PLEASE COMPLETE THE BELOW INFORMATION
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Please note that the information provided in this form will be used to complete the Subscription Form, Investor Declaration and FATCA CRS Form (hereinafter ‘Sub-Documents’) for Quadrum Investment Fund IV Coöperatief U.A. By filling in this form, you acknowledge and accept that the information you have provided will be transferred to the Sub-Documents directly without the need for further input. As you answer the questions, additional questions will appear in the form. Please ensure you complete all questions marked with a red asterisk (*).
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Set","input":false,"tableView":false,"components":[{"html":"Please read the instructions below carefully before continuing with the form.
PLEASE NOTE: The below sections require some knowledge of terms used for classifications under FATCA and CRS. Please refer to the glossary below for detailed descriptions of the terms.
","label":"Content","refreshOnChange":false,"key":"content8","type":"content","input":false,"tableView":false,"placeholder":"","prefix":"","customClass":"","suffix":"","multiple":false,"defaultValue":null,"protected":false,"unique":false,"persistent":true,"hidden":false,"clearOnHide":true,"refreshOn":"","redrawOn":"","modalEdit":false,"dataGridLabel":false,"labelPosition":"top","description":"","errorLabel":"","tooltip":"","hideLabel":false,"tabindex":"","disabled":false,"autofocus":false,"dbIndex":false,"customDefaultValue":"","calculateValue":"","calculateServer":false,"widget":null,"attributes":{},"validateOn":"change","validate":{"required":false,"custom":"","customPrivate":false,"strictDateValidation":false,"multiple":false,"unique":false},"conditional":{"show":null,"when":null,"eq":""},"overlay":{"style":"","left":"","top":"","width":"","height":""},"allowCalculateOverride":false,"encrypted":false,"showCharCount":false,"showWordCount":false,"properties":{},"allowMultipleMasks":false,"id":"ejn1qg"},{"title":"Instructions for completion","collapsible":true,"key":"instructionsForCompletion","type":"panel","label":"Panel","input":false,"tableView":false,"components":[{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"\r\n \r\n
\r\n\r\n In the framework of the Foreign Account Tax Compliance Act (“FATCA”) and\r\n the Common Reporting Standard (“CRS”), we are required to collect and\r\n report to the competent national tax authority certain information about\r\n financial accounts held by some of our Account Holders, and more\r\n specifically where an Account Holder or its beneficial owner(s) fall(s)\r\n under the definition of a U.S. Person, or has a tax residence outside of\r\n the country in which the financial accounts are held.\r\n
\r\n\r\n The information provided on these Forms as well as other financial\r\n information (e.g., the year-end depositary account balance, the total gross\r\n dividend amount received during the calendar year) may be reported on an\r\n annual basis to the competent national tax authority for transmission to\r\n the competent foreign tax authorities.\r\n
\r\n\r\n For joint or multiple Account Holders, please complete a separate\r\n Self-Certification Form for each Account Holder.\r\n
\r\n\r\n If you are completing the Self-Certification Form on behalf of the Account\r\n Holder(s), then you should indicate the capacity in which you have signed\r\n in Section VI. For example, you may be the custodian or nominee of an\r\n account on behalf of the account holder, or you may be completing the\r\n Self-Certification Form under a signatory authority or power of attorney.\r\n
\r\n\r\n If you have any questions about this Self-Certification Form or defining\r\n your FATCA or CRS status, please speak to your tax adviser or local tax\r\n authority.\r\n
\r\n\r\n For further information on CRS please refer to the OECD automatic exchange\r\n of information portal:\r\n \r\n www.oecd.org/tax/automatic-exchange\r\n \r\n
","refreshOnChange":false,"key":"html1","type":"htmlelement","input":false,"tableView":false,"placeholder":"","prefix":"","customClass":"","suffix":"","multiple":false,"defaultValue":null,"protected":false,"unique":false,"persistent":false,"hidden":false,"clearOnHide":true,"refreshOn":"","redrawOn":"","modalEdit":false,"dataGridLabel":false,"labelPosition":"top","description":"","errorLabel":"","tooltip":"","hideLabel":false,"tabindex":"","disabled":false,"autofocus":false,"dbIndex":false,"customDefaultValue":"","calculateValue":"","calculateServer":false,"widget":null,"attributes":{},"validateOn":"change","validate":{"required":false,"custom":"","customPrivate":false,"strictDateValidation":false,"multiple":false,"unique":false},"conditional":{"show":null,"when":null,"eq":""},"overlay":{"style":"","left":"","top":"","width":"","height":""},"allowCalculateOverride":false,"encrypted":false,"showCharCount":false,"showWordCount":false,"properties":{},"allowMultipleMasks":false,"tag":"p","id":"etf8hfr"}],"collapsed":true,"placeholder":"","prefix":"","customClass":"","suffix":"","multiple":false,"defaultValue":null,"protected":false,"unique":false,"persistent":false,"hidden":false,"clearOnHide":false,"refreshOn":"","redrawOn":"","modalEdit":false,"dataGridLabel":false,"labelPosition":"top","description":"","errorLabel":"","tooltip":"","hideLabel":false,"tabindex":"","disabled":false,"autofocus":false,"dbIndex":false,"customDefaultValue":"","calculateValue":"","calculateServer":false,"widget":null,"attributes":{},"validateOn":"change","validate":{"required":false,"custom":"","customPrivate":false,"strictDateValidation":false,"multiple":false,"unique":false},"conditional":{"show":null,"when":null,"eq":""},"overlay":{"style":"","left":"","top":"","width":"","height":""},"allowCalculateOverride":false,"encrypted":false,"showCharCount":false,"showWordCount":false,"properties":{},"allowMultipleMasks":false,"tree":false,"theme":"default","breadcrumb":"default","id":"earamk0i"},{"title":"Glossary of terms","collapsible":true,"key":"glossaryOfTerms","type":"panel","label":"Panel","input":false,"tableView":false,"components":[{"label":"HTML","attrs":[{"attr":"","value":""}],"content":"\r\n \r\n
\r\n\r\n Note: \r\n \r\n These are selected definitions provided to assist you with the\r\n completion of this Self-Certification Form.Further details can be\r\n found in the Directive 2014/107/EU of 9 December 2014 “as regards\r\n mandatory automatic exchange of information” and in the OECD\r\n Standard for Automatic Exchange of Financial Account Information\r\n (“OECD Common Reporting Standard, CRS”).\r\n \r\n
\r\n\r\n \r\n
\r\n\r\n The “Account Holder” in [X] is the person listed or identified as the\r\n holder of the Debt or Equity Interest in [X]. This is regardless of\r\n whether such person is a flow-through Entity.\r\n
\r\n\r\n A person, other than a Financial Institution, holding a Debt or Equity\r\n Interest in [X] for the benefit or account of another person as agent,\r\n custodian, nominee, signatory, investment advisor, or intermediary, is\r\n not treated as holding the account, and such other person is treated as\r\n holding the account.\r\n
\r\n\r\n An entity will be classified as Active NFE if it meets any of the\r\n following criteria:\r\n
\r\n\r\n A. less than 50% of the NFE’s gross income for the preceding calendar\r\n year or other appropriate reporting period is passive income and less\r\n than 50% of the assets held by the NFE during the preceding calendar\r\n year or other appropriate reporting period are assets that produce or\r\n are held for the production of passive income;\r\n
\r\n\r\n B. the stock of the NFE is regularly traded on an established\r\n securities market or the NFE is a Related Entity of an Entity the stock\r\n of which is regularly traded on an established security market;\r\n
\r\n\r\n C. the NFE is a Governmental Entity, an International Organisation, a\r\n Central Bank, or an Entity wholly owned by one or more of the\r\n foregoing;\r\n
\r\n\r\n D. substantially all of the activities of the NFE consist of holding\r\n (in whole or in part) the outstanding stock of, or providing financing\r\n and services to, one or more subsidiaries that engage in trades or\r\n businesses other than the business of a Financial Institution, except\r\n that an Entity does not qualify for this status if the Entity functions\r\n (or holds itself out) as an investment fund, such as a private equity\r\n fund, venture capital fund, leveraged buyout fund, or any investment\r\n vehicle whose purpose is to acquire or fund companies and then hold\r\n interests in those companies as capital assets for investment purposes;\r\n
\r\n\r\n E. the NFE is not yet operating a business and has no prior operating\r\n history, (a “start-up NFE”) but is investing capital into assets with\r\n the intent to operate a business other than that of a Financial\r\n Institution, provided that the NFE does not qualify for this exception\r\n after the date that is 24 months after the date of the initial\r\n organisation of the NFE;\r\n
\r\n\r\n F. the NFE was not a Financial Institution in the past five years and\r\n is in the process of liquidating its assets or is reorganising with the\r\n intent to continue or recommence operations in a business other than\r\n that of a Financial Institution;\r\n
\r\n\r\n G. the NFE primarily engages in financing and hedging transactions\r\n with, or for, Related Entities that are not Financial Institutions, and\r\n does not provide financing or hedging services to any Entity that is\r\n not a Related Entity, provided that the group of any such Related\r\n Entities is primarily engaged in a business other than that of a\r\n Financial Institution; or\r\n
\r\n\r\n H. the NFE meets all of the following requirements (a “non-profit\r\n NFE”):\r\n
\r\n\r\n i. it is established and operated in its jurisdiction of residence\r\n exclusively for religious, charitable, scientific, artistic, cultural,\r\n athletic, or educational purposes; or it is established and operated\r\n inits jurisdiction of residence, and it is a professional organisation,\r\n business league, chamber of commerce, labour organisation, agricultural\r\n or horticultural organisation, civic league or an organisation operated\r\n exclusively for the promotion of social welfare;\r\n
\r\n\r\n ii. it is exempt from income tax in its jurisdiction of residence;\r\n
\r\n\r\n iii. it has no shareholders or members who have a proprietary or\r\n beneficial interest in its income or assets;\r\n
\r\n\r\n iv. the applicable laws of the NFE’s jurisdiction of residence or the\r\n NFE’s formation documents do not permit any income or assets of the NFE\r\n to be distributed to, or applied for the benefit of, a private person\r\n or non-charitable Entity other than pursuant to the conduct of the\r\n NFE’s charitable activities, or as payment of reasonable compensation\r\n for services rendered, or as payment representing the fair market value\r\n of property which the NFE has purchased; and\r\n
\r\n\r\n v. the applicable laws of the NFE’s jurisdiction of residence or the\r\n NFE’s formation documents require that, upon the NFE’s liquidation or\r\n dissolution, all of its assets be distributed to a Governmental Entity\r\n or other non-profit organisation, or escheat to the government of the\r\n NFE’s jurisdiction of residence or any political subdivision.\r\n
\r\n\r\n The definition of an Active NFFE is similar to the definition of an\r\n Active NFE. Certain U.S. (organized) entities are excluded from the\r\n definition of an Active NFFE. Please refer to the applicable provisions\r\n for the differences.\r\n
\r\n\r\n “Control” over an Entity is generally exercised by the natural\r\n person(s) who ultimately has a controlling ownership interest\r\n (typically on the basis of a certain percentage (e.g., 25%)) in the\r\n Entity. Where no natural person(s) exercises control through ownership\r\n interests, the Controlling Person(s) of the Entity will be the natural\r\n person(s) who exercises control of the Entity through other means.\r\n Where no natural person(s) is/are identified as exercising control of\r\n the Entity through ownership interests, then under the CRS the\r\n Reportable Person is deemed to be the natural person who hold the\r\n position of senior managing official.\r\n
\r\n\r\n “Controlling Persons” are the natural person(s) who exercise control\r\n over an entity. Where that entity is treated as a Passive Non-Financial\r\n Entity (“Passive NFE”) then a Financial Institution is required to\r\n determine whether or not these Controlling Persons are Reportable\r\n Persons. This definition corresponds to the term “beneficial owner”\r\n described in Recommendation 10 of the Financial Action Task Force\r\n Recommendations (as adopted in February 2012).\r\n
\r\n\r\n In the case of a trust, the Controlling Person(s) are the settlor(s),\r\n the trustee(s), the protector(s) (if any), the beneficiary(ies) or\r\n class(es) of beneficiaries, or any other natural person(s) exercising\r\n ultimate effective control over the trust (including through a chain of\r\n control or ownership). Under the CRS the settlor(s), the trustee(s),\r\n the protector(s) (if any), and the beneficiary(ies) or class(es) of\r\n beneficiaries, are always treated as Controlling Persons of a trust,\r\n regardless of whether or not any of them exercises control over the\r\n activities ofthe trust.\r\n
\r\n\r\n Where the settlor(s) of a trust is an Entity then the CRS requires\r\n Financial Institutions to also identify the Controlling Persons of the\r\n settlor(s) and when required report them as Controlling Persons of the\r\n trust.\r\n
\r\n\r\n In the case of a legal arrangement other than a trust, “Controlling\r\n Person(s) means persons in equivalent or similar positions.\r\n
\r\n\r\n The term “Financial Institution” means a “Custodial Institution”, a\r\n “Depository Institution”, an “Investment Entity”, or a “Specified\r\n Insurance Company”. Please see the relevant domestic guidance and the\r\n CRS for further classification definitions that apply to Financial\r\n Institutions.\r\n
\r\n\r\n The term “Investment Entity” includes two types of Entities:\r\n
\r\n\r\n i. an Entity that primarily conducts as a business one or more of the\r\n following activities or operations for or on behalf of a customer:\r\n
\r\n\r\n ii. trading in money market instruments (cheques, bills, certificates\r\n of deposit, derivatives, etc.); foreign exchange; exchange, interest\r\n rate and index instruments; transferable securities; or commodity\r\n futures trading;\r\n
\r\n\r\n • individual and collective portfolio management; or\r\n
\r\n\r\n • otherwise investing, administering, or managing Financial Assets or\r\n money on behalf of other persons. Such activities or operations do not\r\n include rendering non-binding investment advice to a customer.\r\n
\r\n\r\n iii. The second type of “Investment Entity” (“Investment Entity managed\r\n by another Financial Institution”\r\n
\r\n\r\n – as defined under §A(6)(b) of Section VIII of the CRS) is any Entity\r\n the gross income of which is primarily attributable to investing,\r\n reinvesting, or trading in Financial Assets where the Entity is managed\r\n by another Entity that is a Depository Institution, a Custodial\r\n Institution, a Specified Insurance Company, or the first type of\r\n Investment Entity.\r\n
\r\n\r\n An Entity is “managed by” another Entity if the managing Entity\r\n performs, either directly or through another service provider on behalf\r\n of the managed Entity, any of the activities or operations described in\r\n clause (i) above in the definition of ‘Investment Entity’.\r\n
\r\n\r\n An Entity only manages another Entity if it has discretionary authority\r\n to manage the other Entity’s assets (either in whole or part).\r\n
\r\n\r\n An “NFE” is any Entity that is not a Financial Institution.\r\n
\r\n\r\n A “Non-Participating Jurisdiction” means a jurisdiction with which no\r\n agreement is in place pursuant to which it will provide the information\r\n set out in the CRS.\r\n
\r\n\r\n The term “Participating Jurisdiction Financial Institution means (i)\r\n any Financial Institution that is tax resident in a Participating\r\n Jurisdiction but excludes any branch of that Financial Institution that\r\n is located outside of that jurisdiction, and (ii) any branch of a\r\n Financial Institution that is not tax resident in a Participating\r\n Jurisdiction, if that branch is located in such Participating\r\n Jurisdiction.\r\n
\r\n\r\n Under the CRS a “Passive NFE” means any: (i) NFE that is not an Active\r\n NFE; and (ii) Investment Entity asdefined under §A(6)(b) of Section\r\n VIII of the CRS resident in a Non-Participating Jurisdiction.\r\n
\r\n\r\n A Passive NFFE is any entity that does not classify as:\r\n
\r\n\r\n i. a financial institution; and\r\n
\r\n\r\n ii. an Active NFFE\r\n
\r\n\r\n This definition can slightly differ from jurisdiction to jurisdiction.\r\n You may want to seek independent professional advice if you are not\r\n sure whether you qualify as a Passive NFFE under FATCA.\r\n
\r\n\r\n An Entity is a “Related Entity” of another Entity if either Entity\r\n controls the other Entity, or the two Entities are under common\r\n control. For this purpose, control includes direct or indirect\r\n ownership of more than 50% of the vote and value in an Entity.\r\n
\r\n\r\n Generally, an Entity will be resident for tax purposes in a\r\n jurisdiction if, under the laws of that jurisdiction (including tax\r\n conventions), it pays or should be paying tax therein by reason of his\r\n domicile, residence, placeof management or incorporation, or any other\r\n criterion of a similar nature, and not only from sources in that\r\n jurisdiction. Dual resident Entities may rely on the tiebreaker rules\r\n contained in tax conventions (if applicable)to solve cases of double\r\n residence for determining their residence for tax purposes. An Entity\r\n such as a partnership, limited liability partnership or similar legal\r\n arrangement that has no residence for tax purposes shall be treated as\r\n resident in the jurisdiction in which its place of effective management\r\n is situated. A trust is treated as resident where one or more of its\r\n trustees is resident.\r\n
\r\n\r\n The term “TIN” means Taxpayer Identification Number or a functional\r\n equivalent in the absence of a TIN. A TIN is a unique combination of\r\n letters or numbers assigned by a jurisdiction to an individual or an\r\n Entity and used to identify the individual or Entity for the purposes\r\n of administering the tax laws of such jurisdiction.\r\n
\r\n\r\n Some jurisdictions do not issue a TIN. However, these jurisdictions\r\n often utilise some other high integrity number with an equivalent level\r\n of identification (a “functional equivalent”). Examples of that type of\r\n number include, for Entities, a Business/ company registration\r\n code/number.\r\n
\r\n\r\n The term ‘‘United States person’’ under FATCA means:\r\n
\r\n\r\n • a citizen or resident of the United States;\r\n
\r\n\r\n • a domestic partnership (partnership organized in the US);\r\n
\r\n\r\n • a domestic corporation (corporation incorporated in the US);\r\n
\r\n\r\n • any estate other than a foreign estate;\r\n
\r\n\r\n • any trust if: a court within the United States is able to exercise\r\n primary supervision over the administration of the trust, and one or\r\n more United States persons have the authority to control all\r\n substantial decisions of the trust;\r\n
\r\n\r\n • the United States government, a State or the District of Columbia\r\n (including any agency, instrumentality or political subdivision\r\n thereof).\r\n
\r\n\r\n A client could be considered a US resident for tax purposes by virtue\r\n of the time spent in the US according to the substantial presence test.\r\n The test must be applied each year that the individual is in the US.\r\n
\r\n\r\n • Students (F1,OPT, J1, Q Visas) are considered Non Resident Aliens for\r\n up to five years, and are exempted from the Substantial Presence Test\r\n for a period of five years.\r\n
\r\n\r\n • Teacher, Researchers (J1, Q Visas) are considered Non Resident Aliens\r\n for up to two years, and are exempted from the Substantial Presence\r\n Test for a period of two years.\r\n
\r\n\r\n • For the other H1B, L1, and other Visa holders.\r\n
\r\n\r\n To meet the Substantial Presence Test, a foreign person must:\r\n
\r\n\r\n • be physically present in the US for at least 31 days during the current\r\n year; and\r\n
\r\n\r\n • be physically present 183 days during the 3 year period that includes the\r\n current year and the 2 years immediately before that, counting: (i) All the\r\n days the individual was present in the current year, and (ii) 1/3 of the\r\n days the individual was present in the year before the current year, and\r\n (iii) 1/6 of the days the individual was present in the year before last;\r\n
\r\n\r\n • F and J student visa holders are to exclude 5 calendar years of presence\r\n for purposes of the substantial presence test. J non-student visa holders\r\n are to exclude 2 years.\r\n
\r\n\r\n The term “United States Citizen” means:\r\n
\r\n\r\n • an individual born in the United States;\r\n
\r\n\r\n • an individual whose parent is a U.S. citizen;\r\n
\r\n\r\n • a former alien who has been naturalized as a U.S. citizen;\r\n
\r\n\r\n • an individual born in Puerto Rico;\r\n
\r\n\r\n • an individual born in Guam; or\r\n
\r\n\r\n • an individual born in the U.S. Virgin Islands.\r\n
\r\n\r\n A USP that is in scope for FATCA Reporting. Broadly speaking, can include\r\n any US individual (e.g. US citizen, resident, green card holder, etc.)\r\n and/or US entity (e.g. US corporation, partnership, etc.).\r\n
\r\n\r\n The term ‘Non-United States person’ means all clients that do not fall\r\n under the formal definition of ‘‘United States person’’ under FATCA.\r\n
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