For Individual Subscribers. (a) For Subscribers that have one or more beneficial owners and to the extent that the beneficial owner’s information is not provided above, please complete the information below with respect to each such beneficial owner. Name Residential Address Date of Birth Occupation PEP¹ Y/N ¹ Is the Owner a Politically Exposed Person? If yes, please attach to this Subscription Agreement a Source of Wealth Letter. The Source of Wealth Letter must describe the economic activity that has generated the individual’s net worth. Subscriber's Bank Account Wire Details (for bank account from which amounts in respect of subscription proceeds will be paid to the Company and to which any amounts due from the Company to the Subscriber will be paid, unless the Company is notified otherwise): Bank Name: Bank Address: __ Bank Swift/ABA Number: __ IBAN Number or Sort Code (if applicable): Correspondent Bank Name: Correspondent Bank Address: Correspondent Bank Account# or swift#: Beneficiary Bank Account Name (should be the same as the Subscriber name above): Beneficiary Bank Account Number: Special instructions for payment through SWIFT. Please note that in order for the Administrator to comply with relevant anti-Money laundering legislation, the Administrator must be able to properly identify the source of funds sent to it for investment. Accordingly, the Subscriber is required to complete both the "Ordering Customer" (field 50) and the "Ordering Institution" (field 52D) when sending a wire payment through the international SWIFT system. I/We hereby certify that the Subscriber is a “Non-U.S. Person” that resides outside of the United States and that information given in this Schedule to the Subscription Agreement is true, accurate and complete. I/we confirm that I/we will, if requested to do so by the Company or the Administrator, provide further information and/or documents to verify this information. Individual Signature(s): _ Entity Signature: Name of Entity Authorized Signatory Payment of Subscription Amount Subscription payments must be made by wire transfer, drawn on a bank account in the same name as that of the subscriber, and must accompany the Subscription Documents when submitted to the Sponsor. Please use the following wiring information: Beneficiary Bank: The Northern Trust International Banking Corporation Harborside Financial Center Plaza 00, Xxxxx 0000, 0 Xxxxxx Xxxxxx, Xxxxxx Xxxx, Xxx Xxxxxx 00000- 0000, XXX SWIFT: CNORUS33 Fedwire (ABA): 000000000 Account Name: B...
For Individual Subscribers. Are you an Accredited Investor? Please check the box below as it relates to the subscribing person, if applicable.
For Individual Subscribers a. The Subscriber represents that he has an individual net worth, or together with his spouse a combined net worth in excess of $1,000,000. For purposes of this representation, "net worth" means the excess of total assets at fair market value, including home* , home furnishings and automobiles, over total liabilities.
For Individual Subscribers. A government issued form of picture identification (e.g., passport or drivers license) in English. ____ Proof of the individual’s current address (e.g., current utility xxxx), if not included in the form of picture identification. * As of the date hereof, countries that are members of the Financial Action Task Force on Money Laundering (“FATF Country”) are: Argentina, Australia, Austria, Belgium, Brazil, Canada, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Italy, Japan, Luxembourg, Mexico, Kingdom of the Netherlands, New Zealand, Norway, Portugal, Russian Federation, Singapore, South Africa, Spain, Sweden, Switzerland, Turkey, United Kingdom and the United States of America. Regulation S Investor Questionnaire ___ A certificate of due formation and organization and continued authorization to conduct business in the jurisdiction of its organization (e.g., certificate of good standing). For Funds of Funds or Entities that Invest on Behalf of Third Parties: ___ A certificate of due formation and organization and continued authorization to conduct business in the jurisdiction of its organization (e.g., certificate of good standing). ___ An “incumbency certificate” attesting to the authority and title of the individual executing these subscription materials on behalf of the prospective investor. ___ A completed copy of a certification that the entity has adequate anti-money laundering policies and procedures (“AML Policies and Procedures”) in place that are consistent with the USA PATRIOT Act, OFAC and other relevant federal, state or non-U.S. anti-money laundering laws and regulations (with a copy of the entity’s current AML Policies and Procedures to which such certification relates). ___ A letter of reference any entity not located in the U.S. or other FATF Country, from the entity’s local office of a reputable bank or brokerage firm that is incorporated, or has its principal place of business located, in the U.S. or other FATF Country certifying that the prospective investor maintains an account at such bank/brokerage firm for a length of time and containing a statement affirming the prospective investor’s integrity.
For Individual Subscribers. Please check at least TWO boxes:
For Individual Subscribers. _______a. The Subscriber represents that he has an individual net worth, or together with his spouse a combined net worth in excess of $1,000,000. For purposes of this representation, "net worth" means the excess of total assets at fair market value, including home*, home furnishings and automobiles, over total liabilities. _______b. The Subscriber represents that he had an individual income of more than $200,000 in each of the last two calendar years or joint income with his spouse in excess of $300,000 in each of those years and reasonably expects to reach the same income level in the current calendar year. (2)
