MWI-nbappl-IIO-tc-0814v2 Page 1 of 16 Momentum Wealth International Limited Registered address: La Plaiderie House, La Plaiderie, St Peter Port, Guernsey, Channel Islands, GY1 1WF Registered in Guernsey No. 30830 Postal address: PO Box 166, La Plaiderie House, La Plaiderie, St Peter Port, Guernsey, Channel Islands, GY1 4HE Switchboard +44 (0) 1481 735 480 Facsimile +44 (0) 1481 735 481 www.momentum.co.gg Momentum Wealth International Limited is licensed by the Guernsey Financial Services Commission to conduct Investment Business Momentum Wealth International Limited is an authorised Financial Services Provider pursuant to the Financial Advisory and Intermediary Services Act No. 37 of 2002 in South Africa A member of the MMI Holdings Group MWI01062011 International Investment Option Investment Application Form for Trusts and Companies IMPORTANT: PLEASE COMPLETE ACCURATELY, IN BLACK INK USING BLOCK CAPITAL LETTERS OR TICKING BOXES, WHERE APPROPRIATE. This Application Form should be completed in discussion with your Financial Adviser. Investors are urged to please read the International Investment Option Terms and Conditions and this application prior to signature, as these documents contain the principal terms, conditions and disclosures of the Agreement between yourself and Momentum Wealth International (hereinafter referred to as Momentum). Please ensure that all fields are fully completed, stating ‘none’ or ‘not applicable’ where appropriate. Failure to provide all relevant information and documentation may result in a delay in processing your application. Further information and documentation may be required during the evaluation process (i.e. questions arising from the information and documentation provided). Section 1A - Client details Name of Company Registration number Date of registration or incorporation - - D D M M Y Y Y Y Country of registration or incorporation Registered office address Postal code Country Principal place of business (if different) Postal code Country Contact numbers (code and number) Home C O D E C O D E Office C O D E C O D E Fax C O D E C O D E Mobile C O D E C O D E E-mail Name of Contact person Nature of the business Start date of activity - - D D M M Y Y Y Y Year end date - - D D M M Y Y Y Y Turnover as at latest year end Profit/loss as at latest year end (if a loss, please precede the amount by a minus) Contract number I N
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MWI-nbappl-IIO-tc-0814v2 Page 1 of 16
Momentum Wealth International Limited Registered address: La Plaiderie House, La Plaiderie, St Peter Port, Guernsey, Channel Islands, GY1 1WF Registered in Guernsey No. 30830
Postal address: PO Box 166, La Plaiderie House, La Plaiderie, St Peter Port, Guernsey, Channel Islands, GY1 4HE Switchboard +44 (0) 1481 735 480 Facsimile +44 (0) 1481 735 481 www.momentum.co.gg
Momentum Wealth International Limited is licensed by the Guernsey Financial Services Commission to conduct Investment Business Momentum Wealth International Limited is an authorised Financial Services Provider pursuant to the Financial Advisory and
Intermediary Services Act No. 37 of 2002 in South Africa A member of the MMI Holdings Group
MWI01062011
International Investment Option Investment Application Form for Trusts and CompaniesIMPORTANT: PLEASE COMPLETE ACCURATELY, IN BLACK INK USING BLOCK CAPITAL LETTERS OR TICKING BOXES, WHERE APPROPRIATE.
This Application Form should be completed in discussion with your Financial Adviser. Investors are urged to please read the International Investment Option Terms and Conditions and this application prior to signature, as these documents contain the principal terms, conditions and disclosures of the Agreement between yourself and Momentum Wealth International (hereinafter referred to as Momentum).
Please ensure that all fields are fully completed, stating ‘none’ or ‘not applicable’ where appropriate. Failure to provide all relevant information and documentation may result in a delay in processing your application. Further information and documentation may be required during the evaluation process (i.e. questions arising from the information and documentation provided).
Section 1A - Client details
Name of Company Registration number Date of registration or incorporation - -D D M M Y Y Y Y
Country of registration or incorporation Registered office address
Postal code
Country Principal place of business (if different)
Postal code
Country
Contact numbers (code and number)
Home C O D E C O D E
Office C O D E C O D E
Fax C O D E C O D E
Mobile C O D E C O D E
E-mail
Name of Contact person Nature of the business Start date of activity - -D D M M Y Y Y Y Year end date - -D D M M Y Y Y Y
Turnover as at latest year end
Profit/loss as at latest year end (if a loss, please precede the amount by a minus)
Contract number I N
Contract number I N
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Tax DetailsIn order to enable Momentum to comply with Applicable Law in circumstances when relevant tax authorities may request information, please complete all countries in which you are resident for tax purposes.
Country
and/or
Country
Please provide your Global Intermediary Identification Number (GIIN) as issued by the US Internal Revenue Service.
OR. Not applicable. .
Please make a copy of this section if necessary.
Section 1B - Client details: Trust
Name of Trust Company Or individual Trustees, as applicable
Name of Trust Trust registration number (if applicable) Date of establishment of Trust - -D D M M Y Y Y Y
Country of establishment Purpose/Type of Trust Postal address
Postal code
Country
Contact numbers (code and number)
Home C O D E C O D E
Office C O D E C O D E
Fax C O D E C O D E
Mobile C O D E C O D E
E-mail
Name of Contact person
Tax DetailsIn order to enable Momentum to comply with Applicable Law in circumstances when relevant tax authorities may request information, please complete all countries in which you are resident for tax purposes.
Country
and/or
Country
Please provide your Global Intermediary Identification Number (GIIN) as issued by the US Internal Revenue Service.
OR. Not applicable. .
Please make a copy of this section if necessary.
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Section 2 - Bank details Future payments from Momentum paid to:
Please provide details of the Bank account to which all redemption proceeds will be paid. This must be an account in your name. Any changes to this Bank account should be notified to us in writing by you.
Name of account holder Bank name Branch address
Account number Sort code Swift code- -
IBAN number
Country in which account is held
Section 3 - Investment detailsIs your deposit: Currency Stock/Security transfer Existing Contract transfer
Section 3.1: Investment amount
3.1.1 Currency
Amount to be invested •
Currency of deposit amount GBP EURor or orJPY USD or
or orAUD HKD CHF
Funds emanating from: Compulsory for all proceeds being transferred to Momentum. Please provide details of the Bank account from where your initial investment proceeds will emanate. If this is not an account in your name, Momentum will require verification of identity in respect of the remitter.
Name of account holder Bank name Branch address
Account number Sort code Swift code- -
IBAN number
Country in which account is held
Please note that the minimum initial investment is USD 25,000 (or currency equivalent).
Please note that if you are investing into an IPSP you must ensure that your investment amount is sufficient to meet the Stockbroker’s minimum investment as defined in the Stockbroker Application Form.
Please transfer the amount set out above into the relevant Client Bank account of Momentum quoting the Contract number above as reference. A Bank Instruction form has been prepared for this purpose. Please ask your Financial Adviser for the appropriate Bank Instruction form.
Attach proof of transfer to this Application Form.
The deposit amount referred to above should not be transferred until you have received confirmation from Momentum that this Application Form has been duly accepted and that it is in order to do so.
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3.1.2 Stock transfer (Fund holdings)
Indicate any Funds to be transferred.
Previous Administrator (or indicate if directly held with the manager) Fund name in full Number of
Fund Interests
Stock transfer form attached
(Y/N)
3.1.3 Security Transfer (from existing Stockbroker)
Name of existing Stockbroker Currency
Value of Securities
being transferred
Please liaise with the prospective IPSP Stockbroker in respect of the Security transfer process.
3.1.4 Existing Contract transfer
IN02
Section 3.2: Investment Allocation
Structure of the Portfolio
The Portfolio will be structured initially as follows:-
If your investment is to include an IPSP please select below the IPSP Trading Currency to be used for all investments and redemptions to and from your IPSP. This IPSP Trading Currency will also be used when valuing your IPSP investment (Please note this will not impact upon the currency of your underlying holdings within your IPSP).
AUD CHFor or or or or orEUR GBP HKD JPY USD
Please note that instructions to invest into a new Stockbroker IPSP must be accompanied by the relevant Stockbroker Application Form, duly completed.
Please select the currency of the GBP EURor USD AUDor or Fee Deposit Account
IMPORTANT: If you do not select a currency, a US dollar Fee Deposit Account will be created.
International Investment Option must contain a Fee Deposit Account in order to facilitate the payment of ongoing annual fees. The Fee Deposit Account will be held and maintained in accordance with the provisions contained in the Terms and Conditions. Accordingly 2% of your deposit amount will be placed initially into the Fee Deposit Account.
Investment Allocation details
Please identify the Funds/Strategic Portfolios/Managed Portfolios/IPSP (subject to availability) that you wish to purchase initially by completing the table below: -
Please ensure the investment amount meets the Stockbroker’s minimum investment stated in the Stockbroker Application Form.
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3. Other
Fund Trading Currency Percentage
Cash Account (mandatory minimum allocation 2%) 2%
Total 100%
Please complete the Fund Name in full, including the share class and currency. For Strategic Portfolios or Managed Portfolios an explicit Discretionary Management fee in addition to the underlying Fund management fee is applicable, to a maximum of 0.5% or 1%, respectively.
IMPORTANT: 2% of your deposit amount will be placed in the Fee Deposit Account.
NOTES:1. If you wish to purchase Fund Interests in a Fund that are denominated in a currency that is not the currency of your deposit amount or to invest
in a Strategic Portfolio/Managed Portfolio that is denominated in a currency that is not the currency of your deposit amount, or to invest in an IPSP for which the Trading Currency that is not the currency of your deposit amount, Momentum will have to convert the relevant part of your deposit into the new currency before any Fund Interests/IPSP are purchased on your behalf. In these circumstances, no Fund Interests/IPSP will be purchased until the relevant foreign exchange transaction has completed.
2. The minimum investment in any one Fund is USD 7,500 or currency equivalent. The Funds in the Fund List and the Strategic Portfolios/Managed Portfolios may have different minimum investment levels. Please ask your Financial Adviser for more details. If you wish to invest in a Fund, please review the relevant Fund’s scheme particulars carefully in order to identify the minimum investment level. The minimum investment amount applicable to an IPSP will be stated in the Stockbroker Application Form.
3. Please note that higher minimum investment levels could apply to Funds that are not recognised by the Financial Services Board (FSB). Such Funds may also have additional investor restrictions that are based upon the investment experience of the investor. Please ask your Financial Adviser for more details. If you choose to invest in any Funds that are not recognised by the FSB, please ensure that you have read the scheme particulars of the relevant Fund in order to satisfy yourself that all the requirements for investing in the relevant Fund have been met and that you understand the terms and conditions of investing in such a Fund.
4. Please note that if you select an investment in any Fund that is not a daily dealing Fund, the investment will be subject to the single phase-in arrangements set out in the Terms and Conditions. Therefore the relevant sum will be transferred to a Cash Account and will earn interest as set out in the Terms and Conditions until the relevant investment is complete (unless you have ticked the box at section 3.4 below).
5. Please note that instructions to invest into a new Stockbroker IPSP must be accompanied by the relevant Stockbroker Application Form, duly completed. The investment amount for an IPSP will be subject to the single phase-in arrangement set out in Section 6 of the Terms and Conditions. Therefore the relevant sum will be transferred to a Cash Account and will earn interest as set out in the Terms and Conditions (unless you have ticked the box at section 3.4 below) until the relevant IPSP with the Stockbroker has been opened.
Section 3.3: DistributionsCertain Funds make distributions to their shareholders/unitholders on a regular basis. If you have elected to invest in any Funds that make such distributions, please choose one of the following options by ticking the relevant box in order to instruct Momentum how to deal with these distributions:-
Option 1
Reinvest all distributions in the Funds from which they originate (this option is only available when the Fund Manager offers a reinvesting share class)
Option 2
Pay all distributions to me/us within 15 Business Days of the end of each calendar quarter
Option 3
Pay all distributions into my/our Fee Deposit Account
NOTES:1. If you choose option 1, please note that Tax consequences may arise. Please ask your Financial Adviser for further details.2. If you choose option 2, following receipt every distribution will be transferred as soon as reasonably practicable into a Distribution Account in
the relevant currency. The credit balances in such Distribution Accounts will be held in accordance with the provisions relating to Distribution Accounts that are contained in the Terms and Conditions. All distribution payments (which will be made net of Bank charges) will be made to the Bank account identified at section 2 above (unless Momentum is notified in writing to the contrary). If you have elected to have Funds that make distributions in more than one currency, the credit balances in each of the Distribution Accounts within your Portfolio will be converted into the relevant currency before any distribution payment is made to you.
3. If you choose option 3, following receipt every distribution will be transferred as soon as reasonably practicable into the Fee Deposit Account. The credit balances in the Fee Deposit Account will be held in accordance with the provisions relating to Fee Deposit Accounts that are contained in the Terms and Conditions.
4. All income received in connection with the Securities and cash held within an IPSP will be dealt with in accordance with the terms of the Stockbroker Mandate and not in accordance with the above.
Section 3.4: Special interest instructionsShould you wish your Portfolio to contain a non-interest bearing Fee Deposit Account, non-interest bearing Distribution Account(s) (if appropriate) and non-interest bearing Cash Account(s) (if appropriate), please indicate your instruction by ticking the box below: -
Please ensure that all Cash Account(s) that are to be opened within my/our Portfolio are non-interest bearing accounts.
NOTE: If this box is ticked, every Cash Account within your Portfolio will be non-interest bearing. This provision will prevail, notwithstanding the provisions in the Terms and Conditions to the contrary, until either (a) the termination of your Portfolio (in accordance with the termination provisions that are set out in the Terms and Conditions) or (b) you provide Momentum with written instructions that you wish the accounts in your Portfolio to be interest-bearing.
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Section 3.5: Anticipated activityPlease provide details of the activity (type, volume and frequency of transactions) expected within your Portfolio.
(Kindly note that statements such as “unknown” or “none at present” will be taken to mean that no instructions other than switches are expected and this could therefore result in delays if additional investments or redemption requests are received in the near future.)
Section 4 - Valuation Statement InstructionsValuation Statements will be available to you through the password protected Momentum Wealth International website.
All valuations will show the value of each Fund, IPSP (in the IPSP Trading Currency), Cash Account(s) and Trading Account(s) within the relevant currency. The aggregate valuation of the Portfolio will be shown in USD. You may request valuations to be prepared in an additional currency. Please indicate the preferred reporting currency (if any) from the list below.
GBP EURor or or or or or orJPY USD AUD HKD CHF ZAR
To facilitate your review of the Portfolio’s valuation on-line a username and password will be sent to you by e-mail.
Should you require Valuation Statements to be posted directly to you at your postal address shown in section 1A, please provide a separate written Notice to this effect to Momentum directly. If your Portfolio includes an IPSP then valuation statements relating to the Securities within the IPSP will be made available by the Stockbroker in accordance with the relevant Stockbroker Mandate.
You are advised that the use of the Internet as a form of communication is not yet secure and information transmitted through the Internet as a communication medium may be intercepted and/or read by third parties.
Section 5 - FeesThis fee information should be read in conjunction with the Terms and Conditions.
Any rebate received by Momentum from various Fund Managers and Stockbrokers may, at the discretion of Momentum, be paid back to you, paid to your Financial Adviser or split in any percentage between the two. Please indicate the request for the payment of rebates in the section below. Please also refer to the notes on rebates below.
Rebates payable to Percentage of rebate received
Financial Adviser
Investor
Total 100%
NOTES:1. Momentum will levy an Annual Administration Fee monthly in arrears which will vary according to the fee structure available to your Financial
Adviser, your investment size and investment allocation and your total investments with MMI Guernsey Branch or Momentum. The maximum fee is 1% per annum of (initially) the deposit amount and thereafter of the value of your Portfolio as determined from the valuations available to you on-line on our password protected website. The rate of charge applied to your Portfolio will be shown in your contract note. Momentum may levy a minimum Administration Fee of USD 100 per contract per annum.
2. Transactional Bank Charges will apply to this instruction as defined in the Terms and Conditions and shown on your contract note.3. A fee of USD 5 per month may be charged by Momentum for each Fund position held within the International FundShop segment.4. Your Financial Adviser’s Ongoing Advice fee will also be deducted from your Portfolio at the rate shown above.5. Momentum charges and those of any Financial Adviser referred to in paragraphs 1 and 4 above are in addition to charges levied in respect of
Strategic Portfolios or Managed Portfolios referred to in section 3.2 and all underlying third party and other charges to which your Portfolio may be subject. This includes management or advisory fees, redemption or subscription charges, fees charged by the Stockbroker on your IPSP (if applicable) and all other third party fees, commissions and expenses that may be applied to any of the underlying holding in your Portfolio.
6. Momentum or any of its associated Companies may have directly or indirectly a material interest or relationship of any description with another party which may or may not potentially conflict with its duties to its Clients. For example such material or potential conflicting duties may arise because:(a) a transaction is in relation to or investment for which Momentum or any associated Company may benefit from a commission, fee, mark up
or mark down payable otherwise than by the Client or may also be remunerated or receive rebates by the counterparty to any transaction.(b) Momentum or its associated Companies act as agent for the Client in relation to transactions where it is also acting as agent for the
account of customers and its associates.(c) the transaction is Fund Interests or securities of any Company of which Momentum or its associated Companies may be the manager,
operator, adviser or Trustee.
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(d) Momentum and its associated Companies may receive remuneration or other benefits by reason of acting or corporate finance or similar transactions involving Companies whose securities are held for its Clients.
Neither Momentum nor any of its associated Companies shall be liable to account to any customer for any profits, commissions, rebates, remuneration or other benefit received by reason of such transaction or connected transactions, unless required by Applicable Law and unless otherwise expressly agreed from time to time with any Client by Momentum its fees and charges to the Client shall not be abated thereby.
7. Notwithstanding paragraph 6 above Momentum may (but shall not be obliged) from time to time in its discretion pay or pass on the benefit of some or all benefits it may receive in respect of transactions in relation to Portfolios administered by it. Payments made by Momentum, when made, will be made in its absolute discretion and will be allocated by or amongst Clients according to transaction volumes, administration fees and/or transaction types. Where a rebate applies to your Portfolio for any period this will be shown on the quarterly Valuation Statement.
Annual Administration Fee payment optionsThe Annual Administration Fee will be paid from the Fee Deposit Account in your Portfolio.
Momentum, as soon as there are insufficient Funds in the Portfolio’s Fee Deposit Account to satisfy the annual fees payable from the Portfolio, in accordance with the Terms and Conditions, will redeem the Fee Deposit Percentage of assets in the Portfolio (such assets to be chosen by Momentum in its absolute discretion) and transfer the redemption proceeds to the Portfolio’s Fee Deposit Account.
Section 6 - Authorised signaturesPlease provide a list detailing the name(s) and signature(s) of the person(s) who you have authorised to send instructions in connection with your Portfolio to Momentum (‘the Authorised Signatory List’). If more than one person is so authorised, please ensure that the Authorised Signatory List clearly states the applicable signing arrangements.
NOTE: Momentum shall be entitled to act upon the instructions of the person(s) named on the Authorised Signatory List until you notify Momentum to the contrary.
Section 7 - Declarations and signature(s) of Client(s)7.1 We have seen the International Investment Option Terms and Conditions and have been given the opportunity to ask questions about any
provisions that we did not understand. In particular, We confirm that the fees that are to be levied on the International Investment Option that is to be created pursuant to this Application Form and the manner in which those fees are to be paid has been explained to us.
7.2 We understand that, if this Application Form is accepted by Momentum, we will be bound by the Agreement between us and Momentum, which comprises this Application Form, the International Investment Option Terms and Conditions and the Brochure.
7.3 We hereby authorise and instruct Momentum to arrange the purchase on our behalf of the investments set out in section 3.2 and 3.4 of this Application Form and thereafter to make and realise investments in accordance with the Terms and Conditions (where such investments include a Strategic Portfolio or Managed Portfolio) and to administer our International Investment Option in accordance with the International Investment Option Terms and Conditions.
7.4 We are not, nor are we acting on behalf of a person(s) who is/are either a resident, national or citizen of the United States of America or a US Person within the meaning of the definition of that term contained in Regulation S of the US Securities Act 1933 (as amended), and we further confirm we are not, nor are we acting on behalf of a person(s) who is/are, a resident for Tax purposes, of Guernsey, Alderney or Herm, or any country that is a member of the European Union.
7.5 We hereby undertake to immediately notify Momentum should either we or the person(s) for whom we are acting at any time become a person, resident, national or citizen at variance with our declaration made in section 7.4 above.
7.6 Prospective investors should take proper independent legal advice prior to signing this Application Form, and at all material times after signing this Application Form, if they are uncertain as to their status, residency, nationality or citizenship applicable to their declarations set out in 7.4 and 7.5. Momentum reserves the right to unilaterally terminate this Agreement or alter the benefits payable under it or otherwise amend the Terms and Conditions of the Agreement as deemed appropriate, in the event that a Client pursuant to this application is or becomes a person, resident, national or citizen at variance with our declaration made in section 7.5 above. Momentum may in these circumstances redeem the investment on terms as if the affected Client had instructed Momentum to redeem the investment on a redemption date determined in Momentum discretion, being not later than 30 Days after Momentum became conclusively aware of the changed status of a Client.
7.7 We acknowledge that Momentum has not provided us with any investment advice in connection with the Funds/Strategic Portfolios/Managed Portfolios/International Personal Share Portfolio that we have listed at section 3.2 of this Application Form. We understand that our Financial Adviser and/or we are responsible for selecting the Funds/Strategic Portfolios/Managed Portfolios/International Personal Share Portfolio that Momentum will invest in on our behalf and that Momentum has no liability for the choice, performance, financial soundness or service of the Funds/Strategic Portfolios/Managed Portfolios/International Personal Share Portfolio available to us.
7.8 We hereby confirm that we are aware that, for operational and/or regulatory reasons, Momentum reserves the right to remove any Fund/ Strategic Portfolio/Managed Portfolio/International Personal Share Portfolios offerings from the Fund List without prior notification and at its own discretion.
7.9 We confirm that we are responsible for seeking our own Tax advice on the consequences of investing through the International Investment Option and agree that no responsibility is assumed by Momentum for any Tax related matters.
7.10 We acknowledge that if we are to hold our International Investment Option as Trustee, we confirm that we are satisfied, on the basis of competent legal advice, that we have all the necessary powers to enter into this Agreement between us. We agree that we will notify Momentum of any change in Trustee and, if required by Momentum, will procure that any new Trustee enter into or otherwise become bound by the terms of this Agreement between us incorporating the information contained in this Application Form, the Terms and Conditions and the Brochure.
7.11 We acknowledge that if we are a Company, we confirm that we are satisfied, on the basis of competent legal advice, that we have all the necessary powers to enter into this Agreement between us.
7.12 As part of the verification process that Momentum is required to undertake in order to comply with applicable laws aimed at the prevention of money laundering or otherwise, we agree that Momentum may contact our Bankers as specified in section 3.1. For the avoidance of doubt, we understand that Momentum shall not accept this Application Form until Momentum has completed such verification procedures as it shall consider necessary in accordance with Guernsey regulations, whether relating to the prevention of money laundering or otherwise, and its internal procedures.
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7.13 We hereby authorise Momentum to accept facsimile/e-mail/other electronic instructions regarding our International Investment Option. We hereby accept that in the event that we suffer any loss as a result of Momentum acceptance or interpretation of any instructions sent by facsimile/e-mail/other electronic means coming from or purporting to come from us or our Discretionary Manager or our Financial Adviser, we shall have no claim against Momentum and further that we jointly and severally agree to indemnify Momentum against any claims, demands, proceedings or actions which may be brought against Momentum (by any person, including us) as a result of Momentum acting in accordance with any instruction given by facsimile/e-mail/other electronic means (other than where there is fraud, gross negligence or wilful misconduct on the part of Momentum or its officers or employees) and any liabilities, costs, charges, losses or expenses which may be incurred directly or indirectly by Momentum as a result of Momentum acting in accordance with any instruction given by facsimile/e-mail/other electronic means (other than where there is fraud, gross negligence or wilful misconduct on the part of Momentum or its officers or employees).
7.14 We acknowledge that Momentum may refuse to accept this Application Form without giving reasons and that this Agreement will come into effect as soon as this Application Form has been accepted by Momentum.
7.15 We confirm that all the information provided in this Application Form is, to the best of our knowledge, true, complete and accurate.7.16 We acknowledge that any credit balance in either our Cash Account(s) or our Distribution Accounts(s) may be aggregated with the credit
balances of other Clients of Momentum and the credit balances of any Clients of any Associates of Momentum that have Cash Account(s) and Distribution Account(s) respectively.
7.17 We understand that our Cash Account(s) and Distribution Account(s) shall be held in the name of the Nominee of Momentum.7.18 We confirm that we understand that Momentum Wealth International Limited is licensed by the Guernsey Financial Services Commission to
conduct Investment Business. Momentum Wealth International Limited is situated at La Plaiderie House, La Plaiderie, St Peter Port, Guernsey GY1 1WF. Registered in Guernsey Number 30830. Momentum Wealth International Limited is an authorised financial service provider pursuant to the Financial Advisory and Intermediary Services Act No. 37 of 2002 in South Africa.
7.19 Client money held by the Nominee as appointed by Momentum will be held in accordance with the provisions of the Licensees (Conduct of Business) Rules 2009 of the Bailiwick of Guernsey.
7.20 We acknowledge that all the personal information that either we or our Financial Adviser shall provide to Momentum pursuant to this application (“our Data”) may be processed by and disclosed to Momentum, or any subsidiary Company within the MMI Holdings Group, whether in Guernsey, South Africa, or elsewhere, under mandate, or to any relevant Stockbroker or Fund Manager, in order to enable Momentum to provide and administer the International Investment Option that is to be created pursuant to this Application Form. Similarly our Financial Adviser, and the authorised firm that he/she represents and/or is employed by (if any), shall be entitled to receive the aforesaid personal information unless we otherwise instruct Momentum to the contrary.
7.21 We understand that neither Momentum nor the Nominee or other Associate/Subsidiary shall use our Data to provide us with marketing information about other services and products that are provided by the MMI Holdings Group from time to time.
7.22 We understand that neither Momentum nor the Nominee or other Associate/Subsidiary shall pass on our Data to any other person to provide us with information about their services and products without our prior written approval.
7.23 We acknowledge that Momentum shall be entitled to act upon the instructions of the person(s) named in the Authorised Signatory List until we notify Momentum to the contrary.
7.24 We declare that to the best of my knowledge the Funds/International Personal Share Portfolios that have been promoted to us by our Financial Adviser, whether acting as a Financial Adviser or in the capacity of a Discretionary Manager, may legally be promoted to us under the applicable laws of the jurisdiction where such promotion took place. If this application includes Funds/International Personal Share Portfolios that are not approved for promotion in the jurisdiction where this Application Form is signed, we confirm that we have specifically requested that such Funds/International Personal Share Portfolios be included herein.
7.25 We hereby give my Financial Adviser and the authorised firm that he/she represents and/or is employed by (if any) at the time of this application, the full authority to forward our/your instructions and receive information in connection with our International Investment Option from you or your authorised agents and in the manner referred to in the Important Notice that accompanies this Application Form:
Please select either 7.25.1 or 7.25.2.
7.25.1 either the Financial Adviser, and the authorised firm that he/she represents and/or is employed by (if any) at the time of this application, named in section 8 below has been appointed as our Discretionary Manager in respect of the Portfolio (excluding the underlying investments within the International Personal Share Portfolio), and to the best of my knowledge is authorised by law to act in such capacity.
7.25.2 or the Financial Adviser, and the authorised firm that he/she represents and/or is employed by (if any) at the time of this application, named in section 8 below, has not been appointed as our Discretionary Manager but we have given such Financial Adviser the authority to forward our instructions and receive information in connection with our International Investment Option (in the manner referred to in the Important Notice that accompanies this Application Form).
Authorised Signatory 1 Capacity in which signed Authorised Signatory 2 Capacity in which signed Signed at
Date - -D D M M Y Y Y Y
Signature: Authorised Signatory 1
Signature: Authorised Signatory 2
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Section 8 - Declarations and signature of Financial Adviser8.1 The Client(s) has/have been known to me for years and all necessary due diligence as required by local law has been satisfactorily
undertaken.8.2 I acknowledge that incomplete documentation may, at the discretion of Momentum, be returned and may, also at the discretion of Momentum,
lead to a delay in processing this Application Form and/or to the return of the Clients’ Funds.8.3 In the case of the Client being a Trust, I have ticked the appropriate boxes and supplied relevant information above as confirmation of the
original source of the funds being used for this investment (i.e. the activity that generated the funds).8.4 I confirm that to the best of my knowledge and belief the Client(s) is/are of good standing and the information provided in relation to the source
of the funds is true and complete.8.5 I am unaware of any activities in which the Client(s) is/are involved which lead me to suspect that the Client(s) is/are involved in any criminal
activity and/or money laundering/terrorist financing.8.6 I confirm that there is no secrecy or data protection legislation that would restrict me from providing Momentum or its appointed Nominee with
information concerning the Client(s) freely on request or similarly from providing such information on request to a law enforcement agency of the jurisdiction of Momentum under court order or relevant mutual assistance arrangement.
8.7 I acknowledge that the Client(s) is/are not a resident, national, or citizen of the United States of America and is/are not a US Person (within the meaning of the definition of that term contained in Regulation S of the US Securities Act 1933 (as amended)), nor are they a resident for Tax purposes of Guernsey, Alderney or Herm, or any country that is a member of the European Union.
8.8 I have provided all necessary product information in connection with this Application Form to my Client(s) and have assessed the suitability of all the investments for my Client(s) and have advised my Client(s) accordingly.
8.9 I understand the risks for Clients associated with investing in international Funds and International Personal Share Portfolios and have conducted a thorough investigation on the suitability of these investments for my Client(s).
8.10 I confirm that I have only promoted to my Client(s) investments that I am aware may be lawfully promoted to them in my jurisdiction and I confirm that I am appropriately licensed by the applicable regulatory authorities to provide the financial services contemplated in this Application Form to the Client.
8.11 I confirm that I have complied with my responsibilities contained in the Important Notices.
Source of the Funds settled into the Trust, being used in connection with this investment
This section is to be completed by the Financial Adviser. Please make a copy of this section if necessary.
Savings from Settlor’s Employment Income
Estimated earnings per annum Name of Settlor
Gift and inheritance
Name of Benefactor Name of Beneficiary
Relationship between Benefactor
and Beneficiary
Amount
- -D D M M Y Y Y YDate received
Disposal of a business or sale of a significant asset
Details of business/Significant asset
Name of owner
Relationship between owner of the
business/asset and Settlor Amount of proceeds following disposal - -D D M M Y Y Y YDate of disposal
OTHER - Please provide meaningful details
The information originates from my first hand knowledge of the Client’s circumstances. If this is not the case, please provide details:
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The fee split below applies to both the Initial and Ongoing Advice Fees, for the entire International Investment Option contract.
Name of Financial Adviser Financial Adviser code Intermediary Firm code Advice Fees split %
1.
2.
Signature of Financial Adviser 1 Date D D – M M – 2 0 Y Y
Signature of Financial Adviser 2 Date D D – M M – 2 0 Y Y
NOTES: The original of this Application Form must be forwarded to Momentum Wealth International Limited, La Plaiderie House, La Plaiderie, St Peter Port, Guernsey, Channel Islands GY1 4HE.
Section 9 - Signatures of Momentum
Full name Capacity in which signed on behalf of Momentum Wealth International Limited
Signature Date D D – M M – 2 0 Y Y
For Internal use by Momentum only
Consultant code
Section 10 - Due diligence documentation Either original or suitably certified (as detailed in section 10.3) copies of the following documentation must be provided to Momentum in respect of each Client and Principal.
10.1.: Company• Certificate of incorporation• Board resolution authorising the Investment• Authorised Signatory list• Summary sheet for each Principal*• Evidence of identity and residential address (as detailed in section 10.3) for each Principal*
*A Principal is any of the following parties: Director Authorised Signatory Shareholder holding 25% or more Any other party with effective control
10.2.: Trust10.2.1 Due diligence in relation to the Trustees
• In the case of a Trust Company and if this is your first application with Momentum, please provide the following documentation: Certificate of Incorporation Regulatory approval/licence Authorised Signatory List Summary Sheet for all Directors and Authorised Signatories (see Appendix 1 to the Application Form)
• In the case of individual Trustees, please provide the following documentation in respect of each Trustee: Summary sheet (see Appendix 1 to the Application Form) Evidence of identity and residential address (as detailed in section 10.3).
10.2.2 Due Diligence in relation to a Trust and its Principals*• Trust Deed• Summary Sheet for each Principal*• Evidence of identity and residential address for each Principal (as detailed in section 10.3) – only required if the Trustees are individual Trustees
(i.e. no Trust Company involved)
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* A Principal is any of the following parties: Settlor (initial and subsequent) Protector Beneficiary with a vested interest or likely to benefit from the Trust
10.3.: Acceptable documents10.3.1 Evidence of identity
Either: Current passport; or Current national identity card (excluding UK national identity card)
Evidence of identity must be valid, contain a clear photograph and the full names, date/place of birth, nationality and identification number of the individual.
10.3.2 Evidence of residential addressAny one of the following documents, reflecting the individual’s full permanent residential address and being dated within the last 12 months:
• Utility Bill (telephone bill (but not for a mobile phone); electricity bill; ...)• Local authority Tax bill• Statement from a recognised Bank, building society, credit card Company or other financial services business with whom the individual has an
existing relationship• Written communication addressed to the individual from a financial services business in an equivalent jurisdiction in connection with one of their
products/services purchased by the individual• Extract of the local register of electors• Written confirmation, addressed to Momentum Wealth International, of the individual’s permanent residential address (if you are a regulated
Financial Adviser in an Equivalent Jurisdiction)
IMPORTANT: Evidence of address must contain the individual’s full permanent residential address. Evidence showing only the PO Box address is not sufficient and will not be accepted.
Written confirmations addressed ‘to whom it may concern’ will not be accepted.
10.3.3 Suitable certificationAny one of the following is accepted as a suitable certifier, unless they are an immediate family member of the individual whose document is being certified:
• an official from the embassy, consulate or high commission of the country of issue of the documentary evidence of identity• a lawyer• an officer of the MMI Holdings Group• a member of the judiciary, a senior civil servant, or a serving police or customs officer• a notary public• an actuary• an accountant holding a recognised professional qualification• a Commissioner of Oaths• a director, officer, or manager of a regulated financial services business operating in an equivalent jurisdiction
A suitable certifier must state the following:• confirmation that he/she has seen the original document• confirmation that the photograph contained in the identity document is a true likeness of the individual• full name, capacity and complete contact details• signature and date
Equivalent jurisdictions:For a full and up-to-date list of equivalent jurisdictions please refer to the Guernsey Financial Services Commissions website – www.gfsc.gg – specifically, Appendix C of the ‘Handbook for Financial Services Businesses on Countering Financial Crime and Terrorist Financing’
10.4.: Summary sheets (See Appendix 1) Please indicate the total number of summary sheets attached
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Momentum Wealth International (“Momentum”) important NoticeThis Notice outlines the respective responsibilities of the service providers and Contractual parties to this application.
Trustee(s)/Company director(s)’ responsibilitiesIt is agreed that the Trustee(s)/Company Director(s) will be responsible for:1. Verification of the identity of all parties to the Contract, including the Principals defined in section 10. The Trustee(s)/Company Director(s) agree
to supply Momentum with copies of the underlying documentary evidence of identity covering name, address, nationality, date/place of birth and signature certified by a suitable certifier as defined in section 10.
2. The accuracy of the information provided to Momentum.
Financial Adviser’s responsibilities It is agreed that the introducing Financial Adviser will be responsible for: 1. Advising the Client of the details and features of the endowment and managing the Client’s assets where instructed by the Client to do so.2. Ensuring that the investment is suitable for the Client.3. Communicating investment proposals, Contract schedules, contract notes and the contents of this Notice to Contract Owners.4. Issuing only approved advertisements for investments provided by Momentum, which are fair and not misleading.5. Assessing the Client’s financial standing in the event that a loan is to be granted in relation to the Contract and ensuring that the Client
acknowledges the terms of the loan in writing, if applicable.6. Ensuring that where there is any conflict of interest the Client is advised in writing of the nature of this conflict. *7. Ensuring that the Client is advised of the fee structure and the basis of any charges involved in the Contract.8. Ensuring that advice is not given to execution-only Clients. *9. Ensuring that the Financial Adviser’s staff selling investment products to Clients are competent and suitably trained. *10. Ensuring that procedures are in place to deal with complaints by the Client.* Additional local statutory and regulatory requirements may apply.
Discretionary Manager’s responsibilities (if applicable)If the Client has indicated in this Application Form that he/she wishes to appoint the Financial Adviser and the authorised firm he/she represents as the Discretionary Manager on this Contract then the following provisions shall apply: -1. The Financial Adviser and the authorised firm he/she represents shall have discretion to decide the composition of the Investment Fund
(excluding the underlying investments within the IPSP), in which the Client has invested, and may request changes be made by Momentum to take account of long-term strategic asset allocation or shorter-term tactical asset allocation or otherwise within the terms specified for the Investment Fund between the Client and his/her Financial Adviser and the authorised firm he/she represents. If the composition of a relevant Investment Fund is thereby changed, the Client hereby authorises Momentum to sell or redeem and purchase an IPSP or subscribe for Fund Interests in such Funds as may be required in order to make the relevant Client’s Investment Fund replicate the composition specified by the Discretionary Manager. Otherwise there are no specific restrictions on the proportion of any Investment Fund that may be invested in a particular Fund or IPSP.
2. Without prejudice, Momentum will not be liable to the Client for any cost, loss, liability or expense (including in connection with any Taxation) suffered by the Client in connection with a change to the composition of his/her Investment Fund, unless such cost, loss, liability or expense arises from its gross negligence, wilful default or fraud. Momentum does not give any guarantee or accept any responsibility for the performance of any Fund or IPSP or any Investment Fund as a whole.
3. Only the Client or his/her appointed Authorised Signatory may withdraw monies from the Portfolio by written Notice to Momentum. The Client retains the right to terminate the authorisation of the Financial Adviser and the authorised firm he/she represents to act as the Discretionary Manager on this Contract, at any time, subject to written notification to Momentum.
Momentum’s responsibilities1. All dealing and settlement obligations in respect of the Investment Fund arising from instructions received via the Financial Adviser.2. Executing orders and instructions received via the Financial Adviser on an execution-only basis. Momentum will under no circumstances
provide any investment advice.3. Ensuring that advertisements it issues for the International Investment Option are fair, not misleading and comply with Guernsey
regulatory requirements.4. Disclosure in appropriate documentation of the nature of risks involved.5. Notifying the Financial Adviser of the basis on which services are provided.6. In accordance with the provisions of the attached Application Form, providing the Client and/or the Financial Adviser with a contract note in
connection with each transaction undertaken within the Investment Fund (excluding underlying trades within the IPSP).7. In accordance with the provisions of the Application Form, providing the Client and/or the Financial Adviser with the Valuation Statements.8. Ensuring that all order instructions and investments are dealt with fairly, in due turn and under the Licensees (Conduct of Business) Rules 2009
of the Bailiwick of Guernsey.9. Ensuring that orders from the Financial Adviser will be executed as soon as reasonably practicable and in the best interests of the Client.10. Ensuring that any material interest of Momentum will not affect its fair treatment of its Clients.11. Ensuring that the basis of charges (including those of associates) are disclosed.
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Appendix 1 - Summary sheetsSummary sheet for Principals of Companies and Trusts - Individual
Title Surname First name and other initials Former/Other names (i.e maiden name)
Identification/Passport number Date of birth - -D D M M Y Y Y Y
Nationality Country of birth Permanent residential address
Postal code
Country Occupation (if retired, please state so and provide
details of former occupation)
Any public position currently or previously held (i.e. member of parliament, judge etc. Please provide details of the position and relevant dates)
Declaration of the person completing this summary sheet1. We confirm that this information originates from our first hand knowledge of the Principal’s circumstances. We further confirm that this
information is true, complete and accurate.2. We are unaware of any activities in which the Principal is involved which lead us to suspect that the Principal is involved in any criminal activity
and/or money laundering/terrorist financing. Should we subsequently have or become aware of suspicions of this nature, we shall immediately inform the Compliance Department of MMI Guernsey Branch.
3. We confirm that there is no secrecy or data protection legislation that would restrict us from providing Momentum or its appointed administrator with information concerning the Principal freely on request or similarly from providing such information on request to a law enforcement agency of the jurisdiction of MMI Guernsey Branch under court order or relevant mutual assistance arrangement.
Full name of Signatory 1 Relationship to Client (Trustee, director) Full name of Signatory 2 Relationship to Client (Trustee, director)
Signature: Signatory 1 Signature: Signatory 2
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Appendix 1 - Summary sheetsSummary sheet for Principals of Companies and Trusts - Company
Name Registration number Date of registration or incorporation - -D D M M Y Y Y Y
Country of registration or incorporation Registered office address
Postal code
Country Principal place of business (if different)
Postal code
Country Nature of Company’s business
Declaration of the person completing this summary sheet
1. We have attached a separate summary sheet for the following Principals of the Company:• Directors• Shareholders holding 25% or more• Any other party with effective control
2. We confirm that this information originates from our first hand knowledge of the Principal’s circumstances. We further confirm that this information is true, complete and accurate.
3. We are unaware of any activities in which the Principal is involved which lead us to suspect that the Principal is involved in any criminal activity and/or money laundering/terrorist financing. Should we subsequently have or become aware of suspicions of this nature, we shall immediately inform the Compliance Department of MMI Guernsey Branch.
4. We confirm that there is no secrecy or data protection legislation that would restrict us from providing Momentum or its appointed administrator with information concerning the Principal freely on request or similarly from providing such information on request to a law enforcement agency of the jurisdiction of MMI Guernsey Branch under court order or relevant mutual assistance arrangement.
Full name of Signatory 1 Relationship to Client (Trustee, director) Full name of Signatory 2 Relationship to Client (Trustee, director)
Signature: Signatory 1 Signature: Signatory 2
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Appendix 1 - Summary sheetsSummary sheet for Principals of Companies and Trusts - Trust
Name of Trust Trust registration number (if applicable) Date of establishment of Trust - -D D M M Y Y Y Y
Country of establishment Names of Trust Company or individual Trustees, as applicable
Purpose/Trust of Type
Declaration of the person completing this summary sheet
1. We have attached a separate summary sheet for the following Principals of the Trust:• Trustees (not applicable in the case of a Company acting as Trustee)• Settlors (initial and any subsequent Settlors)• Beneficiaries with a vested interest or likely to benefit from the Trust• Protectors
2. We confirm that this information originates from our first hand knowledge of the Principal’s circumstances. We further confirm that this information is true, complete and accurate.
3. We are unaware of any activities in which the Principal is involved which lead us to suspect that the Principal is involved in any criminal activity and/or money laundering/terrorist financing. Should we subsequently have or become aware of suspicions of this nature, we shall immediately inform the Compliance Department of MMI Guernsey Branch.
4. We confirm that there is no secrecy or data protection legislation that would restrict us from providing Momentum or its appointed administrator with information concerning the Principal freely on request or similarly from providing such information on request to a law enforcement agency of the jurisdiction of MMI Guernsey Branch under court order or relevant mutual assistance arrangement.
Full name of Signatory 1 Relationship to Client (Trustee, director) Full name of Signatory 2 Relationship to Client (Trustee, director)
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