Opening an Account For Individuals

Transcription

1 Application Form Opening an Account For Individuals 79 D. Agmashenebeli Ave Tbilisi, Georgia Phone: (32) Fax: (32) [email protected]

2 Important Notice As a professional brokerage institution observing the applicable laws, by-laws, rules, and regulations adopted by state authorities, domestic and international regulatory agencies and professional associations, we are required to protect our client s interests, for which purpose we believe our primary tasks are to understand our clients, the nature of their business, source of funds, and to ensure that we understand fully their investment objectives and specific investment experience. Thus, you certify that all statements made in this Account Opening Application Form (the Application ) and all information, documentary or otherwise, provided to us (the Information ) are complete, true and accurate, and that they are provided upon your initiative. You agree to be fully liable for all such Information, and do not object that the Information collected be also used to confirm your business reputation and solvency according to practices applicable in international securities markets. The Information provided in this Application shall be kept confidential and shall not be disclosed by us to a third party without your consent other than by explicit requirement under the applicable laws. You agree and acknowledge that if required to disclose any such information, we shall, without your additional consent, submit information only to the extent required by the appropriate regulations and only to the person stated in such regulations. Please sign below to confirm your acceptance and agreement to the conditions stated above. Signature This General Information is to be completed by all clients wishing to open a Brokerage Account with us. Please fill out this questionnaire COMPLETELY using clear capital letters. 2

3 PLEASE NOTE! Completion of this Account Opening Application Form does not impose any obligation on us to open a Brokerage/Custody Account for you. This information is necessary for us to accomplish our due diligence in determining whether we may establish an Agency service relationship with you. This form is also proposed to satisfy the demands of U.S. Tax legislation (particularly of Foreign Accounts Tax Compliance Act (FATCA)) and Intergovernmental Agreement (IGA) between Georgia and United States of America. Please fill in ALL the fields I. Identification and Client Information. Part I Account Opening Information Date:, 2014 Name: Registered Address / Place of residence: Mailing Address (if different from Registered Address): Phone Number: Fax Number: URL: Passport/Personal ID Card Details: Number Series Issue Date Issuing Authority Date of Birth Place of Birth Country of Citizenship Country of Tax Residency Taxpayer ID (if any): Georgian Tax ID (if available): Do you currently have any pending litigation in Georgia, or have you ever had litigation, disputed accounts, or unresolved matters with a Georgian or other broker, investment firm, custodian, stock exchange or investment advisor? Yes No If Yes, please provide details Have you, or a firm in which you were a senior officer, ever been convicted of a crime? Yes No If yes, please describe briefly Did you hold a position in any governmental body for during the previous one year? Do any of your immediate family members or close associates hold a position in any governmental body? If yes please provide us with the following details: Name Position Duration 3

4 Did any of your immediate family members or close associates hold a position in any governmental body during the previous year? If yes please provide us with the following details: Name Position Duration II. Authorizations Person(s) authorized to give us trade and transfer orders (if different from the account holder): 1. Name: Phone: Acting as authorized by (please attach duly executed evidence of authorization): 2. Name: Phone: Acting as authorized by (please attach duly executed evidence of authorization): Is there any currently effective power of attorney or signatory authority granted to a person with U.S. legal/actual address? Yes No III. Settlements and Account Information Bank transfer instructions IV. Required KYC Documentation* for Individuals Copy of the information page of your passport or other ID documents containing your photo and signature Information from Bank on availability of the client s Current cash account Copy of the Georgian Taxpayer s Certificate** *Documents should be duly notarized and apostilled. ** If client doesn t have Georgian Taxpayer s ID, Galt & Taggart is required by Georgian Law to withhold from the client capital gain and other applicable taxes upon completion of transaction 4

5 Terms and Conditions 1. If you are citizen and/or tax resident of the U.S., submit the form of Request for Taxpayer identification Number (TIN) and Certification, composed by Internal Revenue Service of the U.S. (see the link or substitute form presented by representative of JSC Galt & Taggart (Form W-9), if Form W-9 is not submitted within 14 calendar days after signing of this form JSC Galt & Taggart shall not be responsible for additional obligations imposed on you under U.S. Tax legislation. In case the circumstances of this paragraph exist, JSC Galt & Taggart will be authorized to present to relevant body information and/or documentation related to you and stored in JSC Galt & Taggart (including personal data, information about brokerage accounts, financial operations etc.) to fulfill obligations under Foreign Accounts Tax Compliance Act (FATCA) and Intergovernmental Agreement (IGA) between Georgia and United States of America. 2. If you are not citizen and/or tax resident of the U.S., but born in the U.S., submit the form of Certificate of Foreign Status of Individuals for United States Tax Withholding and Reporting, composed by Internal Revenue Service of the USA (see the link or substitute form presented by representative of JSC Galt & Taggart (Form W-8BEN) with the corresponding reasonable written explanation (about individual s renunciation of US citizenship or the reason the individual didn t obtain US citizenship at births) or Certificate of Loss of Nationality of the U.S., if documents mentioned in this paragraph are not submitted within 14 calendar days after signing of this form, you will be considered as U.S. tax resident and JSC Galt & Taggart will be authorized to present to relevant body information and/or documentation related to you and stored in JSC Galt & Taggart (including personal data, information about brokerage accounts, financial operations etc.) to fulfill obligations under Foreign Accounts Tax Compliance Act (FATCA) and Intergovernmental Agreement (IGA) between Georgia and United States of America. 3. If you are not citizen and/or tax resident of the U.S., but you have legal/actual address in the U.S. and/or telephone number registered in the U.S. and/or power of attorney or signatory authority is granted to a person with U.S. legal/actual address, submit the Form W-8BEN, if the Form W-8BEN is not submitted within 14 calendar days after signing of this form, you will be considered as U.S. tax resident and JSC Galt & Taggart will be authorized to present to relevant body information and/or documentation related to you and stored in JSC Galt & Taggart (including personal data, information about brokerage accounts, financial operations etc.) to fulfill obligations under Foreign Accounts Tax Compliance Act (FATCA) and Intergovernmental Agreement (IGA) between Georgia and United States of America. 4. Abovementioned Terms and Conditions become affective after the account is opened at JSC Galt & Taggart. Signature By signing this form I certify, that: a) I agree with the terms and conditions presented in the form and declare that information presented by me is true and complete; b) I am responsible to inform JSC Galt & Taggart about any circumstances that may produce changes in the information submitted by me and filled in this form, within 30 calendar days after formation of these circumstances; c) I am ready to collaborate with JSC Galt & Taggart to ensure fulfillment of its obligations under Foreign Account Tax Compliance Act (FATCA) and Intergovernmental Agreement (IGA) between Georgia and United States of America; d) I will indemnify JSC Galt & Taggart from any loss, action, expense or liability which arises or is incurred by JSC Galt & Taggart Georgia under Foreign Account Tax Compliance Act (FATCA) and Intergovernmental Agreement (IGA) between Georgia and United States of America if I don t fulfill my obligations under this form. Name: Signature: Date: 5

6 Consent to Indemnity Customer s General Representations and Warranties. Risk Disclosure Statement The Customer hereby agrees to indemnify us and any of our affiliated entities and subsidiaries, including their directors, officers and managers from any responsibility and reimburse us for any loss or damages for any result that may arise in connection with decisions that may be made based on the Information provided by the Customer, or as a result of the Information being incomplete, untrue and inaccurate. Risk Disclosure Statement The Customer acknowledges that investing in Georgian securities involves certain considerations and a high degree of risk not usually associated with investing in other capital markets. Such risks include, but are not limited to, greater political risks of expropriation, nationalization, confiscatory taxation, and political, social and economic instability, greater likelihood of currency devaluation and more pronounced currency exchange rate fluctuations, certain policies that may restrict profitability of investment opportunities, including without limitation, restrictions on investing in businesses deemed to be sensitive to relevant national interests. Name: Signature: Date: Seal 6