Quadrum FATCA form

Foreign Account Tax Compliance Act (“FATCA”) and
the Common Reporting Standard (“CRS”)

PART I: ENTITY SELF-CERTIFICATION FORM FOR FATCA AND CRS Section

Section 1: Account Holder Identification (please refer to the glossary)

{{#if (equalsTo chooseType 'naturalPerson')}} {{else}} {{/if}} {{#unless (equalsTo chooseType 'naturalPerson')}} {{/unless}} {{#if (equalsTo chooseType 'naturalPerson')}} {{else}} {{else}} {{legalentityadd.address.formatted_address}} {{/if}} {{/if}} {{/if}} {{#if (equalsTo chooseType 'naturalPerson')}} {{#if mailingAddressDifferent}} {{/if}} {{else}} {{#if (equalsTo mailingAddressDifferentLE 'yes')}} {{/if}} {{/if}}

Name	Name (the Entity)	{{#unless (equalsTo chooseType 'naturalPerson')}} {{#if entityName1}} {{entityName1}} {{/if}} {{/unless}} {{#if (equalsTo chooseType 'naturalPerson')}} {{#if firstName}} {{firstName}} {{else}} {{#if constantData.firstName}} {{constantData.firstName}} {{/if}} {{/if}} {{#if lastName}} {{lastName}} {{else}} {{#if constantData.lastName}} {{constantData.lastName}} {{/if}} {{/if}} {{/if}}
Country of Incorporation or Organisation	{{countryOfRegistration}}
Registered Address
Address	{{#if naturalPersonAddress}} {{naturalPersonAddress}} {{/if}} {{#if naturalPersonAddress2}} {{naturalPersonAddress2}} {{/if}}
City	{{#if naturalPersonCity}} {{naturalPersonCity}} {{/if}}
Postal Code	{{#if naturalPersonZipCode}} {{naturalPersonZipCode}} {{/if}}
Country	{{#if naturalPersonCountry}} {{naturalPersonCountry}} {{/if}}
Address	{{#if legalentityadd}} {{#if (equalsTo legalentityadd.mode 'manual')}}
Address	{{#if legalentityadd.address.address1}} {{legalentityadd.address.address1}} {{/if}} {{#if legalentityadd.address.address2}} {{legalentityadd.address.address2}} {{/if}}
City	{{#if legalentityadd.address.city}} {{legalentityadd.address.city}} {{/if}}
Postal Code	{{#if legalentityadd.address.zip}} {{legalentityadd.address.zip}} {{/if}}
Country	{{#if legalentityadd.address.country}} {{legalentityadd.address.country}} {{/if}}
Mailing address (if different from above)
Address	{{#if naturalPersonAddress}} {{naturalPersonAddress}} {{/if}}
City	{{#if naturalPersonCity1}} {{naturalPersonCity1}} {{/if}}
Postal Code	{{#if naturalPersonZipCode1}} {{naturalPersonZipCode1}} {{/if}}
Country	{{#if naturalPersonCountry1}} {{naturalPersonCountry1}} {{/if}}
Mailing address (if different from above)
Address	{{#if legalPersonAddress4}} {{legalPersonAddress4}} {{/if}}
City	{{#if legalPersonCity2}} {{legalPersonCity2}} {{/if}}
Postal Code	{{#if legalPersonZipCode2}} {{legalPersonZipCode2}} {{/if}}
Country	{{#if legalPersonCountry2}} {{legalPersonCountry2}} {{/if}}

Section 2: FATCA Declaration of U.S. Citizenship or U.S. Residence for Tax purposes*:

Section 2: FATCA Declaration Specified U.S. Person:

{{#if (equalsTo chooseType 'naturalPerson')}} {{#if (or (equalsTo areYouAUsCitizen 'yes') (equalsTo areYouAUsTaxResident 'yes') )}} I confirm that I am a U.S. citizen and/or resident in the U.S. for tax purposes and my U.S. federal

Taxpayer Identifying Number (U.S. TIN) is as follows: {{#if ssnitin}}{{ssnitin}}{{/if}} {{else}} I confirm that I am not a U.S. citizen or resident in the U.S. for tax purposes. {{/if}} {{else}} {{#if (equalsTo isEntityAUsTaxResident 'yes')}} The Entity is a Specified U.S. Person and the Entity’s U.S. Federal Taxpayer Identifying Number
(U.S. TIN) is as follows: {{entitytin}} {{else}} The Entity is not a Specified U.S. Person (please also complete Sections 3, 4 and 5). {{#if entitytin}}
(U.S. TIN) is as follows: {{entitytin}} {{/if}} {{/if}} {{/if}}

Section 3: Entity’s FATCA Classification* (the information provided in this section is for FATCA purposes, please note your classification may differ from your CRS classification in Section 5):

3.1 Financial Institutions under FATCA:

{{#if (equalsTo CategoryOfFinancialInstitution2 'netherlandsFinancialInstitution')}} Netherlands Financial Institution or a Partner Jurisdiction Financial Institution {{/if}} {{#if (equalsTo CategoryOfFinancialInstitution2 'registeredDeemedCompliantForeignFinancialInstitution')}} Registered Deemed Compliant Foreign Financial Institution {{/if}} {{#if (equalsTo CategoryOfFinancialInstitution2 'participatingForeignFinancialInstitution')}} Participating Foreign Financial Institution {{/if}} {{#if entityGiin}}

3.2 Please provide the Entity’s Global Intermediary Identification Number (GIIN)

3.2 The Entity is a Financial Institution but unable to provide a GIIN

{{#if (equalsTo unableToProvideAGiin 'partnerJurisdictionFinancialInstitutionAndHasNotYetObtainedAGiin')}} Partner Jurisdiction Financial Institution and has not yet obtained a GIIN {{/if}} {{#if (equalsTo unableToProvideAGiin 'notYetObtainedAGiin')}} The Entity has not yet obtained a GIIN, but is sponsored by another entity which does have a GIIN Sponsor's Name: {{sponsorsName}} Sponsor's GIIN {{sponsorsGiin}} {{/if}} {{#if (equalsTo unableToProvideAGiin 'exemptBeneficialOwner')}} Exempt Beneficial Owner {{/if}} {{#if (equalsTo unableToProvideAGiin 'certifiedDeemedCompliantForeignFinancialInstitutionIncludingADeemedCompliantFinancialInstitutionunderAnnexIiOfTheAgreement')}} Certified Deemed Compliant Foreign Financial Institution (including a deemed compliant Financial Institution under Annex II of the Agreement) {{/if}} {{#if (equalsTo unableToProvideAGiin 'nonParticipatingForeignFinancialInstitution')}} Non-Participating Foreign Financial Institution {{/if}} {{#if (equalsTo unableToProvideAGiin 'exceptedForeignFinancialInstitution')}} Excepted Foreign Financial Institution {{/if}} {{#if (equalsTo unableToProvideAGiin 'uSPersonButNotASpecifiedUSPerson')}} U.S. Person but not a Specified U.S. Person {{/if}} {{/if}} {{else}}

Non-Financial Institutions under FATCA:

{{#if (equalsTo nonFinancialnstitution 'activeNonFinancialForeignEntity')}} Active Non-Financial Foreign Entity {{/if}} {{#if (equalsTo nonFinancialnstitution 'passiveNonFinancialForeignEntity')}} Passive Non-Financial Foreign Entity {{/if}} {{#if (equalsTo nonFinancialnstitution 'exceptedNonFinancialForeignEntity')}} Excepted Non-Financial Foreign Entity {{/if}} {{#if (equalsTo nonFinancialnstitution 'theEntityIsAUSPersonButNotASpecifiedUSPerson')}} The Entity is a U.S. Person, but not a Specified U.S. Person {{/if}} {{/if}} {{/unless}} {{#if (equalsTo chooseType 'naturalPerson')}}

Section 3: CRS Declaration of Tax Residence (please note you may choose more than one country) *:

Please indicate your country of Tax Residence (if resident in more than one country please detail all countries of Tax Residence and associated Tax Identification Numbers). {{else}}

Section 4: CRS Declaration of Tax Residency*

Please indicate the Entity’s place of Tax Residence for CRS purposes (if resident in more than one country please detail all countries of Tax Residence and associated Tax Identification Numbers). {{/if}}

Country of Tax Residency	Tax Identification Number¹
{{#if countryOfTaxResidence}}{{countryOfTaxResidence}}{{else}}N/A{{/if}}	{{#if taxIdentificationNumber}}{{taxIdentificationNumber}}{{else}}{{#if reasonTaxNumberNotApplicable}}{{reasonTaxNumberNotApplicable}}{{else}}N/A{{/if}}{{/if}}
{{#if countryOfTaxResidence1}}{{countryOfTaxResidence1}}{{else}}N/A{{/if}}	{{#if taxIdentificationNumber1}}{{taxIdentificationNumber1}}{{else}}{{#if reasonTaxNumberNotApplicable1}}{{reasonTaxNumberNotApplicable1}}{{else}}N/A{{/if}}{{/if}}
{{#if countryOfTaxResidence2}}{{countryOfTaxResidence2}}{{else}}N/A{{/if}}	{{#if taxIdentificationNumber2}}{{taxIdentificationNumber2}}{{else}}{{#if reasonTaxNumberNotApplicable2}}{{reasonTaxNumberNotApplicable2}}{{else}}N/A{{/if}}{{/if}}
{{countryOfTaxResidence6}}	{{#if taxIdentificationNumber6}}{{taxIdentificationNumber6}}{{else}}{{#if reasonTaxNumberNotApplicable6}}{{reasonTaxNumberNotApplicable6}}{{else}}N/A{{/if}}{{/if}}
{{countryOfTaxResidence7}}	{{#if taxIdentificationNumber7}}{{taxIdentificationNumber7}}{{else}}{{#if reasonTaxNumberNotApplicable7}}{{reasonTaxNumberNotApplicable7}}{{else}}N/A{{/if}}{{/if}}
{{countryOfTaxResidence8}}	{{#if taxIdentificationNumber8}}{{taxIdentificationNumber8}}{{else}}{{#if reasonTaxNumberNotApplicable8}}{{reasonTaxNumberNotApplicable8}}{{else}}N/A{{/if}}{{/if}}

¹ Provision of a Tax Identification Number (TIN) is required unless you are a tax resident in a Jurisdiction that does not issue a TIN. If applicable, please specify the reason for non-availability of a Tax Identification Number: {{#if (equalsTo chooseType 'naturalPerson')}}

Section 4: Declarations and Undertakings

I declare that:

I have examined the information in this form and that to the best of my knowledge and belief, it is true, correct and complete;
I will submit a new form within 30 days if, due to a change of circumstances, any certification or information on this form becomes incorrect;
I acknowledge that, in case the Country(ies) of Tax Residence listed in Section 4 is/are CRS Reportable Jurisdiction/s, the information disclosed in this Form together with the required information related to my financial account will be reported to the Netherlands Tax and Customs Administration or any other authorised delegates under Netherlands law, and subsequently exchanged with the tax authorities of the CRS Reportable Jurisdiction(s) listed in Section 4, pursuant to international agreements to exchange financial account information;
Upon request, I will have access to the data concerning me that are disclosed to the competent national tax authority, and I will be in a position to rectify any of my personal data. The data collected will not be kept longer than necessary for the purpose for which they were gathered.

Section 5: Entity’s CRS Classification* (the information provided in this section is for CRS, please note your CRS classification may differ from your FATCA classification in Section 3)

{{#if (equalsTo entitysCrsClassification 'custodialInstitutionDepositoryInstitutionSpecifiedInsuranceCompanyOrInvestmentEntityOtherThanAnInvestmentEntityUnderA6BOfSectionViiiOfTheCrsResidentInANonParticipatingJurisdiction')}} Custodial Institution, Depository Institution, Specified Insurance Company or Investment Entity other than an Investment Entity under A(6)(b) of Section VIII of the CRS resident in a Non- Participating Jurisdiction {{/if}} {{#if (equalsTo entitysCrsClassification 'custodialInstitutionDepositoryInstitutionSpecifiedInsuranceCompanyOrInvestmentEntityOtherThanAnInvestmentEntityUnderA6BOfSectionViiiOfTheCrsResidentInANonParticipatingJurisdiction')}} An Investment Entity under A(6)(b) of Section VIII of the CRS resident in a Non-Participating Jurisdiction (If this box is ticked, please include Controlling Person Self-Certification Forms for each of your Controlling Persons) {{/if}} {{#if (equalsTo entitysCrsClassification 'activeNonFinancialEntity')}} Active Non-Financial Entity: {{#if (equalsTo TypeOfActiveNonFinancialEntity 'aCorporationTheStockOfWhichIsRegularlyTradedOnAnEstablishedSecuritiesMarket')}} a corporation, the stock of which is regularly traded on an established securities market.
If you fall under this definition, please provide the name of the established securities market on which the corporation is regularly traded: {{SecuritiesMarket}} {{/if}} {{#if (equalsTo TypeOfActiveNonFinancialEntity 'aCorporationWhichIsARelatedEntityOfSuchACorporation')}} a corporation which is a related entity of such a corporation.
If you fall under this definition, please provide the name of the regularly traded corporation that the entity identified in section I of this form is a Related entity of: {{RelatedEntity}} {{/if}} {{#if (equalsTo TypeOfActiveNonFinancialEntity 'aGovernmentEntityOrCentralBank')}} a Government Entity or Central Bank {{/if}} {{#if (equalsTo TypeOfActiveNonFinancialEntity 'anInternationalOrganisation')}} an International Organisation {{/if}} {{#if (equalsTo TypeOfActiveNonFinancialEntity 'otherThanAnyOfTheAboveForExampleAStartUpNfeOrANonProfitNfe')}} other (for example a start-up NFE or a non-profit NFE) {{/if}} {{/if}} {{#if (equalsTo entitysCrsClassification 'passiveNonFinancialEntity')}} Passive Non-Financial Entity
(If this box is ticked, please include Controlling Person Self- Certification Forms for each of your Controlling Persons) {{/if}}

Section 6: Declarations and Undertakings

I declare that:

I have examined the information in this form and that to the best of my knowledge and belief, it is true, correct and complete;
I will submit a new form within 30 days if, due to a change of circumstances, any certification or information on this form becomes incorrect;
I acknowledge that, in case the Country(ies) of Tax Residence listed in Section 4 is/are CRS Reportable Jurisdiction/s, the information disclosed in this Form together with the required information related to my financial account will be reported to the Netherlands Tax and Customs Administration or any other authorised delegates under Netherlands law, and subsequently exchanged with the tax authorities of the CRS Reportable Jurisdiction(s) listed in Section 4, pursuant to international agreements to exchange financial account information;
Upon request, I will have access to the data concerning me that are disclosed to the competent national tax authority, and I will be in a position to rectify any of my personal data. The data collected will not be kept longer than necessary for the purpose for which they were gathered.

PART II: CONTROLLING PERSON SELF-CERTIFICATION FORM FOR FATCA AND CRS

Filled for each Controlling person individually {{#if firstNameCP1}}

Section 7: Identification of a Controlling Person

No controlling person data has been provided

Section 7.1: Name of Controlling Person*:

Family Name or Surname(s):	{{lastNameCP1}}
First or Given Name:	{{firstNameCP1}}
Middle Name(s):	{{middleNameCP1}}

Section 7.2 Current Residential Address*:

Street:	{{street1CP1}}
Postal/Zip Code:	{{postcodeCP1}}
City:	{{cityCP1}}
Country:	{{countryCP1}}

Section 7.3 Mailing address (if different from above):

Street:	{{Mailstreet1CP1}}
Postal/Zip Code:	{{MailpostcodeCP1}}
City:	{{MailcityCP1}}
Country:	{{MailcountryCP1}}

Section 7.{{#if (equalsTo differentMailingAddressCP1 'yes')}}4{{else}}3{{/if}} Place of birth*

Town or city of birth:	{{cityOfBirthCP1}}
Country of birth:	{{countryOfBirthCP1}}
Date of birth:	{{formatDate dateOfBirthCP1}}

Section 7.{{#if (equalsTo differentMailingAddressCP1 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Legal Entity {{increment @index}}:

Section 7.1: Name of Controlling Person*:

Family Name or Surname(s):	{{lastNameCP2}}
First or Given Name:	{{firstNameCP2}}
Middle Name(s):	{{middleNameCP2}}

Section 7.2 Current Residential Address*:

Street:	{{street1CP2}}
Postal/Zip Code:	{{postcodeCP2}}
City:	{{cityCP2}}
Country:	{{countryCP2}}

Section 7.3 Mailing address (if different from above):

Street:	{{Mailstreet1CP2}}
Postal/Zip Code:	{{MailpostcodeCP2}}
City:	{{MailcityCP2}}
Country:	{{MailcountryCP2}}

Section 7.{{#if (equalsTo differentMailingAddressCP2 'yes')}}4{{else}}3{{/if}} Place of birth*

Town or city of birth:	{{cityOfBirthCP2}}
Country of birth:	{{countryOfBirthCP2}}
Date of birth:	{{formatDate dateOfBirthCP2}}

Section 7.{{#if (equalsTo differentMailingAddressCP2 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Legal Entity {{increment @index}}:

Section 7.1: Name of Controlling Person*:

Family Name or Surname(s):	{{lastNameCP3}}
First or Given Name:	{{firstNameCP3}}
Middle Name(s):	{{middleNameCP3}}

Section 7.2 Current Residential Address*:

Street:	{{street1CP3}}
Postal/Zip Code:	{{postcodeCP3}}
City:	{{cityCP3}}
Country:	{{countryCP3}}

Section 7.3 Mailing address (if different from above):

Street:	{{Mailstreet1CP3}}
Postal/Zip Code:	{{MailpostcodeCP3}}
City:	{{MailcityCP3}}
Country:	{{MailcountryCP3}}

Section 7.{{#if (equalsTo differentMailingAddressCP3 'yes')}}4{{else}}3{{/if}} Place of birth*

Town or city of birth:	{{cityOfBirthCP3}}
Country of birth:	{{countryOfBirthCP3}}
Date of birth:	{{formatDate dateOfBirthCP3}}

Section 7.{{#if (equalsTo differentMailingAddressCP3 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Legal Entity {{increment @index}}:

Section 7.1: Name of Controlling Person*:

Family Name or Surname(s):	{{lastNameCP4}}
First or Given Name:	{{firstNameCP4}}
Middle Name(s):	{{middleNameCP4}}

Section 7.2 Current Residential Address*:

Street:	{{street1CP4}}
Postal/Zip Code:	{{postcodeCP4}}
City:	{{cityCP4}}
Country:	{{countryCP4}}

Section 7.3 Mailing address (if different from above):

Street:	{{Mailstreet1CP4}}
Postal/Zip Code:	{{MailpostcodeCP4}}
City:	{{MailcityCP4}}
Country:	{{MailcountryCP4}}

Section 7.{{#if (equalsTo differentMailingAddressCP4 'yes')}}4{{else}}3{{/if}} Place of birth*

Town or city of birth:	{{cityOfBirthCP4}}
Country of birth:	{{countryOfBirthCP4}}
Date of birth:	{{formatDate dateOfBirthCP4}}

Section 7.{{#if (equalsTo differentMailingAddressCP4 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Legal Entity {{increment @index}}:

Section 7.1: Name of Controlling Person*:

Family Name or Surname(s):	{{lastNameCP5}}
First or Given Name:	{{firstNameCP5}}
Middle Name(s):	{{middleNameCP5}}

Section 7.2 Current Residential Address*:

Street:	{{street1CP5}}
Postal/Zip Code:	{{postcodeCP5}}
City:	{{cityCP5}}
Country:	{{countryCP5}}

Section 7.3 Mailing address (if different from above):

Street:	{{Mailstreet1CP5}}
Postal/Zip Code:	{{MailpostcodeCP5}}
City:	{{MailcityCP5}}
Country:	{{MailcountryCP5}}

Section 7.{{#if (equalsTo differentMailingAddressCP5 'yes')}}4{{else}}3{{/if}} Place of birth*

Town or city of birth:	{{cityOfBirthCP5}}
Country of birth:	{{countryOfBirthCP5}}
Date of birth:	{{formatDate dateOfBirthCP5}}

Section 7.{{#if (equalsTo differentMailingAddressCP5 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Legal Entity {{increment @index}}:

Signing log

Personal information of the signer

Device info of the signer

Contract hash

{{verificationKey}}

Foreign Account Tax Compliance Act (“FATCA”) andthe Common Reporting Standard (“CRS”)

PART I: ENTITY SELF-CERTIFICATION FORM FOR FATCA AND CRS Section

Section 1: Account Holder Identification (please refer to the glossary)

Section 2: FATCA Declaration of U.S. Citizenship or U.S. Residence for Tax purposes*:

Section 2: FATCA Declaration Specified U.S. Person:

Section 3: Entity’s FATCA Classification* (the information provided in this section is for FATCA purposes, please note your classification may differ from your CRS classification in Section 5):

3.1 Financial Institutions under FATCA:

3.2 Please provide the Entity’s Global Intermediary Identification Number (GIIN)

3.2 The Entity is a Financial Institution but unable to provide a GIIN

Non-Financial Institutions under FATCA:

Section 3: CRS Declaration of Tax Residence (please note you may choose more than one country) *:

Section 4: CRS Declaration of Tax Residency*

Section 4: Declarations and Undertakings

I declare that:

Section 5: Entity’s CRS Classification* (the information provided in this section is for CRS, please note your CRS classification may differ from your FATCA classification in Section 3)

Section 6: Declarations and Undertakings

I declare that:

PART II: CONTROLLING PERSON SELF-CERTIFICATION FORM FOR FATCA AND CRS

Section 7: Identification of a Controlling Person

No controlling person data has been provided

Section 7.1: Name of Controlling Person*:

Section 7.2 Current Residential Address*:

Section 7.3 Mailing address (if different from above):

Section 7.{{#if (equalsTo differentMailingAddressCP1 'yes')}}4{{else}}3{{/if}} Place of birth*

Section 7.{{#if (equalsTo differentMailingAddressCP1 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Section 7.1: Name of Controlling Person*:

Section 7.2 Current Residential Address*:

Section 7.3 Mailing address (if different from above):

Section 7.{{#if (equalsTo differentMailingAddressCP2 'yes')}}4{{else}}3{{/if}} Place of birth*

Section 7.{{#if (equalsTo differentMailingAddressCP2 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Section 7.1: Name of Controlling Person*:

Section 7.2 Current Residential Address*:

Section 7.3 Mailing address (if different from above):

Section 7.{{#if (equalsTo differentMailingAddressCP3 'yes')}}4{{else}}3{{/if}} Place of birth*

Section 7.{{#if (equalsTo differentMailingAddressCP3 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Section 7.1: Name of Controlling Person*:

Section 7.2 Current Residential Address*:

Section 7.3 Mailing address (if different from above):

Section 7.{{#if (equalsTo differentMailingAddressCP4 'yes')}}4{{else}}3{{/if}} Place of birth*

Section 7.{{#if (equalsTo differentMailingAddressCP4 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Section 7.1: Name of Controlling Person*:

Section 7.2 Current Residential Address*:

Section 7.3 Mailing address (if different from above):

Section 7.{{#if (equalsTo differentMailingAddressCP5 'yes')}}4{{else}}3{{/if}} Place of birth*

Section 7.{{#if (equalsTo differentMailingAddressCP5 'yes')}}5{{else}}4{{/if}} Legal name of the relevant entity Account Holder(s) of which you are a Controlling Person

Foreign Account Tax Compliance Act (“FATCA”) and
the Common Reporting Standard (“CRS”)