ANNEXE TO THE BUSINESS RELATIONSHIP FORM / LEGAL ETITY

Account No______________

Declaration concerning the Non-US Person/US Person status of the shareholder or beneficial owner

The undersigned 1

-------------------------------------------------------------------------------------------------------------------------------Family name/First name/Company name

The purpose of this declaration is to determine the Non-US Person/US Person status of the shareholder or beneficial owner2 (BO) and
pertains to the business relationship form of the legal entity with which the shareholder or BO is connected.

Declaration concerning Non-US Person /US Person status of the shareholder or BO (natural person)
Please tick the appropriate boxes
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------Family name/First name of the shareholder or BO
(A separate form must be completed for each of the companys shareholders and/or BO)

Is the shareholder or BO a US citizen?

Yes

No

Was the shareholder or BO born in the USA (or in US territory3)?

Yes

No

Does the shareholder or BO have a US passport or identity card?

Yes

No

Does the shareholder or BO have a Green Card (regardless of the expiry date)?

Yes

No

Yes

No

Yes

No

Does the shareholder or BO have a US telephone number?

Yes

No

Does the shareholder or BO have a postal address in the US (including US PO Box)?

Yes

No

Is the shareholder or BO considered to be a tax resident of a European Union country?

Yes

No

Does the shareholder or BO carry out an activity (professional or investment) which generates US-source income?

Yes

No

Does the shareholder or BO declare his/her income to the US tax authorities?

Yes

No

Is the shareholder or BO married?

Yes

No

If Yes,
Is the spouse a US citizen?

Yes

No

(Answer Yes if several nationalities, including US.)

(Does the shareholder or BO have an alien registration card for permanent legal residence issued by the US
Citizenship and Immigration Service [USCIS]?)

Is the shareholder or BO considered to be a US resident under US tax regulations?

(The shareholder or BO is considered to be a US resident if he/she meets the Substantial Physical Presence Test criteria.

The Test is satisfied if, for the year in progress, he/she was physically present in the USA for at least 183 days, as follows:
[number of days during current year x 1]+[number of days in the first preceding year x1/3]+[number of days in the second preceding year x 1/6]=>183 days)

Apart from the Substantial Physical Presence Test above, is the shareholder or BO still resident in the USA?
(If the shareholder or BO left the USA during this calendar year with no intention of returning or satisfying the Substantial Physical Presence Test criteria
for the following year, you should answer No. An up to date certificate of official residence must be provided.)

(Answer Yes if several nationalities, including US.)

The singular includes the plural and the masculine includes the feminine.
Delete as appropriate
3
US: American Samoa, Guam, Guantanamo Bay (Cuba), Northern Mariana Islands, Puerto Rico, Minor outlying islands, US Virgin Islands, Wake Island.
2

Change of status of a Non-US Person

In accordance with amendments made to US tax law, the undersigned undertakes to inform Compagnie Mongasque de Banque
(CMB) immediately of any change in Non-US Person status concerning either the shareholder or the BO. The undersigned also
acknowledges that any failure to inform CMB immediately of any change in status of the shareholder or BO or any false declaration
made in this respect will give CMB justifiable grounds to terminate the entire banking relationship.

Signature

---------------------------------------------Place

-----------------------------------Date

--------------------------------------------------------------Signature

If the shareholder or beneficial owner is a US Person, CMB advises it to consult its tax advisor, in order to ensure full compliance with US
tax declaration and payment requirements.