Beneficial Ownership Register Declaration Form

In order to fulfil your Entity’s obligations under the Beneficial Ownership Transparency Act (the “Act”), please complete the relevant sections below by providing the details of the individuals and/or entities (“legal persons”) that should appear on the Entity’s Beneficial Ownership Register (the “Register”), in addition to the Required Particulars for each. Any definitions not found throughout may be found in the Beneficial Ownership Transparency Act or Guidance on Complying With Beneficial Ownership Obligations In The Cayman Islands.

Client Name (the “Entity”)(Required)

Section 1: Beneficial Ownership Register Entry

Please complete the below fields for the Entry that should appear on the Entity’s Register.

The term “Entry” is used below as a general reference to the individual(s) or legal person(s) that you have selected to appear on the Entity’s Register. To determine the Entry, except where the Entity itself is regulated, you must identify an individual or legal person which directly or indirectly owns 25% of the shares or otherwise has control of the Entity that falls into one of the categories listed within the Type of Entry section. Indirect ownership is captured by performing this exercise at each level of the structure until an Entry is found. If, after this analysis is performed, there are no qualifying individuals or legal persons, a senior managing official of the Entity should be chosen. The Act defines the meaning of beneficial owner and can assist with the classification.

Type of Entry:(Required)

Using the dropdown, select the ‘Type of Entry’.

This will be an individual or legal person that falls into one of the following categories: an Individual or Reportable Legal Entity (legal person registered in the Cayman Islands) (together, “Registrable Beneficial Owner”) or a corporate foreign trustee or, if the Entity is itself regulated in the Cayman Islands, or is listed on an approved stock exchange, “Fund Regulated in The Cayman Islands”, “Other Entity Regulated in The Cayman Islands”, “listed on an Approved Stock Exchange” or “Subsidiary of an entity Listed on an Approved Stock Exchange” can be selected, as relevant, as the Entity it qualifies for an Alternative Route to Compliance. If the Entity does not qualify for an Alternate Route to Compliance, and there is no Registrable Beneficial Owner or corporate foreign trustee, an individual must be identified that will be considered under mechanism of control as a Senior Managing Official.

Definitions

Reportable Legal Entityi
a legal person incorporated in Cayman, which, in relation to the Entity, means another legal person, other than a foreign company, foreign entity or a foreign limited partnership, that if it were an individual would be a beneficial owner of the Entity.
Deemed Beneficial Owneri
(a) a corporation sole;
(b) a government or government department of a country or territory or a part of a country or territory;
(c) an international organisation whose members include two or more countries or territories (or their governments); and
(d) a public authority
Approved Stock Exchange i
means a stock exchange listed in Schedule 4 of the Companies Act (2023 Revision)
Subsidiary of a Listed Entityi
a) the listed entity holds seventy-five per cent or more of the shares or voting rights in the subsidiary legal person;
(b) the listed entity exercises ultimate effective control over the subsidiary legal person; or
(c) the listed entity controls the subsidiary legal person by other means.
Registrable Beneficial Owneri
an individual that the legal person identifies pursuant to section 6(2)(a) as a beneficial owner of the legal person; or a reportable legal entity identified pursuant to section 6(2)(b) — that directly holds a relevant interest in the legal person or meets one or more of the specified conditions; or through which any beneficial owner or reportable legal entity indirectly holds a relevant interest in the legal person.

Full Legal Name of the Entry:(Required)

Input the name of the individual or legal person which directly or indirectly owns 25% of the shares or otherwise has control of the Entity identified above. If the Entity is itself regulated in the Cayman Islands, or is listed on an approved stock exchange, the name of the Entity itself should be used in the “Legal Name of the Entry” as it qualifies for an Alternative Route to Compliance.

Mechanism of Control:(Required)

Using the dropdown, select how exactly the individual or legal person owns or controls the entity. When an individual is selected because there is no individual or legal person falling into the categories in the Type of Entry dropdown that owns 25% or more, For corporate trustees, “ultimate effective control” must be selected.

Definitions

Partnership Interesti
means the interest of a partner in a limited partnership, exempted limited partnership or limited liability partnership in respect of profit, capital and voting or other rights, benefits or obligations to which the partner is entitled or subject pursuant to the partnership agreement.
Ultimate Effective Control i
includes ownership or control exercised through a chain of ownership or by means of control other than direct control.
Senior Managing Official i
includes a director or a chief executive officer of the legal person.
Other Meansi
Such as debt instruments or financing arrangements. For example, where a lender or creditor has a contractual right to control a Legal Person via the provisions of a lending agreement (which might include convertible debt instruments that are convertible into voting equity), or by a third party who can otherwise influence a shareholder by financial or relational means such that they have control over a Legal Person. Generally, a regulated lending or credit institution providing financing to a Legal Person will rarely be considered as exercising control for the purposes of the Act as the lender or creditor is unlikely to have ultimate control.

Section 2: Contact Person Information

Please provide information for the Contact Person i

Senior Managing Official (Section 4(4) of the Act) or, in the instance of a regulated private or mutual fund, licensed fund administrator or another contact person licensed or registered under a regulatory law for providing beneficial ownership information located within the Islands (Section 12(4)(c) of the Act). More information on the contact person can be found in Section 8 of the Guidance.

if the “Type of Entry” in Section 1 is one of the following: a Corporate Foreign Trustee; Liquidator/Receiver or a Fund regulated in the Cayman Islands under the Private Funds Act or Mutual Funds Act.

Individual’s Full Legal Name:

Telephone Number

Email Address:

Section 3: Alternate Routes to Compliance

Listed on an Approved Stock Exchange

If the “Type of Entry” in Section 1 is “Listed on an Approved Stock Exchange” or its subsidiary, please complete the following.

Name of Stock Exchange

Jurisdiction of Stock Exchange

Name of Listed Parent Company

Regulated in the Cayman Islands

If the “Type of Entry” in Section 1 is “Fund Regulated in the Cayman Islands” or “Other Entity Regulated in the Cayman Islands”, please complete the following.

Type of License

Section 4: Additional Entries

Each form can accommodate up to 2 additional entries. If you need to add more than 2 entries, please fill out a new form for the extra entries.

i. Are there any additional entries that need to be included in the Entity’s Register?

Yes

Appendix 1

Section 1: Beneficial Ownership Register Entry

Please complete the below for the Registrable Beneficial Owner (individual or Reportable LegalEntity), corporate trustee or the legal person that qualifies for an Alternative Route to Compliance(together, the “Entry”) that should appear on the Entity’s Register:

Type of Entry (select one):

Full Legal Name of the Entry:

Mechanism of Control (select one):

Section 2: Contact Person Information

Please provide information for the Contact Person if the “Type of Entry” in Section 1 is one of the following: a Corporate Foreign Trustee; Liquidator/Receiver or a Fund regulated in the Cayman Islands under the Private Funds Act or Mutual Funds Act. Otherwise, put “N/A”.

Individual’s Full Legal Name:

Email Address:

Section 3: Alternate Routes to Compliance

Listed on an Approved Stock Exchange

If the “Type of Entry” in Section 1 is “Listed on an Approved Stock Exchange” or its subsidiary, please complete the following.

Name of Stock Exchange

Jurisdiction of Stock Exchange

Name of Listed Parent Company

Regulated in the Cayman Islands

If the “Type of Entry” in Section 1 is “Fund Regulated in the Cayman Islands” or “Other Entity Regulated in the Cayman Islands”, please complete the following.

Type of License

ii. Are there any additional entries that need to be included in the Entity’s Register?

Yes

Appendix 1

Section 1: Beneficial Ownership Register Entry

ii. Type of Entry (select one):

ii. Full Legal Name of the Entry:

ii. Mechanism of Control (select one):

Section 2: Contact Person Information

ii. Individual’s Full Legal Name:

ii. Email Address:

Section 3: Alternate Routes to Compliance

Listed on an Approved Stock Exchange

Section 3: Alternate Routes to Compliance (if applicable)

If the “Type of Entry” in Section 1 is “Listed on an Approved Stock Exchange” or its subsidiary, please complete the following. Otherwise, put “N/A”.

ii. Name of Stock Exchange

ii. Jurisdiction of Stock Exchange

ii. Name of Listed Parent Company

Regulated in the Cayman Islands

If the “Type of Entry” in Section 1 is “Fund Regulated in the Cayman Islands” or “Other Entity Regulated in the Cayman Islands”, please complete the following. Otherwise, put “N/A”.

ii. Type of License

Section 5: Required Particulars

Required Particulars are necessary for all Entries. If not already provided, Highvern will request the appropriate supporting documentation, including identification, proof of address, formation documents and/or registers.

What are Required Particulars?

The required particulars of an individual […] are — (a) full legal name; (b) residential address; (c) an address for service of notices under this Act; (d) date of birth; (e) nationality; (f) information from the individual’s unexpired and valid passport, driver’s licence or other government-issued document that identifies the individual including — (i) identification number; (ii) country of issue; and (iii) date of issue and of expiry; (g) nature in which the individual owns or exercises control of the legal person; and (h) the date on which the individual became or ceased to be a registrable beneficial owner in relation to the legal person in question.

The required particulars of [a Deemed Beneficial Owner] are — (a) name; (b) principal office; (c) the legal form of the individual and the law by which the individual is governed; and (d) the date on which the individual became or ceased to be registrable beneficial owner in relation to the legal person in question.

The required particulars of a reportable legal entity are — (a) corporate or firm name; (b) registered or principal office; (c) the legal form of the entity and the law by which it is governed; (d) the nature of the reportable legal entity’s ownership or its exercise of control of the legal person; (e) the register in which it is entered and its registration number in that register; and (f) the date on which it became or ceased to be a registrable beneficial owner in relation to the legal person in question.

Section 6: Declaration

I hereby confirm that this form serves as written confirmation of the Entity’s Registrable Beneficial Owner(s)or Alternative Route to Compliance and corresponding Required Particulars, in accordance with Section 12 of the Act and that:

All of the information contained in this form is accurate and that should there be any change in the information I will inform Highvern immediately;
I agree and acknowledge, on behalf of the Entity, that the Entity will provide Highvern with such additional information, as is required by the Act and/or the Regulations (as applicable) to the extent any Required Particulars in this confirmation ceases to be true, are inaccurate or incomplete, as outlined in the Terms of Business;
Highvern shall be able to rely on the accuracy of the information in this form without further enquiry;
I confirm that accurate, current Required Particulars corresponding to the entries above, will be, or previously have been, provided to Highvern Cayman Limited (“Highvern”)to fulfil the Register obligations of the Entity;
Highvern shall bear no responsibility or liability in relation to any Beneficial Ownership Register created as a result of the information contained in this form;
I acknowledge that there are administrative fines which can be levied against the Entity for submitting false information or failure to provide information, as prescribed in Section 26 of the Act and Schedule 1 of the Monetary Authority Administrative Fines Regulations as amended from time to time;
I hereby agree on behalf of the Entity to hold harmless and fully indemnify Highvern and its directors and officers for any and all loss, expenses, costs (including legal fees) or fines arising out of any misleading, inaccurate or false information supplied to Highvern by or on behalf of the Entity for the purposes of filing the Required Particulars; and
I further confirm that I have read and understand the Privacy Policy.

I hereby instruct Highvern, as the Entity’s registered office, to file the Required Particulars for each Registrable Beneficial Owner or Entity qualifying for Alternative Route to Compliance contained herein with the Competent Authority on behalf of the Entity, in accordance with Section 13 of the Act, in such form and manner as prescribed by the Competent Authority.

The information you provide in response to this form will be processed for the purposes described above, in accordance with the General Data Protection Regulation and/or equivalent Data Protection legislation depending on the relevant jurisdiction. For more information about how we process your data, please see Highvern’s privacy statement which can be found at www.highvern.com/privacy-statement/ Where you are providing information relating to other data subjects, you confirm that you have obtained the necessary informed consent for such disclosure.

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Beneficial Ownership Register Declaration Form