Suitability Notice Template for Senior Officers under the Non-Bank Deposit Takers Act 2013

SUITABILITY NOTICE FOR SENIOR OFFICER UNDER THE NON-BANK DEPOSIT TAKERS ACT 2013 Name of Non-bank Deposit Taker (‘NBDT’) or NBDT licence applicant this notice relates to: Section 1: Senior Officer to whom this suitability notice relates Full name of senior officer or proposed senior officer to which this suitability notice relates: Date of birth of senior officer: Position the above person holds or will hold (e.g. Chief Financial Officer): Previous names of above person (if any): Is this person currently a director or senior officer of the above entity? Yes / No If this is a role that the person proposes to take up in the future, when are they expected to take up this role? Has this senior officer been resident overseas in the past 10 years (if yes, list relevant jurisdictions)? Yes / No Name of Senior Officer this notice relates to: _____________________________________________________________________

2 Section 2: Contact details for the senior officer to whom this suitability notice relates Correspondence address: Residential address (if different): Telephone: E-mail address: Section 3: Certification (to be completed by the certifying directors) I am a director (as defined in section 4 of the Non-bank Deposit Takers Act 2013) of the above NBDT, and I have taken all appropriate steps to ensure that the information in this form is accurate. I have read and understood this notice and the “Guidance note on suitability assessments under the Non-bank Deposit Takers Act 2013” (PDF 215KB). I certify that, to the best of my knowledge, and having completed due inquiries, the above individual does / does not [delete as appropriate] raise one or more of the suitability concerns set out in the Non-bank Deposit Takers (Debt Securities and Suitability Concerns) Regulations 2014. Where the above individual does raise one or more suitability concerns, all of these are listed in Appendix 1 of this document. I understand that any person who signs a suitability notice and who knows, or ought to know, that the suitability notice is false or misleading in a material respect may be committing an offence. Director One Director Two Name: _______________________ Name: _______________________________ Position: _____________________ Position: _____________________________ Signature: _____________________ Signature: ____________________________ Date: _________________________ Date: ________________________________ Name of Senior Officer this notice relates to: __________________________________________________________________________

3 Note: Where a senior officer does raise one or more suitability concerns a list of these concerns should be included in in Appendix 1 of this document. Further information about suitability concerns (see paragraph 29 of the “Guidance note on suitability assessments under the Non￾bank Deposit Takers Act 2013” (PDF 215KB) can be included in Appendix 1 or provided separately in another document. The completed suitability notice should be accompanied by the other information requested by the Bank as set out in paragraph 66 of the the “Guidance note on suitability assessments under the Non-bank Deposit Takers Act 2013” (PDF 116KB). Submitting this form Completed suitability notices and accompanying documentation for all directors and senior officers should be sent to the Reserve Bank together with the rest of the NBDT licence application. Further information about submitting suitability notices and licence applications to the Bank is contained in “Guidelines for Non-bank Deposit Taker Licence applicants” (PDF 116KB), available on the NBDT licensing page. Privacy and Confidentiality Statement Personal information collected by the Bank during the process of determining whether a person is unsuitable to be a director or senior officer (as the case may be) of an NBDT may be used for the purpose of performing the Bank’s functions under the Non-bank Deposit Takers Act 2013, or other such purpose permitted by law. Information supplied or disclosed to, or obtained by, the Bank during the process of determining whether a person is unsuitable to be a director or senior officer (as the case may be) of an NBDT will be treated as confidential under section 54 of the Non-bank Deposit Takers Act 2013 and will only be published or disclosed by the Bank in accordance with that section. Contact for further information Website http://www.rbnz.govt.nz/regulation_and_supervision/non-bank_deposit_takers/ Email nbdt@rbnz.govt.nz Telephone +64 4 471 3949 Mail Reserve Bank of New Zealand Prudential Supervision – NBDT Licensing PO Box 2498 Wellington 6140 Name of Senior Officer this notice relates to: __________________________________________________________________________

4 APPENDIX 1 – LIST OF SUITABILITY CONCERNS RAISED BY SENIOR OFFICER (if applicable) Further information about any suitability concerns listed here may either be included in this appendix or provided separately in another document. Name of Senior Officer this notice relates to: __________________________________________________________________________

5 APPENDIX 2 – CONSENT TO MAKE ENQUIRIES ABOUT CREDIT AND CRIMINAL HISTORY (to be completed by the (proposed) senior officer) I understand that the Reserve Bank of New Zealand (‘the Bank’) may make whatever enquiries it thinks fit to assist the Bank to determine my suitability as a senior officer of a Non-bank Deposit Taker. I acknowledge that such enquiries may include asking any person that the Bank considers may assist with an assessment of my suitability to supply information or respond to queries. As part of these enquiries I authorise the release to the Bank of credit information held about me by credit reporters. I agree to cooperate with the Bank and take whatever steps are necessary to enable the Bank to undertake criminal and credit history checking. Name: ________________________________________ Position: ______________________________________ Signature: _____________________________________ Date: _________________________________________ Name of Senior Officer this notice relates to: __________________________________________________________________________