Individual Controller Form for Non-bank Deposit Takers Licensing

INDIVIDUAL CONTROLLER FORM This form must, in certain circumstances, be used to accompany applications for a Non-bank Deposit Takers licence under the Non￾bank Deposit Takers Act 2013 (the ‘Act’) Name of Non-bank Deposit Taker licence applicant (the ‘applicant’) that this form relates to:

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Name of controller (the ‘controller’):

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Who should complete this form This form should be completed by a natural person that has the ability directly or indirectly to appoint 25% or more of the members of the governing body of the applicant, or has a direct or indirect qualifying interest in 20% or more of the voting securities issued or allotted by the applicant. For the purposes of this document, a person able to exercise such control over an applicant is defined as a ‘controller’. For more information about the circumstances in which this form must be completed, refer to section 3 of the NBDT licence application form, available on the NBDT licensing page. Important information controllers should read before completing this form It is important that the controller provides accurate and complete information, and discloses all relevant facts where appropriate. If they do not, they may be committing a criminal offence and it may cause the Reserve Bank of New Zealand (‘the Bank’) to review decisions made upon the basis of this information. Where information provided in this form changes materially prior to a licence being granted to the NBDT the controller must notify the applicant and the Bank immediately. Completing the form Controllers should answer the questions and provide the required information where appropriate, using the spaces in this form to note which documents contain the information required. All questions in this form should be answered. If a controller believes that a question, or an information requirement, does not apply to them they should answer ‘not applicable’. If a controller does not provide the information requested, or leaves a question blank, the Bank will

2 treat the form as incomplete. This will increase the time taken to assess the applicant’s application. When supplying required information, the Bank has no objection to receiving relevant material produced for other purposes (e.g. business plans). Personal Information and Confidentiality Personal information collected by the Bank during the process of deciding whether to grant a licence to the applicant may be used for the purposes of performing the Bank’s functions under the Act or other such purposes permitted by law. Information supplied or disclosed to, or obtained by, the Bank during the process of deciding whether to grant a licence to the applicant will be treated as confidential under section 54 of the Act and will only be published or disclosed by the Bank in accordance with that section. Questions and further information If controllers have questions about the information they need to provide, they should: • discuss the matter with the applicant, or if further information is required; • contact the Bank at nbdt@rbnz.govt.nz or on +64 4 472 2029. Submitting this form A completed and signed Individual Controller Form, together with all of the information requested in the form, should be provided to the applicant for onward submission to the Bank. Individual Controller Form

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1. CONTACT DETAILS 1.1 The controller should complete the sections below: Address of Controller: Correspondence address (if different): Contact details for the controller: Name: Tel: E-mail: Individual Controller Form

4 2. BACKGROUND 2.1 The controller should provide below (or in an accompanying document) details of their current occupation, current directorships and business activities in the previous 8 years. Continue on a separate sheet if necessary  Attached  n/a Document reference(s): ____________________________________ Individual Controller Form

5 3. FINANCIAL INFORMATION 3.1 The controller should provide details of any financial commitments (such as guarantees) that they have made, or know or expect that they will make, to the applicant, or any financial commitments made by the applicant to the controller.  Attached  n/a Document reference(s): ____________________________________ Individual Controller Form

6 4. FINANCIAL MARKETS COMPLIANCE 4.1 Has the controller been found guilty of fraudulent activity in New Zealand or in another jurisdiction? This includes an offence under sections 377-380 of the Companies Act 1993 or of any crime involving dishonesty (including those defined by section 2(1) of the Crimes Act 1961), or other comparable overseas law?  Yes  No 4.2 Has the controller acknowledged a breach of, or proven to have breached, any legislation arising out of their participation in financial markets in New Zealand or in another jurisdiction (including any breaches of the Reserve Bank of New Zealand Act 1989, the Non-bank Deposit Takers Act 2013, the Insurance (Prudential Supervision) Act 2010, the Securities Act 1978, the Financial Markets Conduct Act 2013, the Securities Markets Act 1988, the Companies Act 1993, the Friendly Societies and Credit Unions Act 1982, the Building Societies Act 1965, and the Anti-Money Laundering and Countering the Financing of Terrorism Act 2009), or other comparable overseas law?  Yes  No 4.3 If question 4.1 or 4.2 was answered “yes”, the controller must provide further information about any such matter that led to the breach / action. This should include a description of: • how the matter arose, and any legal obligation breached; • any adverse finding or penalty imposed on the controller; • the length of time over which the matter occurred; and • how the matter was dealt with and any remedial actions taken.  Attached  n/a Document reference(s): ________________________________________ Individual Controller Form

7 5. DECLARATION As a controller, I confirm that: • The information provided in this document and in the accompanying documents is true and correct to the best of my knowledge and belief. I have taken reasonable steps to confirm that this information is true and correct. • I understand that the Bank may make further enquiries and seek further information as, and from whoever, it sees fit to verify the information provided. • I understand that the Bank may require the controller to provide further information or documents at any time after the form has been submitted and before a decision has been made to grant a licence to the applicant. • I understand that any material changes to the information provided in this application form, or in the accompanying documentation, prior to a decision being made to grant a licence to the applicant, must be communicated to the applicant and the Bank. • I understand that it may be a criminal offence to make any statement or application, or supply any document or thing, to the Bank knowing that it is false or misleading in a material respect. This declaration must be signed by the controller. Name:

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Position:

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Signature:

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Date:

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Individual Controller Form