SOURCE OF WEALTH DECLARATION. 21 A CERTIFICATION REQUIREMENTS Where certified copies of documents are presented, please note the certification requirements below. Documents may be certified by a bank, accountancy professional, legal professional, notary public or a regulated financial institution. Company / corporate documents may also be certified by the Registry of Companies, the Company Secretary, a director of the company or an officer of the company accompany- ing a similar position. The certifier must sign and date the copy document (indicating his name clearly beneath the signature) and clearly indicate his profession, designation or capacity on it and provide his contact details. All certified documents are to be provided true ink (original) and copies cannot be accepted. Certification of identity documents should be evidenced by a written statement that: the document is a true copy of the original document; the document has been seen and verified by the certifier; and the photo is a true likeness of the holder Certification of other documents should be evidenced by a written statement that the document is a true copy of the original as seen and verified by the certifier.
SOURCE OF WEALTH DECLARATION. To be returned with the subscription form / stock transfer form In the event that there is more than 1 investor or ultimate beneficial owner a separate sheet must be completed for each. Name of investor / Ultimate Beneficial Owner: I provide the following details in relation to the source of wealth (i.e. the economic activity which gener- ated your total net worth): ☐Employment: please provide details on i) job title(s)/function(s) held; ii) name(s) of employer(s); and iii) length of employment. ☐ Self-employed: details of the nature of the employment / business (including commencement of the self-employed activity). ☐ Business owner: details of the nature of the business (including date when you started or the acquired the business). ☐ Inheritance. ☐ Other (please provide a detailed description). Consent is hereby given to the fund and/or the administrator to disclose this transaction to those institu- tions which are legally entitled to receive the information contained herein. Individual self-certification form This self-certification form (the ‘Form’) must be completed by all individual shareholders. The Fund is obliged under the US IGA as well as by agreements to give effect to the Common Reporting Standards (CRS), to collect certain information from all shareholders to determine their tax status. Please note that Apex House Fund Services (Netherlands) B.V. (Apex), on behalf of the Fund, is obliged to share this information with relevant tax authorities. Terms referenced in this Form shall have the same meaning as applicable under the relevant IGA’s, applicable regulations and guidance notes. If any of the information below regarding either your tax residency or classification changes in the future you are obliged to notify Apex of these changes promptly. If you have any questions about how to com- plete this form, please contact your tax advisor. In situations where there are joint shareholders each is required to complete a separate Form, along with any power of attorney (if appointed), on behalf of the shareholder(s).
SOURCE OF WEALTH DECLARATION. SOURCE OF WEALTH DECLARATION - Individual All information provided in this document will remain strictly confidential Document to be returned by post as original Name and First Name: Country of Residence: Occupation: Please provide a precise description of activity: (as example: employee of post office, manager of bank, restaurant owner, car salesman…) Profession: _ _ If retired or unemployed, please indicate former profession: Retired: _ _ Unemployed: _ I declare: I am the ultimate beneficial owner of the monies invested …………………………………………………… I am not the ultimate beneficial owner of the monies invested ……………………………………………………………………………. (a certified ID/Passport copy of this person is to be sent with this declaration) I further declare: The monies invested do not originate from criminal activity, of whatever nature, and in particular do not constitute the proceeds of money laundering. Any profits derived from my investment will not be used for terrorism financing. I declare that the monies invested do not come from a third party and is drawn from my own bank account. These funds originate from the following source: Salary savings Inheritance* Real Estate Sale (please specify*): _ _ Gift (Please specify*): Other* (please add a precise source): _ *Please be advised, that the Administrator in its capacity as Registrar and Transfer Agent may request additional information if necessary. Signature…………………………….……………………………………………………………. Date ………………………………………. SOURCE OF WEALTH DECLARATION - Company All information provided in this document will remain strictly confidential Completed form to be returned by post as original Name of Company Representative: Country of Residence of Representative: Company Name: Commercial Register No. of Company: Issuing Authority: Position of Company Representative: _ _ As Company Representative please state your position. I, as Company Representative declare: The represented Company is the ultimate beneficial owner of the monies invested The represented Company is not the ultimate beneficial owner of the monies invested, which is (please specify*): _ _ I, as Company Representative further declare: The monies invested do not originate from criminal activity, of whatever nature, and in particular do not constitute the proceeds of money laundering. Any profits derived from my investment will not be used for terrorism financing. I, as Company Representative declare that the monies invested are drawn from the Company’s bank account and do not com...
