FATCA (Foreign Account Tax Compliance Act) Form The Foreign Account Tax Compliance Act (FATCA) was enacted by US Congress to increase transparency regarding US citizens and US residents who hold offshore assets and to improve tax compliance. It imposes certain due diligence and reporting obligations on non-US financial institutions, including Australian institutions. Australia and the US signed an Intergovernmental agreement (IGA) to support Australian institutions’ compliance with FATCA. Australian Ethical Investment Ltd is required to collect, identify and report to the Australian Taxation Office (ATO) on various account-related information of all investors deemed to be a US person (subject to any applicable threshold or exemption). If Australian Ethical Investment limited does not receive this information, we are required to withhold US withholding tax on certain income or other payments received on your investments. In addition, we may be required to report any non-compliance to the relevant US authorities via the ATO. SEND YOUR COMPLETED FORM TO: Australian Ethical Investment Ltd, Reply Paid 3993, Sydney, NSW, 2001. Phone: 1800 021 227 Fax: 02 9252 1987 [email protected] Email: Please complete all application details using BLACK ink and print in clear BLOCK LETTERS. STEP 1 – INVESTOR DETAILS Investor number Business/Company name (as registered with ASIC) ABN | ACN Legal name (Individual, Trustee, joint/sole trader, partnership, Trust) Street number and name Suburb State Postcode Country Contact number STEP 2 – FATCA DETAILS Mark one box with an X to indicate the relevant category and if required provide further information requested. Only complete this form if you have selected "not FATCA exempt" on the Application Form. A An individual who is a US citizen or resident of the US for tax purposes Please provide your US Taxpayer Identification Number (TIN) B A company, partnership, trust or association established under the laws of the US or a US taxpayer Please provide the entity's US Taxpayer Identification Number (TIN) C A financial institution or trust with a trustee that is a financial institution (eg: custodial, depository institution, an investment entity or a specified insurance company for FATCA purposes) Please provide the entity's Global Intermediary Identification Number (GIIN) If the financial institution does not have a GIIN, please tick one box to clarify its FATCA status: GIIN applied for but not yet issued Non-Reporting IGA Foreign Financial Institution (FFI) (list in Annex II of IGA) Resident of non IGA country or not otherwise subject to IGA: managed funds exempt beneficial owner Non -Participating FFI GIIN applied for but not yet issued deemed compliant australianethical investments FATCA (Foreign Account Tax Compliance Act) Form D A proprietary partnership, trust or association that is not a financial institution (as described above) and in the preceding reporting period either: - earned 50% or more of its gross income from distributions, dividends, rental, interest or other investment income; or - held 50% or more of its assets in shares, properties, bonds or similar investment assets that generate passive income Beneficial Owner If you ticked this category, are any of the shareholders holding a controlling interest (i.e. holding more than 25% of the company's issued capital through one or more shareholdings) or are any of the partners, beneficiaries, trustees or settlors US citizens or US taxpayers? Yes. Please provide the following details: Name (in full) Address US Taxpayer Identification Name (in full) Address US Taxpayer Identification *If there are more than 2 US persons, please provide the details of the additional US persons on a separate sheet. By completing and signing this form that forms part of my application for units in the Australian Ethical Managed Funds I/we declare that: y the information provided by me/us in this form, which forms part of my/our application for units in Australian Ethical Managed Investment Funds to enable Australian Ethical Investment Limited to comply with FATCA, its supporting regulations and any related laws designed to implement those laws in Australia is correct and where relevant reflects my/our tax status for the purposes of FATCA. y I/we will promptly notify Australian Ethical Investment Limited and provide them with any changes to the information provided by me/us in connection with FATCA and on request, with any further information which is necessary or desirable for Australian Ethical Investment Limited to comply with any obligations it may have in connection with FATCA. Signatures If the application is signed by more than one person, who will operate the account? SIGNATURE A Any to sign SIGNATURE B Date / All to sign together Date / / Name Name If a company Officer, you MUST specify your corporate title: If a company Officer, you MUST specify your corporate title: Director Sole Director Director Sole Director Trustee Other Trustee Other SIGNATURE C SIGNATURE D Date / / Date / Name Name If a company Officer, you MUST specify your corporate title: If a company Officer, you MUST specify your corporate title: Director Sole Director Director Sole Director Trustee Other Trustee Other managed funds / / 1800 021 227 | australianethical.com.au