SUBSCRIPTION FORM
Company
How to open an account for a company with Keytrade Bank Luxembourg S.A.
COMPLETE AND SIGN...
The subscription form and add the following documents:
• A copy of an up-to-date official statutes + annexes
• A list of authorized signatures or a certificate from the last board of directors given power – and in which degree - to the authorized persons to
engage the company.
• A recent certificate of the trade register (< 3 months).
• A report of the board of directors in which it was decided to open an account and to authorize the person(s) (= the representative(s)) to open and
manage the account in name of and for the account of the company.
• A declaration of the beneficial owner(s).
• A certified copy of the identity card (or passport) from the administrators, the beneficial owner(s) and the representative(s). If the persons cannot
come to our offices, the copy(ies) need(s) to be certified by an authorized public authority (e.g., Town Hall, Police Office, …) or another financial
institution falling under the European law.
• A copy of shareholder’s register
• A copy of the convention of domiciliation (only for the foreign companies establishing a head office with a third party
• Proof of the Tax Identification Number (TIN)
After approval of your account opening request, you will receive your access codes to Keytrade Bank Luxembourg S.A.’s (‘the Bank’) secured web site.
CREDIT THE ACCOUNT
By Cash : (only in EUR) by a cash deposit in our offices. Please note that the evidence of the origin of the fund dating less than one
month is mandatory for any deposit superior to 10.000 EUR
By a bank transfer: on one of these accounts
By shares transfer: For any security transfer,please contact us.
1 -Account in EUR
Banque de Luxembourg, swift BLUXLULLXXX
On the account n° LU82 0081 3337 6300 1003 Keytrade Bank Luxembourg S.A.
Communication : account number + name
2 - Account in USD
Banque de Luxembourg, swift BLUXLULLXXX
On the account n° LU50 0081 3337 6300 2840 Keytrade Bank Luxembourg S.A.
Communication : account number + name
For all questions: (+352) 45 04 39 or [email protected]
FOR BANK USE ONLY:
Approuved by ...................................................................................................................
Post
Office
Date ...................................................................................................................................
Account number .................................................................................................................
Signature: ............................................................................................................................................
12/ 2016
Saving account nr ................................................................................................................
2.
TYPE OF COMPANY AND DENOMINATION complete in capital letters
Denomination ...............................................................................................................................................................................................................................................
Type of company ............................................................................................................. Tax identification number* .......................................................................
Nationality ......................................................................................................................................................................................................................................................
Sector of activity ..........................................................................................................................................................................................................................................
Activity description ......................................................................................................................................................................................................................................
Domiciliataire ................................................................................................................................................................................................................................................
Capital ............................................................................................................ Trade register ....................................................................................................................
VAT nr ....................................................................................................................................... Formation date ................................................................................................
Head office:
Street ........................................................................................................................................................................................................ Nr ....................... Box .................
Zipcode .............................. City ...................................................................................................................... Country .............................................................................
Phone ....................................................................................................................................... Fax ...............................................................................................................
E-mail address ...............................................................................................................................................................................................................................................
MANDATORY(IES) Complete in capital letters
Mandatory 1
Mr
Mrs
Mandatory 2
Mr
Miss
Mrs
Miss
Last name
................................................................................................
................................................................................................
First name
................................................................................................
................................................................................................
Function in the company
................................................................................................
................................................................................................
Political mandate**
Yes
No
Yes
No
................................................................................................
................................................................................................
Street and n°
................................................................................................
................................................................................................
Zipcode and City
................................................................................................
................................................................................................
Country
................................................................................................
................................................................................................
Date and place of birth
................................................................................................
................................................................................................
Nationality
................................................................................................
................................................................................................
Identity documents
................................................................................................
................................................................................................
ID card n°
................................................................................................
................................................................................................
Passport n°
................................................................................................
................................................................................................
Expiration date
................................................................................................
................................................................................................
Are you an insider?
.
If so, which securities?
................................................................................................
If yes, please specify
Official address
Yes
No
Yes
No
................................................................................................
SIGNATURE(S)
Place ............................................................................................................................................................................ date .................................................................................
Signature of the mandatory 1
Signature of the mandatory 2 (if applicable)
* Please visit the website of the European Commission (https://ec.europa.eu/taxation_customs/tin/tinByCountry.html?locale=en), or the OECD (http://www.oecd.org/tax/automatic-exchange/
crs-implementation-and-assistance/tax-identificationnumbers/), or contact the tax administration of your country of tax residence.
** Politically exposed persons («PEP») refers to all natural persons who are or have been entrusted with prominent public functions, or who was still in there less than a year, or a relative or known
associate of that person (eg. spouse, partner legally recognized, children and their spouses, parents). These functions include among others Head of state or government, senior politicians,
senior officials (judicial or military), senior executives of state owned corporations, important political party officials.
3.
Company name ............................................................................................................................................................................................................................................
Account number ...........................................................................................................................................................................................................................................
BENEFICIAL OWNER(S) Complete in capital
( letters
Beneficial owner 1
Mr
Mrs
Beneficial owner 2
Mr
Mrs
Miss
Miss
Name (individual
................................................................................................
................................................................................................
First name(s)
................................................................................................
................................................................................................
Date and place of birth
................................................................................................
................................................................................................
Nationality
................................................................................................
................................................................................................
Identity card n°
................................................................................................
................................................................................................
Passport n°
................................................................................................
................................................................................................
Expiration date
................................................................................................
................................................................................................
Tax identification number*
................................................................................................
................................................................................................
Profession
................................................................................................
................................................................................................
Function in the company
................................................................................................
................................................................................................
Street and n°
................................................................................................
................................................................................................
Zipcode and City
................................................................................................
................................................................................................
Country
Legal address:
................................................................................................
................................................................................................
Private phone n°
................................................................................................
................................................................................................
Office phone n°
................................................................................................
................................................................................................
E-mail address
................................................................................................
................................................................................................
Political mandate**
If yes, which?
Are you an insider?
If so, which securities?
Yes
Yes
No
................................................................................................
Yes
................................................................................................
Yes
No
................................................................................................
No
No
................................................................................................
SIGNATURE(S)
Place ..........................................................................................................................................................................date ...................................................................................
Signature(s) of the beneficial owner(s) 1
Signature(s) of the beneficial owner(s) 2
* Please visit the website of the European Commission (https://ec.europa.eu/taxation_customs/tin/tinByCountry.html?locale=en), or the OECD (http://www.oecd.org/tax/automatic-exchange/
crs-implementation-and-assistance/tax-identificationnumbers/), or contact the tax administration of your country of tax residence.
** Politically exposed persons («PEP») refers to all natural persons who are or have been entrusted with prominent public functions, or who was still in there less than a year, or a relative or known
associate of that person (eg. spouse, partner legally recognized, children and their spouses, parents). These functions include among others Head of state or government, senior politicians,
senior officials (judicial or military), senior executives of state owned corporations, important political party officials.
4.
BANK ACCOUNT NUMBER
On the secured site, you can instruct online transactions from your account with Keytrade Bank Luxembourg S.A. to another bank account in
the name of the company holder. If you do not give us a bank account number, you can only request a cash transfer by signed document along
with copy of an identity card (postal mail, e-mail or fax).
Please register my Bank account mentioned on the statement enclosed.
INVESTOR PROFILE
Which percentage of your financial assets do you intend to invest via Keytrade Bank Luxembourg S.A?
0-25 %
25-50 %
50-75 %
75-100 %
What is the source of the funds, which you intend to invest?
................................................................................................................................................................................................................................................................................
A form about your knowledge and experience with financial product needs to be filled in directly on the secured platform
CORRESPONDENCE
How do you wish to receive the passwords, which give you access to the secured site (1 answer)
I withdraw them in your office
By Postal mail, to the address mentioned previously (page 2)
DECLARATIONS
The signatory(ies) declare(s)
• that the assets held, or to be held at any time, on his (their) account have no criminal origin, are the product of a legal activity and will not be
used for money laundering, nor for terrorism financing,
• that the information contained in this document is complete, accurate and true,
• to have received and read the general conditions and terms and the overview of the characteristics and essential risks of the financial instruments,
that he (they) will respect and accept all the clauses contained therein,
• to assume the responsibility and all the risks relating to the orders which will be transmitted to Keytrade Bank Luxembourg S.A.
Keytrade Bank Luxembourg S.A. will not assume any liability for the customer’s investment decisions and the financial consequences of these
trades
• to act for his (their) own account, and in the opposite, he (they) will state to the company the identity of the third party for which he (they)
act(s),
• to commit himself (themslef) to inform the company about any change of the provided information.
SIGNATURE(S)
Place............................................................................................................................................................................. date ................................................................................
Read and approved
Signature mandatory 1
Read and approved
Signature mandatory 2 (if applicable)
DECLARATION OF “ NON-US PERSON”
Each beneficial owner must fill out 1 declaration
The following declaration allows Keytrade Bank Luxembourg S.A. to confirm to the American authorities that its clients are neither American
citizens nor American residents nor persons liable to tax in the United States, in order to benefit from the favorable treatment relating to
withholding tax on dividends originating from American securities. Each signatory additionally declares that he/she allows this form to be
submitted to any competent authority.
The beneficial owner declares and confirms to Keytrade Bank Luxembourg S.A. the following information
• Are you a US citizen (single or double nationality)?
Yes
No
• Have you got a residence in the USA or a permanent US residence permit?
(you are qualified as permanent resident if, you are in possession of a “green card”,
have made a prolonged stay in the US during the current year and during the last two years)
Yes
No
1
He/she is not intending to reside in the United States for more than 183 days per year and is not bound by any Business obligations in the United States.
• The signatory declares that he is the beneficial owner of the assets and income confided or to be confided to Keytrade Bank Luxembourg S.A.
• The signatory declares that he will inform Keytrade Bank Luxembourg S.A. immediately of all changes in the abovementioned information,
especially relating to his nationality, residence and tax address.
Under penalties or perjury, the signatory confirms that the information given in this document is complete,
accurate and genuine
Name& First name of the beneficial owner .................................................................................................................................................................................................
SIGNATURE
Place .............................................................................................................................................................................................. date .................................................................
Signature Beneficial owner
DECLARATION BENEFICIAIRE(S) EFFECTIF(S)
B
Numéro d’entreprise
Adresse du siège social
Adresse du siège social
Qualité de
bénéficaire effectif 3
Bourse de la cotation
Profession
Si applicable, bourse de la cotation
D
3
2
1
Indiquez la fonction exacte des personnes qui ont pouvoir de représenter la personne morale (administrateur, président, gérant, …).
Veuillez joindre une copie recto-verso de la carte d'identité ou d'une autre preuve d'identité (passeport).
Veuillez ajouter une preuve d'adresse si elle n'est pas renseignée sur le document d'identité.
Indiquez la qualité du bénéficiaire effectif (actionnaire, administrateur, …).
Le client confirme que toutes les informations communiquées sont exactes et correctes et s'engage irrévocablement à informer la banque, par écrit et immédiatement, de tout changement à
la liste de(s) bénéficiaire(s) effectif(s) et à lui faire parvenir copie des pièces d'identité des nouveaux bénéficiaires effectifs. La banque se réserve le droit de cesser la relation avec le client,
sans mise en demeure préalable ni indemnisation, s'il apparait qu'elle n'a pas été avertie d'un changement dans la liste des bénéficiaires effectifs. Dans ce cas le client sera averti par
courrier ordinaire.
Nom de la société
… ou que le bénéficiaire effectif est la société cotée suivante:
Déclare(nt) qu'à la date du …../…../20…. le(s) bénéficiaire(s) effectif(s) est(sont) les personnes physiques suivantes:
Date de
Lieu de
Adresse du domicile
Nom et prénom 2
naissance
naissance
(rue, numéro, commune, éventuellement pays)
Dénomination du client
agissant en qualité de représentant(s) de
D
C
B
Diverses réglementations dont la loi anti-blanchiment impose aux banques l'obligation d'identifier le(s) bénéficiaire(s) effectif(s) des comptes ouverts au nom des personnes morales. Le
document en annexe donne plus d'informations à ce sujet.
Le(s) soussigné(s)
Qualité 1
Nom et prénom
Signature
A
C
A
Pour un transfert de titres, veuillez nous contacter.
Form
W-8BEN
Certificate of Foreign Status of Beneficial Owner for United
States Tax Withholding and Reporting (Individuals)
(Rev. February 2014)
▶
Department of the Treasury
Internal Revenue Service
OMB No. 1545-1621
▶ For use by individuals. Entities must use Form W-8BEN-E.
Information about Form W-8BEN and its separate instructions is at www.irs.gov/formw8ben.
▶ Give this form to the withholding agent or payer. Do not send to the IRS.
Do NOT use this form if:
• You are NOT an individual
Instead, use Form:
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• You are a U.S. citizen or other U.S. person, including a resident alien individual
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. W-8BEN-E
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• You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the U.S.
(other than personal services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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• You are a beneficial owner who is receiving compensation for personal services performed in the United States .
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• A person acting as an intermediary
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Part I
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Identification of Beneficial Owner (see instructions)
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2
Country of citizenship
1
Name of individual who is the beneficial owner
3
Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
City or town, state or province. Include postal code where appropriate.
4
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. W-8ECI
8233 or W-4
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. W-8IMY
Mailing address (if different from above)
5
U.S. taxpayer identification number (SSN or ITIN), if required (see instructions)
7
Reference number(s) (see instructions)
Part II
10
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W-9
Country
City or town, state or province. Include postal code where appropriate.
9
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8
Country
6
Foreign tax identifying number (see instructions)
Date of birth (MM-DD-YYYY) (see instructions)
Claim of Tax Treaty Benefits (for chapter 3 purposes only) (see instructions)
within the meaning of the income tax treaty
I certify that the beneficial owner is a resident of
between the United States and that country.
Special rates and conditions (if applicable—see instructions): The beneficial owner is claiming the provisions of Article
of the treaty identified on line 9 above to claim a
% rate of withholding on (specify type of income):
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Explain the reasons the beneficial owner meets the terms of the treaty article:
Part III
Certification
Under penalties of perjury, 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 further
certify under penalties of perjury that:
•
I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income to which this form relates or
am using this form to document myself as an individual that is an owner or account holder of a foreign financial institution,
•
The person named on line 1 of this form is not a U.S. person,
•
The income to which this form relates is:
(a) not effectively connected with the conduct of a trade or business in the United States,
(b) effectively connected but is not subject to tax under an applicable income tax treaty, or
(c) the partner’s share of a partnership's effectively connected income,
•
•
The person named on line 1 of this form is a resident of the treaty country listed on line 9 of the form (if any) within the meaning of the income tax treaty between
the United States and that country, and
For broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions.
Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or
any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. I agree that I will submit a new form within 30 days
if any certification made on this form becomes incorrect.
▲
Sign Here
Signature of beneficial owner (or individual authorized to sign for beneficial owner)
Print name of signer
For Paperwork Reduction Act Notice, see separate instructions.
Date (MM-DD-YYYY)
Capacity in which acting (if form is not signed by beneficial owner)
Cat. No. 25047Z
Form
W-8BEN (Rev.
2-2014)