Schroder Investment Management (Luxembourg) S.A.
Page 1
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
In this Application Form the singular
(“I/my”) includes the plural (“we/our”)
and vice versa.
Unless otherwise stated or as the context
shall otherwise require, defined terms and
expressions used in this Application Form
shall have the meanings ascribed to them
in the Prospectus.
Please complete using black ink, in BLOCK
CAPITALS.
1. Registration Details*
Account registration address is the address
of the first holder.
Important notes :
- All joint investors, legal guardians or representatives must sign this form.
- Please note that all correspondence will be sent to the address of the first joint
account holder.
- The right is reserved to reject any application.
- A certified copy of the relevant identification document(s) should be attached
to this form when required (see Important Terms and Conditions Section 6).
- An original Application Form must be provided for initial investments in the Fund range.
Intermediary number :
Intermediary reference number :
Date and signature of intermediary :
(Authorised signatories)
First holder
Please affix official stamp above.
/ Minor holder **
Mr / Mrs / Ms
Surname
First Name(s) (in full)
Company
(*) Mandatory information to be provided.
Street / No.
(**) If the applicant is a minor or legal
guardian please contact Schroder
Investment Management (Luxembourg) S.A.
Post Code / City
(***) Country of residence : if this is outside
of the European Union, but your current
Passport or Identity Card has been issued
by a State / Territory which applies European
Union Directive 2003 /48 / EC to its residents,
then the Issuer Country will be considered
the Country of Residence – unless a valid
Tax Residency Certificate is provided.
Telephone (daytime)
(****) If you have more than one nationality,
please list all nationalities.
(*****) In some countries, the tax identification
number is replaced by other identification
numbers, such as the social security number.
Country (***)
Telephone (evening)
Fax
E-mail
Date of Birth
Place of Birth
Country of Birth
Nationality(****)
Passport / ID document
Expiry date
Tax ID Number (*****)
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder GAIA AF Private Investor, Version 3, 05_2012
Issued by (country)
Country of taxation
Schroder Investment Management (Luxembourg) S.A.
Page 2
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
Occupation*
(*) Mandatory information to be provided.
Name of Employer
Politically Exposed Persons
If the following is applicable to you, please tick accordingly :
Politically Exposed Person (PEP)
Related /associated to a Politically Exposed Person
Politically Exposed Persons (PEPs) are defined as natural persons who are or
have been entrusted with prominent public functions e.g. Heads of States or of
Governments, senior politicians, senior Government/judicial/military officers, senior
executives of state owned corporations, important political party officials, etc. and
immediate family members or persons known to be close associates, of such persons.
Second holder / Legal guardian or representative (**)
Mr / Mrs / Ms
Surname
First Name(s) (in full)
Street / No.
Post Code / City
Country (***)
Telephone (daytime)
(**) If the applicant is a minor or legal
guardian please contact Schroder
Investment Management (Luxembourg) S.A.
(***) Country of residence : if this is outside
of the European Union, but your current
Passport or Identity Card has been issued
by a State / Territory which applies European
Union Directive 2003 /48 / EC to its residents,
then the Issuer Country will be considered
the Country of Residence – unless a valid
Tax Residency Certificate is provided.
(****) If you have more than one nationality,
please list all nationalities.
(*****) In some countries, the tax identification
number is replaced by other identification
numbers, such as the social security number.
Telephone (evening)
Fax
E-mail
Date of Birth
Place of Birth
Country of Birth
Nationality(****)
Passport / ID document
Issued by (country)
Expiry date
Tax ID Number (*****)
Country of taxation
If there are more than two joint shareholders, minor holders or legal representatives,
the other names should be attached to this form on a separate sheet of
paper with the above information given in full (maximum four holders/persons).
Please note that ALL joint shareholders must sign.
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder Investment Management (Luxembourg) S.A.
Page 3
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
Occupation*
(*) Mandatory information to be provided.
Name of Employer
Politically Exposed Persons
If the following is applicable to you, please tick accordingly :
Politically Exposed Person (PEP)
Related /associated to a Politically Exposed Person
Politically Exposed Persons (PEPs) are defined as natural persons who are or
have been entrusted with prominent public functions e.g. Heads of States or of
Governments, senior politicians, senior Government/judicial/military officers, senior
executives of state owned corporations, important political party officials, etc. and
immediate family members or persons known to be close associates, of such persons.
Account Designation
If a designation is required please specify up to 18 characters.
If an account with identical registration details exists, your investment will
automatically be placed on this account. However, if you wish to open an additional
account a designation is required in order to differentiate between the accounts.
If you are an existing investor, please indicate your account number
If you wish to open a new account, please tick here
Single Signatory Authority (see Important Terms and Conditions).
Joint Signatory Authority (see Important Terms and Conditions).
If no preference is expressed we will assume that only single signatory
authority is required.
2. Origin of Funds*
(*) Mandatory information to be provided.
I declare that the origin of the funds used for subscription is coming from:
(please tick as appropriate)
Salary
Savings
Inheritance
Sale of real estate
Other (please describe)
I confirm that the amounts used to purchase shares were not and are not directly or
indirectly derived from activities that may contravene applicable laws & regulations,
including anti-money laundering laws and regulations.
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder Investment Management (Luxembourg) S.A.
Page 4
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
3. S
ubscription Prerequisites
(Key Investor Information
Document)*
Please make one of the following choices (tick one of the following boxes) :
I wish to be provided with the Key Investor Information Document (“KIID”) in
electronic format by means of Schroders’ website www.schroders.lu/kiid for all of
Schroders’ Luxembourg funds. I understand that Schroder Investment Management
(Luxembourg) S.A. will process my subscription orders on the basis that I have been
provided with the relevant KIID (If you select this option you need not attach a copy
of the KIID to this Application Form or any subsequent subscription order).
(*) Mandatory information to be provided.
or
I wish to be provided with the KIID in paper format. I understand that I must contact
Schroder Investment Management (Luxembourg) S.A. to request each KIID and that
KIIDs may be updated without notice. I understand that my subscription orders may
be delayed or rejected if I do not attach a copy of the most recently published KIID
to my order.
I attach a copy of the KIID for each investment that is described in Section 4, page 5
of this Application Form and I understand that my application may be delayed if I do
not do so.
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder Investment Management (Luxembourg) S.A.
Page 5
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
4. Investment Details
Please refer to the minimum subscription
and top-up subscription amounts stated
in the Prospectus.
I would like to invest in the following Funds and Classes of Schroder GAIA.
Please include details of the payment currency.
ISIN/Sedol/Cusip/Valoren-Nr./WKN
or Name of Fund Class of Shares*
N° of Shares or Investment Amount & Currency
* Please refer to the Important Terms and Conditions, Section 4. Alternatively, please
indicate the relevant ISIN/Sedol/Cusip/Valoren-Nr./WKN for the relevant Share Class.
Details of these codes can be obtained from the Registrar and Transfer Agent. If you
provide a ISIN/Sedol/Cusip/Valoren-Nr./WKN this will prevail.
Fax Authority :
I authorise Schroder Investment Management (Luxembourg) S.A. to act upon instructions
received by fax (see Important Terms and Conditions Section 3).
Yes
No
If no preference is expressed we will assume that fax authority is required.
Valuations :
I would like to receive my valuations in (please tick one box only)
GBP
EUR
JPY
USD
CHF
HKD
Other (please specify)
Please note that dividends (see Important Terms and Conditions Section 5)
will be reinvested unless the following box is ticked.
I would like all dividend payments to be paid to my bank account noted in
Section 6, page 6 Redemptions and Dividend Payments
Please note that if payments to your account (as shown in Section 6, page 6) require
foreign exchange the costs of any foreign exchange transactions will be borne by you
and we take no responsibility for the rate of exchange obtained. You should also be
aware that charges made for foreign exchange may comprise a substantial part of the
income distributed.
(**) Country of residence : if this is outside
of the European Union, but your current
Passport or Identity Card has been issued
by a State/Territory which applies European
Union Directive 2003 /48 / EC
to its residents, then the Issuer Country will
be considered the Country of Residence –
unless a valid Tax Residency Certificate
is provided.
Taxation
Under the provisions of the European Union Directive 2003 /48 / EC on taxation of savings
income in the form of interest payments as implemented in Luxembourg law with effect
from (01/07/2005), a withholding tax might be applied to investments by private investors
who reside in an EU Member State(**). Such tax would, however, not be applicable if the
investor consents to the relevant paying agent providing details of their situation for tax
authorities in the country of residence of the investor (exchange of information). Similarly,
no tax would be levied if the paying agent receives a tax certificate from the investor
evidencing that their investments will be taxed in their country of residence.
If you wish to select the exchange of information option, please tick here If you wish to select the tax certificate option, please tick here and provide a copy
of your tax certificate If no preference is expressed, a withholding tax will be applied, where applicable.
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder Investment Management (Luxembourg) S.A.
Page 6
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
5. Method of Subscription Payment
Please indicate how settlement will be made.
Electronic bank transfer
Bank
Sort code
BIC code
Settlement in cleared funds should be made to Schroder Investment Management
(Luxembourg) S.A. within three business days of your application being placed.
Please note that in respect of certain Funds, different settlement deadlines may apply,
as more fully described in the Prospectus. Please note that Schroder Investment
Management (Luxembourg) S.A. does not accept third party payments.
6. Bank Account Details
a) Redemption Payments
The following details must be given
in order to ensure timely processing
of payments made to you.
Account Name
Account Number
Bank
IBAN Number
Branch Address
Sort code
BIC code
Currency
Intermediary bank (if applicable)
b) Dividend Payments
(if different from 6 (a) above)
Account Name
Account Number
Bank
Please note that Schroder Investment
Management (Luxembourg) S.A. does
not make third party payments.
If this Section is not completed payments
to you may be delayed.
If you would like to provide us with
additional account details for other
currencies, please attach a separate list.
IBAN Number
Branch Address
Sort code
BIC code
Currency
Intermediary bank (if applicable)
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder Investment Management (Luxembourg) S.A.
Page 7
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
7. Signatures & Representations
Please see the Important Terms and
Conditions on the next page.
If you are not acting on your own behalf,
please indicate the name and address
of the ultimate economic beneficiary on
an additional document providing the
same information and documents as
requested for account holders.
Please return to :
Schroder Investment Management
(Luxembourg) S. A.
5, rue Höhenhof
L-1736 Senningerberg
Grand Duchy of Luxembourg
Tel. :(+352) 341 342 202
Fax :(+352) 341 342 344
http://www.schroders.lu
1) I confirm that the Shareholder is the ultimate economic beneficiary of the Shares
being subscribed for.
2) I understand and accept that this application is made on the basis of and subject
to the current Prospectus of Schroder GAIA.
3) I agree to accept Shares to the value applied for, or to such smaller value as may
be allotted, and request that such Shares be registered in the name(s) referred to
in Section 1, page 1 - Registration Details of this form.
4) I declare that I am over 18 years of age.
5) I am not a United States Person as defined in the Prospectus*.
6) I confirm that the payment is coming from an account in my name.
7) I am aware of the risks associated with investments in the Fund.
8) I hereby declare that the information contained in this Application Form is correct
at the time of completion and I hereby undertake to inform the Company of any
change in my details contained herein.
I have read and understood the Terms and Conditions of the Application Form
attached hereafter (the “Important Terms and Conditions”).
Name of first holder or legal representative
Name of second holder
or legal representative
Date
Signature Date
Signature
Name of third holder or legal representative
(*) I declare that I am not a US Person as
defined in the Prospectus and that I am not
applying as the proxy-holder of a person
who is a US Person ; that I have not been
solicited to purchase shares while physically
present within the US ; that at the time
I placed my order to buy shares I was
outside of the US ; that I will not transfer
any of the shares or any interest therein to a
US Person; if my underlying investor status
as a non-US person should change, I will
immediately inform you.
In such event, I agree that the Fund shall
be entitled to (but shall not be obligated to)
repurchase, or to require me to sell my
shares to a person designated by the Fund.
Name of fourth holder
or legal representative
Date
Signature Date
Signature
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder Investment Management (Luxembourg) S.A.
Page 8
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
Important Terms and Conditions
1.Schroder GAIA Schroder GAIA (the “Company”) is registered under Part I of the list of undertakings
for collective investment provided by the Luxembourg Law of 17 December 2010 relating
to undertakings for collective investment. The distribution of the current Prospectus
and the offering of shares of Schroder GAIA may be restricted and accordingly persons
into whose possession the Prospectus may come are required to inform themselves
and observe such restrictions.
2.Single Signatory Authority
If you apply as joint investors and you have chosen “single signatory authority” or did
not express any preference in Section 1, the following Conditions apply :
1.The Company, the Manager or Registrar and Schroder Investment Management
(Luxembourg) S.A. are authorised to act upon instructions given in writing (and, if you
have selected so, by fax) by one of the signatories with regard to the Shares or any
matter in connection with the joint investors.
2.The signature of one signatory will bind all joint investors. Any signatory can instruct
transactions, payments and change payment details, but can neither remove any joint
investor from the account nor modify the registration details of the joint account.
3.Upon the death of any of the signatories, the power granted to each signatory will
remain in force and act on instructions made by any authorised signatory with regard to
transactions and monies, standing to the credit of the joint investors or any other matter
in connection therewith. In this respect, neither Schroder Investment Management
(Luxembourg) S.A., nor the Company or the Investment Manager shall be held liable
for having acted based on the instructions received from one authorised signatory.
4.The single signatory authority shall apply to any further Shares of the Company
purchased, transferred or otherwise held registered in the names of the joint investors.
5.The single signatory authority shall remain in force until the moment Schroder
Investment Management (Luxembourg) S.A. receives a notice in writing from all
signatories confirming the termination of the single signatory authority or instructing the
replacement of the authorised signatories.
6.The single signatory authority shall be construed in accordance with and governed by
the laws of the Grand Duchy of Luxembourg.
7.In signing the Application Form, the joint investors express their consent and agreement
with the above mentioned Conditions.
Joint Signatory Authority If you have chosen “joint signatory authority”, all signatories have to sign any instruction
communicated to the Company, the Manager and Schroder Investment Management
(Luxembourg) S.A.
If a signatory is missing, the instructions communicated will be ignored unless relevant
documentation is provided explaining the reasons for the missing signatory.
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder Investment Management (Luxembourg) S.A.
Page 9
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
3.Fax Authority
The fax authority shall remain in force until notice in writing of its termination is received by
Schroder Investment Management (Luxembourg) S.A.
This fax authority does not apply to notifications of change of name and death, stock
transfers, deeds of pledge and the use of powers of attorney where original documentation
must be sent by post to Schroder Investment Management (Luxembourg) S.A.
4.Class of Shares
Shares are generally issued as Accumulation Shares. Distribution Shares will only be
issued within a Fund at the Directors’ discretion. You must indicate under Class of Shares
(Section 4, page 5) not only if you wish to invest in A, B or C Shares but also if you
would like Accumulation or Distribution Shares i.e. you should write A Accumulation or
A Distribution Shares. If you wish to receive income from your investment (in the form of
dividend payments) you should invest in Distribution Shares. If you do not wish to receive
any income you should invest in Accumulation Shares which capitalise income and
therefore do not pay dividends. If you do not state a preference, Accumulation Shares
will be issued.
5.Dividends
The Board may decide that dividends be automatically reinvested by the purchase of
further Shares. However, no dividends will be distributed if their amount is below EUR 50
or its equivalent. Such amount will automatically be reinvested.
6.Proof of Identity According to applicable laws and regulations on combating money laundering and terrorist
financing, obligations have been imposed on professionals of the financial sector to verify
the identity of shareholders, economic beneficiaries and legal representatives to prevent the
use of Funds for the purpose of money laundering and terrorist financing.
The Application Form must be accompanied at least by the following documents truly
certified by a competent authority in accordance with local laws :
- in the case of individuals a copy of a valid and official document (e.g. passport, identity card)
bearing the owners name, signature, date and place of birth ;
- in case of legal entities, please contact Schroder Investment Management (Luxembourg)
S.A. for the list of required due diligence documentation.
The transfer agent and/or distributor reserve the right to request additional information and
to retain any redemption proceeds if exceptionally the identification process could not be
completed before.
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818
Schroder Investment Management (Luxembourg) S.A.
Page 10
5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - Tel. : (+352) 341 342 202 - Fax : (+352) 341 342 344 - http://www.schroders.lu - RCS Luxembourg : B 37799
Schroder GAIA
Application Form
Luxembourg
Private Investor
7.Data Protection
The personal data in relation to the Holder is required to enable the Company to
fulfil the services required by the Holder, and in particular the services required under this
Application Form, and to comply with its legal and regulatory obligations.
The Holder hereby expressly agrees that the personal data be stored, changed, otherwise
used or disclosed (i) to any other member of the Schroders Group and other parties which
intervene in the process of the business relationship (e.g. external processing centers,
dispatch or payment agents), including companies based in countries where data protection
laws might not exist or be of a lower standard than in the European Union or (ii) when
required by law or regulation (Luxembourg or otherwise).
The Company agrees that it shall not use or disclose personal data to any person other
than as outlined in the preceding paragraph without the Holders consent.
The Company has taken reasonable measures to ensure confidentiality of the personal
data transmitted within each of the relevant entities of the Schroders Group. However the
Holder acknowledges that due to the fact that the information is transferred electronically
and made available outside of Luxembourg, the same level of confidentiality and the
same level of protection in relation to data protection regulation as currently in force in
Luxembourg may not be guaranteed while the information is kept abroad.
The Holder hereby expressly recognises that the Company or any of the relevant entities
of the Schroders Group will accept no liability with respect to any unauthorised third party
receiving knowledge of or having access to such personal data, except in the case of
negligence by the Company, any entities of the Schroders Group or any of its employees
or offices.
The Holder has a right of access and of rectification of the personal data in cases where
such data is incorrect or incomplete.
The personal data shall not be held for longer than necessary with regard to the purpose
of the data processing.
8.Applicable Law
This agreement is subject to the law and jurisdiction of the courts of the Grand Duchy
of Luxembourg.
Schroder GAIA is an open-ended investment company incorporated under the laws of the
Grand Duchy of Luxembourg as a Société d’Investissement à Capital Variable.
Schroder GAIA - 5, rue Höhenhof - L-1736 Senningerberg - Grand Duchy of Luxembourg - RCS Luxembourg : B148818