Level in Ownership Registration Address Residence Address Legal Form Percentage Structure (L1/L2/L3…) and Country and Country Company Name / Control Residence Full Name Shares (1) / Address and (Surname, First Date of Birth Country of Birth Gender Citizenship(s) Percentage Participation (2)/ Country (at Name) Control (3) least country) Please provide information about your executive board members: Full Name Residence Address and (Surname, First Date of Birth Country of Birth Gender Citizenship(s) Function Country (at least country) Name) Please provide information regarding your FATCA Status: Compliant Non-Compliant Deemed-Compliant Exempt (please specify) Please provide the contact details of the FATCA responsible person:
Company Name Legal Form Registration Address and Country Residence Address and Country Percentage Level in Ownership Structure (L1/L2/L3…) / Control Full Name (Surname, First Name) Date of Birth Country of Birth Gender Citizenship(s) Residence Address and Country (at least country) Percentage Shares (1) / Participation (2)/ Control (3) Please provide information about your executive board members: Full Name (Surname, First Name) Date of Birth Country of Birth Gender Citizenship(s) Residence Address and Country (at least country) Function Please provide information regarding your FATCA Status: Compliant Non-Compliant Deemed-Compliant Exempt (please specify) Please provide the contact details of the FATCA responsible person:
826124957350877869-826099713680572860_826100653204670448-1095391597709443771-1-1-NA.docx