DD/MM/YYYY)

9. Country or territory of incorporation

10. Country or territory of current registration if different from 9. above

11. Registered or other official identification number

12. Business activities

13. Relationship to settlor (NB only beneficiaries need to provide details)

14. Details of Company’s source of wealth [NB only the settlor(s) or other person introducing assets to the Trust need to provide details.] Please include a description of the geographical sphere of activity that has generated the source of wealth.

15.Details of the source of B1513-0203/1235025/1 10 funds or assets to be transferred to the Trust [NB. only the Settlor(s) or any other person introducing assets to the Trust need to provide details.] Please include a description of the geographical sphere of activity that has generated the funds.

C1.2.2 PRINCIPALS AND MANAGEMENT

1. Full lawful name of all current Name directors and officers of the Position held Company Name Position held Name Position held

2. Full lawful name of each Name shareholder holding 25% or Percentage holding/assets held more of the issued share Name capital or net assets of the Percentage holding/assets held company. Please state Name percentage holding or asset(s) Percentage holding/assets held Held

3. Regarding any shares or assets Name held by nominees, companies, Percentage holding/assets held in trust, or in bearer form, please Name name each ultimate beneficial Percentage holding/assets held owner and state percentage Name holding or asset(s) held Percentage holding/assets held

4. Is the company capable of issuing bearer shares Yes No

If so, please provide details

5. Full lawful name and position Name held of all individuals who Position held have the authority to operate an Name account or give instructions Position held concerning the use or transfer Name of assets or who otherwise have Position held ultimate effective control over Name the capital or assets of the Position held company and otherwise all Name authorised signatories of the Position held company

C1.2.3 TAX RESIDENCY

1. Country or territory of tax residence

2. Company’s taxpayer B1513-0203/1235025/1 11 identification number (“TIN”) or tax reference number

3. If the company is not a US specified person please tick this box

1. Copy of Certificate of Incorporation or Good Standing

2. Copy of Memorandum and Articles of Association/Incorporation or equivalent constitutional documentation

3. Copy of latest audited financial statements or unaudited annual accounts

4. Copy of Register of directors

5. Copy of Register of shareholders

6. Certified copy documents evidencing identity and address of each current director, officer and authorised signatory

7. Certified copy documents evidencing identity and principal residential address of each shareholder owning 25% or more of the issued share capital or net assets of the company

8. Completed W8-BEN form (companies not resident for tax purposes in the United States only)

9. Bearer shares declaration (companies with bearer shares in issue and/or capable of issuing bearer shares)

10. Due diligence declaration (NB this is only required from the settlor and any protector or enforcer

Section D: ADMINISTRATIVE

1. Please provide full details of the individuals from whom we are able to accept instructions:

1.1 Name

1.2 Address

Postcode

1.3 Telephone number(s)

1.4 Email

2. Accounting

B1513-0203/1235025/1 12 Please provide guidance in respect of any accounts or directors financial statements that may be required in addition to any required under local legislation or guidance, as detailed below:

2.1 Accounting currency

Sterling Euro US$

2.2 Accounting year to (DD/MM/YYY) to (DD/MM/YYYY)

Required frequency of financial statements

Completion of financial statements will be charged in accordance with the applicable fee scale from time to time.

Section E: ADVISORS

Please provide details of any incumbent advisers, or (if BFGL has or is to have the power of appointment) advisers you wish to be appointed in relation to the Trust

1. Lawyer

Name Firm Address

Telephone number

Facsimile number

Email address

2. Accountant

Address

Telephone number

Facsimile number

Email address

B1513-0203/1235025/1 13 3. Tax advisor

Address

Telephone number

Facsimile number

Email address

Section F: DECLARATIONS

F1.1 INDIVIDUAL DECLARATION

I hereby declare that the information provided herein I hereby declare that I will not: a) hinder, delay or and herewith may be held, processed and retained by defraud any creditors, b) engage in any illegal or BFGL and its associated, parent and subsidiary criminal conduct, or c) supply, trade in or move goods companies, and their assigns (collectively or severally or services in contravention of international sanctions or “Blenheim”) for the purposes of complying with anti- import/export controls in Guernsey or in other money laundering laws and regulations. I further applicable countries. declare that the information/documentation may be disclosed or provided to financial institutions, banks, Furthermore, I declare that neither Blenheim nor any investment houses and others for the purposes of entities serviced, administered and/or managed by satisfying their verification and due diligence Blenheim will be sought or retained to assist, facilitate requirements. or engage in any illegal or criminal act, activities, trade or conduct nor will they be sought or retained to I hereby declare that the source of funds and other undertake licensed, regulated or restricted activities assets placed in any entity serviced, administered or without proper authority or valid licence. managed by Blenheim results from the activities listed under C1.1.3 above and that the transferors have full I hereby undertake to comply with applicable anti- and unencumbered legal right and title and authority to bribery and corruption legislation including but not those funds and assets immediately prior to their limited to the Prevention of Corruption (Bailiwick of transfer to any such entity. Guernsey) Law, 2003, as amended, the UK Bribery Act, 2010, as amended and The Foreign Corrupt Practices I hereby declare that I am not involved in and have not Act, 1977, as amended. By accepting or benefiting been involved in, nor do any of my assets, net worth, from Blenheim’s services, I undertake not to render, income or activities relate to, any criminal act, activity or procure or benefit from any improper advantage event including (but not limited to) armaments, illegal whatsoever. drugs or controlled substances, prostitution, bribery, corruption or money laundering or terrorist financing. I hereby undertake to advise Blenheim of any changes to the information contained herein within 30 days and I hereby declare that I am not insolvent. upon request to provide copies of any replacements of documentation attached herewith. I hereby declare that neither have I been, nor am I presently, the subject of any court action, legal I hereby agree expressly, specifically and without proceedings or dispute of any nature whatsoever, qualification to hold harmless and indemnify Blenheim, whether civil or criminal, which has been taken, is being its owners and subsidiaries, its officers, employees and taken or (to the best of my knowledge) is about to be associates and all other entities and individuals that taken against me. engage in any transaction in reliance on any fact or statement contained in this declaration from any liability of any kind with respect to any fact or statement contained in this declaration which is false, untrue or inaccurate in any manner.

Signed ………………………………………….. Date …………………………………..

Print name ………………………………………

B1513-0203/1235025/1 14 F1.2 CORPORATE DECLARATION

Where Section C1.2 has been completed by or in respect of a company, an appropriately authorised signatory of that company must read and sign the following declaration:

The Company hereby declares that the information The Company hereby declares that the Company will provided herein and herewith may be held, processed not: a) hinder, delay or defraud any creditors; b) engage and retained by BFGL and its associated, parent and in any illegal or criminal conduct; or c) supply, trade in subsidiary companies, and their assigns (collectively or or move goods or services in contravention of severally “Blenheim”) for the purposes of complying with international sanctions or import/export controls in anti-money laundering laws and regulations. The Guernsey or in other applicable countries. Company further declares that the information/ documentation may be disclosed or provided to financial Furthermore, the Company declares that neither institutions, banks, investment houses and others for Blenheim nor any entities serviced, administered and/or the purposes of satisfying their verification and due managed by Blenheim will be sought or retained to diligence requirements. assist, facilitate or engage in any illegal or criminal act, activities, trade or conduct nor will they be sought or The Company hereby declares that the source of funds retained to undertake licensed, regulated or restricted and other assets placed in any entity serviced, activities without proper authority or valid licence. administered or managed by Blenheim results from the activities listed under C1.2.1 question 12 above and that The Company hereby undertakes to comply and to the Company as transferor has full and unencumbered procure that its directors will comply with applicable anti- legal right and title and authority to those funds and bribery and corruption legislation including but not assets immediately prior to their transfer to any such limited to the Prevention of Corruption (Bailiwick of entity. Guernsey) Law, 2003, as amended, the UK Bribery Act, 2010, as amended and The Foreign Corrupt Practices The Company hereby declares that neither the Act, 1977, as amended. By accepting or benefiting from Company nor its directors are involved in or have been Blenheim’s services, the Company undertakes not to involved in, nor do any of the Company’s assets, net render, procure or benefit from any improper advantage worth, income or activities relate to, any criminal act, whatsoever. activity or event including (but not limited to) armaments, illegal drugs or controlled substances, The Company hereby undertakes to advise Blenheim of prostitution, bribery, corruption or money laundering or any changes to the information contained herein within terrorist financing. 30 days and upon request to provide copies of any replacements of documentation attached herewith. The Company hereby declares that neither the Company nor any of its directors is insolvent. The Company hereby agrees expressly, specifically and without qualification to hold harmless and indemnify The Company hereby declares that neither the Blenheim, its owners and subsidiaries, its officers, Company nor any of its directors have been or are employees and associates, and all other entities and presently the subject of any court action, legal individuals that engage in any transaction in reliance on proceedings or dispute of any nature whatsoever, any fact or statement contained in this declaration from whether civil or criminal, which has been taken, is being any liability of any kind with respect to any fact or taken or (to the best of its knowledge) is about to be statement contained in this declaration which is false, taken against the Company or its directors. untrue or inaccurate in any manner.

For and on behalf of

Company name …………………………………..

Signed ……………………………………………..

Print name ………………………………………… Date …………………………………

Signed ……………………………………………..

Print name ………………………………………… Date …………………………………

B1513-0203/1235025/1 15 F1.3 To expedite matters, in the first instance, you may wish to email or fax this form and the requested documentation to BGFL, but in any event BFGL will require the original completed hard copies which may be sent to BFGL by courier or normal post to:

Second Floor, St Peter’s House, Le Bordage, St Peter Port, Guernsey, GY1 1BR Email: [email protected] Fax: + 44 (0) 1481 724 116

BFGL is licensed as a fiduciary by the Guernsey Financial Services Commission.

B1513-0203/1235025/1 16 Appendix: additional forms C and F (to be completed by all second and subsequent persons who come within C1.1 or C2.1)

B1513-0203/1235025/1 17 Section C: KEY PERSONS QUESTIONNAIRE ADDITIONAL FORMS C1.1 INDIVIDUALS

Each of the following persons who is an individual must complete the following section. If there is more than one person in a particular category, this section and section F must be filled out by each person.

Please indicate in what capacity you are providing the following information:

Settlor (the person(s) who is/are instigating or who has/have instigated the establishment of the Trust and, if different, who will be providing/ provided the initial capital or any subsequent capital)

Beneficiary

Individual that comes within C1.2.2

C.1.1.1 IDENTIFICATION

1. Full lawful name

2. Former names (such as maiden name) or other name(s) known by

3. Principal residential address including postcode NB Please do not use PO Box address Postcode

4. Other addresses

Postcode

B1513-0203/1235025/1 18 5. Telephone number(s)

6. Email address(es)

7. Date of birth

8. Place and country of birth

9. Nationality (individuals with dual or multi-country nationalities should state each country of which they are a citizen)

10. Relationship with settlor NB This only needs to be answered by beneficiaries

11. Number of dependants (if any) NB This only needs to be answered by beneficiaries

C1.1.2 TAXATION INFORMATION

NB This only needs to be completed by the beneficiaries

Please list all countries in which you are a resident for tax purposes and detail the associated Tax Reference Numbers

2. If you are a citizen of or resident in the United States of America (US) what is your US Tax Identification Number

3. If you are not resident in any country for tax purposes please give details

4. Please confirm domicile for tax purposes

C1.1.3 BUSINESS ACTIVITIES AND SOURCE OF WEALTH

NB This only needs to be completed by the settlor and beneficiaries

1. Name of current employer

2. Address of current employer including postcode NB Please do not use

B1513-0203/1235025/1 19 PO Box address Postcode

3. Current occupation including job title

4. Business activities other than employment

5. Details of any public position(s) you have held at any time

6. Details of your source of wealth [NB. only the Settlor(s) or other persons introducing assets to the Trust need to provide details.] Please provide a description of the geographical sphere of activity that has generated the source of wealth.

7. Details of the source of the funds or assets to be transferred to the Trust [NB Only the Settlor(s) or other persons introducing assets to the Trust need to provide details.] Please provide a description of the geographical sphere of activity that has generated the funds.

8. Have you or any member of your family ever held a prominent public function or position of significant local or national influence, or ever been appointed to such a function or position in a country or territory other than Guernsey?

Please tick Yes No

9. Details of the position including length of service in it (from ______to ______)

10. If not you, what is that person’s relationship to you?

11. Do you consider yourself to be commercially exposed (for example, because of your position as senior executive of a well-known commercial enterprise) or otherwise high profile?

Please tick Yes No

12. If ‘yes’ to 11. above, B1513-0203/1235025/1 20 please provide details

1. Certified copy proof of identity

2. Certified copy proof of principal residential address

3. Documents evidencing your:

3.1 Source of wealth

3.2 Source of funds

4. Due diligence declaration (NB this is only required from the settlor and any protector or enforcer.

It is possible that BFGL may need to conduct further investigations into the above, in which case you shall be contacted and may be requested to provide a letter of authorisation authorising a third party to release details to BFGL or a letter requesting a third party to provide a reference to BFGL.

F1.1 INDIVIDUAL DECLARATION

I hereby declare that the information provided herein I hereby declare that I will not: a) hinder, delay or and herewith may be held, processed and retained by defraud any creditors, b) engage in any illegal or BFGL and its associated, parent and subsidiary criminal conduct, or c) supply, trade in or move goods companies, and their assigns (collectively or severally or services in contravention of international sanctions or “Blenheim”) for the purposes of complying with anti- import/export controls in Guernsey or in other money laundering laws and regulations. I further applicable countries. declare that the information/documentation may be disclosed or provided to financial institutions, banks, Furthermore, I declare that neither Blenheim nor any investment houses and others for the purposes of entities serviced, administered and/or managed by satisfying their verification and due diligence Blenheim will be sought or retained to assist, facilitate requirements. or engage in any illegal or criminal act, activities, trade or conduct nor will they be sought or retained to I hereby declare that the source of funds and other undertake licensed, regulated or restricted activities assets placed in any entity serviced, administered or without proper authority or valid licence. managed by Blenheim results from the activities listed under C1.1.3 above and that the transferors have full I hereby undertake to comply with applicable anti- and unencumbered legal right and title and authority to bribery and corruption legislation including but not those funds and assets immediately prior to their limited to the Prevention of Corruption (Bailiwick of transfer to any such entity. Guernsey) Law, 2003, as amended, the UK Bribery Act, 2010, as amended and The Foreign Corrupt Practices I hereby declare that I am not involved in and have not Act, 1977, as amended. By accepting or benefiting been involved in, nor do any of my assets, net worth, from Blenheim’s services, I undertake not to render, income or activities relate to, any criminal act, activity or procure or benefit from any improper advantage event including (but not limited to) armaments, illegal whatsoever. drugs or controlled substances, prostitution, bribery, corruption or money laundering or terrorist financing. I hereby undertake to advise Blenheim of any changes to the information contained herein within 30 days and I hereby declare that I am not insolvent. upon request to provide copies of any replacements of documentation attached herewith. I hereby declare that neither have I been, nor am I I hereby agree expressly, specifically and without presently, the subject of any court action, legal qualification to hold harmless and indemnify Blenheim, proceedings or dispute of any nature whatsoever, its owners and subsidiaries, its officers, employees and whether civil or criminal, which has been taken, is being associates and all other entities and individuals that taken or (to the best of my knowledge) is about to be engage in any transaction in reliance on any fact or

B1513-0203/1235025/1 21 taken against me. statement contained in this declaration from any liability of any kind with respect to any fact or statement contained in this declaration which is false, untrue or inaccurate in any manner.

Signed ………………………………………….. Date …………………………………..

Print name ………………………………………

To expedite matters, in the first instance, you may wish to email or fax this form and the requested documentation to BGFL, but in any event BFGL will require the original completed hard copies which may be sent to BFGL by courier or normal post to:

BFGL is licensed as a fiduciary by the Guernsey Financial Services Commission

B1513-0203/1235025/1 22 Section C: KEY PERSONS QUESTIONNAIRE: ADDITIONAL FORMS

C.1.2 COMPANIES

Each of the following persons who is a company must complete the following section. If there is more than one person in a particular category, this section and section F must be filled out by each person.

Please indicate in what capacity the following information is being provided:

Settlor (the person(s) who is/are instigating or who has/have instigated the establishment of the Trust and, if different, who will be providing/provided the initial capital (or any subsequent capital)

Beneficiary

Corporate entity that comes within C1.2.2

C1.2.1 GENERAL INFORMATION

1. Full registered name

2. Trading and/or former name or any alias

3. Full registered address including postcode NB Please do not use PO Box address Postcode

4. Full principal business/trading address (if different from 3. above) NB Please do not use PO Box address

B1513-0203/1235025/1 23 Postcode

5. Telephone number(s) and name or job title of individual contact

Postcode

6. Website address

7. Email address of individual contact

8. Date of incorporation (DD/MM/YYYY)

9. Country or territory of incorporation

10. Country or territory of current registration if different from 9. above

11. Registered or other official identification number

12. Business activities

13. Relationship to settlor (NB only beneficiaries need to provide details)

14. Details of Company’s source of wealth [NB only the settlor(s) or other person introducing assets to the Trust need to provide details.] Please include a description of the geographical sphere of activity that has generated the source of wealth.

15. Details of the source of funds or assets to be transferred to the Trust [NB only the Settlor(s) or any other person introducing assets to the Trust need to provide details.] Please include a description of the geographical sphere of activity that has generated the funds.

B1513-0203/1235025/1 24 C1.2.2 PRINCIPALS AND MANAGEMENT

1. Full lawful name of all current Name directors and officers of the Position held company Name Position held Name Position held

2. Full lawful name of each Name shareholder holding 25% or Percentage holding/assets held more of the issued share Name capital or net assets of the Percentage holding/assets held company. Please state Name percentage holding or asset(s) Percentage holding/assets held held

3. Regarding any shares or assets Name held by nominees, companies, Percentage holding/assets held in trust, or in bearer form, please Name name each ultimate beneficial Percentage holding/assets held owner and state percentage Name holding or asset(s) held Percentage holding/assets held

4. Is the company capable of issuing bearer shares Yes No

If yes, please provide details

5. Full lawful name and position Name held of all individuals who Position held have the authority to operate an Name account or give instructions Position held concerning the use or transfer Name of assets or who otherwise have Position held ultimate effective control over Name the capital or assets of the Position held company and otherwise all Name authorised signatories of the Position held company

C1.2.3 TAX RESIDENCY

1. Country or territory of tax residence

2. Company’s taxpayer identification number (“TIN”) or

B1513-0203/1235025/1 25 tax reference number

3. If the company is not a US specified person please tick this box

1. Copy of Certificate of Incorporation or Good Standing

2. Copy of Memorandum and Articles of Association/Incorporation or equivalent constitutional documentation

3. Copy of latest audited financial statements or unaudited annual accounts

4. Copy of Register of directors

5. Copy of Register of shareholders

6. Certified copy documents evidencing identity and address of each current director, officer and authorised signatory

7. Certified copy documents evidencing identity and principal residential address of each shareholder owning 25% or more of the issued share capital or net assets of the company

8. Completed W8-BEN form (companies not resident for tax purposes in the United States only)

9. Bearer shares declaration (companies with bearer shares in issue and/or capable of issuing bearer shares)

10. Due diligence declaration (NB this is only required from the settlor and any protector or enforcer

F1.2 CORPORATE DECLARATION

Where Section C1.2 has been completed by or in respect of a company, an appropriately authorised signatory of that company must read and sign the following declaration:

The Company hereby declares that the information The Company hereby declares that the Company will provided herein and herewith may be held, processed not: a) hinder, delay or defraud any creditors; b) engage and retained by BFGL and its associated, parent and in any illegal or criminal conduct; or c) supply, trade in subsidiary companies, and their assigns (collectively or or move goods or services in contravention of severally “Blenheim”) for the purposes of complying with international sanctions or import/export controls in anti-money laundering laws and regulations. The Guernsey or in other applicable countries. Company further declares that the information/ documentation may be disclosed or provided to financial Furthermore, the Company declares that neither institutions, banks investment houses and others for the Blenheim nor any entities serviced, administered and/or purposes of satisfying their verification and due managed by Blenheim will be sought or retained to diligence requirements. assist, facilitate or engage in any illegal or criminal act, activities, trade or conduct nor will they be sought or The Company hereby declares that the source of funds retained to undertake licensed, regulated or restricted and other assets placed in any entity serviced, activities without proper authority or valid licence.

B1513-0203/1235025/1 26 administered or managed by Blenheim results from the activities listed under C1.2.1, question 12, above and The Company hereby undertakes to comply and to that the Company as transferor has full and procure that its directors will comply with applicable anti- unencumbered legal right and title and authority to bribery and corruption legislation including but not those funds and assets immediately prior to their limited to the Prevention of Corruption (Bailiwick of transfer to any such entity. Guernsey) Law, 2003, as amended, the UK Bribery Act, 2010, as amended and The Foreign Corrupt Practices The Company hereby declares that neither the Act, 1977, as amended. By accepting or benefiting from Company nor its directors are involved in or have been Blenheim’s services, the Company undertakes not to involved in, nor do any of the Company’s assets, net render, procure or benefit from any improper advantage worth, income or activities relate to, any criminal act, whatsoever. activity or event including (but not limited to) armaments, illegal drugs or controlled substances, The Company hereby undertakes to advise Blenheim of prostitution, bribery, corruption or money laundering or any changes to the information contained herein within terrorist financing. 30 days and upon request to provide copies of any replacements of documentation attached herewith. The Company hereby declares that neither the Company nor any of its directors is insolvent. The Company hereby agrees expressly, specifically and without qualification to hold harmless and indemnify The Company hereby declares that neither the Blenheim, its owners and subsidiaries, its officers, Company nor any of its directors have been or are employees and associates and all other entities and presently the subject of any court action, legal individuals that engage in any transaction in reliance on proceedings or dispute of any nature whatsoever, any fact or statement contained in this declaration from whether civil or criminal, which has been taken, is being any liability of any kind with respect to any fact or taken or (to the best of its knowledge) is about to be statement contained in this declaration which is false, taken against the Company or its directors. untrue or inaccurate in any manner.

For and on behalf of

Company name …………………………………..

Signed ……………………………………………..

Print name ………………………………………… Date …………………………………

Signed ……………………………………………..

Print name ………………………………………… Date …………………………………

To expedite matters, in the first instance, you may wish to email or fax this form and the requested documentation to BGFL, but in any event BFGL will require the original completed hard copies which may be sent to BFGL by courier or normal post to:

BFGL is licensed as a fiduciary by the Guernsey Financial Services Commission.

B1513-0203/1235025/1 27