Fidus Investments Cyprus

Please complete the following form using English alphabet characters only.

1. Account Details

Base currency *Please select base currency

Account Type *Please select Account Type

2. Personal Details (Authorised User)

First Name *Please enter valid First Name

Last Name *Please enter valid Last Name

Father's Name *Please enter valid Father's Name

Mother's Name *Please enter valid Mother's Name

Identity Card/Passport Number *Please enter valid Indentity Card/Passport Number

Expiry Date *Please select expiry date

Issuance Country *Please select Issuance Country

Nationality *Please select Nationality

Date of Birth *Please select date of birth

Country Of Birth *Please select country of birth

Tax Country *Please select tax country

Marital Status *Please enter valid Marital Status

Tax Identification Number *Please enter valid Tax Identification Number

Holder of Green Card (USA) *Please select an option

Do you or any of your family members maintain any other accounts with FIDUS Investments Cyprus Ltd? *Please select an option

Do you or any of your family members or any of your close associates hold or ever held any Political standing? *Please select an option

Do you maintain any other accounts with other Investment Companies? *Please select an option

Occupation/Profession *Please enter valid Occupation/Profession

Name of Employer (if not self-employed) *Please enter valid Name of Employer

Employment Address (including country) *Please enter valid Employment Address

Employer's Line of Business *Please enter valid Employer's Line of Business

Please state the nature of activities generating the net worth if other from your main Occupation/Profession mentioned above. Please provide detailed description and avoid vague or general terms. *Required

Do you preserve investments or properties in the United States? *Please select an option

Do you expect any revenue or profits from the United States? *Please select an option

What is your annual Fixed Income? *Please enter valid What is your annual Fixed Income?

Other Income *Please enter valid Other Income

Immovable Property *Please select an option

Financial Wealth *Please select an option

Please state the anticipated Annual Turnover through Electronic Transfers

In EUR *Please enter valid In EUR

In USD *Please enter valid In USD

Please provide details on the expected Turnover

INCOMINGS

	Country	Name of Sender	Name of Sending Bank
1	*Required	*Required	*Required
2	*Required	*Required	*Required
3	*Required	*Required	*Required

OUTGOINGS

	Country	Name of Beneficiary	Name of Beneficiary Bank
1	*Required	*Required	*Required
2	*Required	*Required	*Required
3	*Required	*Required	*Required

3. Residential Address (Authorised User)

Street Address *Please enter a valid Street

Town *Please enter a valid Town

ZIP *Please enter a valid Town

Country *Please select Country

Is your correspondence address different from the home address?

Street Address *Please enter a valid Street

Town *Please enter a valid Town

ZIP *Please enter a valid Town

Country *Please select Country

4. Contact Details (Authorised User)

Home Phone Number (Optional) *Please enter a valid Phone number

Office Phone Number (Optional) *Please enter a valid phone number

Mobile Number *Please enter a valid Phone number

Email *Please enter a valid email

Fax Number (Optional) *Please enter a valid Fax number

Power of Attorney *Please select an option

5. Product Governance (Authorised User)

Investment Preference

Please select your preferred type of financial instruments *Please select an option

What percentage of your capital investment can you bear to lose? *Please select an option

Please choose the most relevant answer that best describes your risk appetite *Please select an option

What is the time horizon of your investment objectives? *Please select an option

Please state whether you want your investments to consider sustainability factors *Please select an option

6. Self Certification (Authorised User)

INTRODUCTION

Tax Regulations require us to collect certain information about each investor’s tax residency and tax classifications. Tax Regulations as a term, refers to regulations created to enable automatic exchange of information and include Foreign Account Tax Compliance Act (FATCA).
In certain circumstances (including if we do not receive a valid self-certification from you) we may be obliged to share information on your account(s) with the relevant tax authorities.

Neither this form nor any related written or oral statements of FIDUS Investments Cyprus Ltd or any of its employees can be considered as tax advice. FIDUS recommends that clients consult a qualified tax adviser in order to determine their appropriate FATCA Status.

Do you hold either single or multiple nationality including being a US citizen? Notification: If YES to the above, please provide with a copy of the US Passport *Please select an option

Are you holder of an active US Green Card? Clarification: Once activated, a U.S. Green Card remains active for U.S. tax purposes (even if the holder resides outside the U.S. and even if the Green Card itself expires) until either: (1) it is voluntarily returned to the U.S. immigration authorities; or (2) it is administratively or judicially revoked by U.S. immigration authorities or a U.S. federal court. *Please select an option

Country of Residence for Tax Purposes

Additional Countries of Residence for Tax Purposes (if applicable)

	Country	TIN (Tax Identification Number)
1	*Required	*Required
2	*Required	*Required
3	*Required	*Required

Substantial Presence Test
Have you been physically present in the U.S. on at least 31 days during the current year, and 183 days during the 3-year period that includes the current year and the 2 years immediately before? For further definitions please consult the IRS website: http://www.irs.gov/taxtopics/tc851.html *Please select an option

Declarant's Authorizations, Undertakings and Declarations

I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete.
I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect or incomplete.
I authorise the recipient of this form to provide, directly or indirectly, to any relevant tax authority or any party authorised to conduct an audit or other similar review of the recipient for tax purposes.
I acknowledge and agree that information contained on this form may be reported to any relevant tax authority.

Please choose one of the below two declarations:

I am a "Specified U.S. Person"

I am not a "Specified U.S. Person"

If you declare that you are a "Specified U.S. Person" you should provide a complete W-9 IRS Form *Please select an option

7. Personal Details (2nd Person)