Application form for a license for a clearing institution with its seat in the Netherlands

80-119-1 Application form for a license for a clearing institution with its seat in the Netherlands Article 2:4 jo. 2:5, Financial Supervision Act (Wft) De Nederlandsche Bank (DNB) will include the data provided on the basis of this application form in a personal data processing operation within the meaning of the Personal Data Protection Act (Wbp). The personal data processing operation has been registered with the Personal Data Protection Authority. The registration form is available for inspection at DNB. We always handle your data carefully. We may only exchange your data with third parties if legally permitted, for example with supervisors and criminal justice authorities in the Netherlands or abroad. Any change in circumstances on the basis of which the questions below should be answered differently by you must be reported to DNB on your own initiative and without delay. We request that you indicate which documents you are attaching to this form by checking the boxes next to the relevant questions. 1 Data as referred to in Article 4, first paragraph, item a, Decision on Market Access for Financial Undertakings Wft Name of the clearing institution Telephone number Address of the clearing institution Postal address of the clearing institution 2 Data as referred to in Article 4, first paragraph, item b, Decision on Market Access for Financial Undertakings Wft Legal form of the clearing institution 3 Data as referred to in Article 4, first paragraph, item c, Decision on Market Access for Financial Undertakings Wft Statutory name of the clearing institution Statutory seat of the clearing institution Trade name(s) of the clearing institution 4 Data as referred to in Article 4, first paragraph, item d, Decision on Market Access for Financial Undertakings Wft The registration number in the trade register of the Chamber of Commerce 5 Data as referred to in Article 4, first paragraph, item e, Decision on Market Access for Financial Undertakings Wft A certified copy of the articles of association of the clearing institution. Attached as Appendix A 6 Data as referred to in Article 4, first paragraph, item f, Decision on Market Access for Financial Undertakings Wft A statement of the activities that the clearing institution will perform. Attached as Appendix B

80-119-2 7 Data as referred to in Article 4, first paragraph, items g and h, Decision on Market Access for Financial Undertakings Wft a Completed and signed Notification forms for proposed appointments, for each of the persons who determine or co-determine the policy of the clearing institution (that is to say, directors and other policy determiners), if applicable together with the completed and signed Reliability Assessment Forms and the attachments mentioned on these forms* b Completed and signed Notification forms for proposed appointments regarding each of the persons who are part of a body charged with supervising the policy and the general course of affairs of the clearing institution (such as supervisors), together with the completed and signed Reliability Assessment Forms and the attachments mentioned on these forms* Names of persons (surname, initial(s)): Names of persons (surname, initial(s)): Number of Notification forms sent Number of Notification forms sent Number of Reliability Assessment Forms sent Number of Reliability Assessment Forms sent Attached as Appendix C1 Attached as Appendix C2 Attached as Appendix D 8 Data as referred to in Article 4, first paragraph, item i, Decision on Market Access for Financial Undertakings Wft A description of the proposed policy regarding sound business conduct, referred to in Article 3:10, first paragraph, Wft. Attached as Appendix E 9 Data as referred to in Article 4, first paragraph, item j, Decision on Market Access for Financial Undertakings Wft A description of the ownership structure on the basis of which it can be assessed whether Article 3:16, Wft, is complied with. Attached as Appendix F 10 Data as referred to in Article 4, first paragraph, item k, Decision on Market Access for Financial Undertakings Wft A description of the organization of the business operations regarding sound and proper business conduct, referred to in Article 3:17, first paragraph, Wft. Attached as Appendix G ** The Reliability Assessment Form only needs to be submitted if the person in question has not previously been assessed for reliability. You can download the notification form for proposed appointments and the reliability form via our website (www.dnb.nl).

80-119-3 11 Data as referred to in Article 4, first paragraph, item l, Decision on Market Access for Financial Undertakings Wft Documents from which the assets, referred to in Article 3:53, first paragraph, Wft, and the expected solvency, referred to in Article 3:57, first and second paragraphs, Wft, and liquidity, referred to in Article 3:63, first paragraph, Wft, are evident. Attached as Appendix H 12 Fees Details of the person to whom the invoice in the context of the processing of this application can be sent: Name of contact person Name of legal entity Postal address 13 Signature by the person(s) authorized to represent The undersigned declare(s) to have taken note of the above-mentioned statements regarding the processing of personal data in accordance with the Wbp and the making of notifications of any changes in the answers to the questions asked. The undersigned declare(s) to have completed this questionnaire and the attachment(s) fully and truthfully. Date Place Name Function Signature Date Place Name Signature Function The fully completed and signed form can be sent, together with attachments, to: De Nederlandsche Bank NV, Market Access Expertise Centre, P.O. Box 98, 1000 AB Amsterdam. For any questions, you can contact the DNB Information Desk via telephone number 0800 - 020 10 68 or e-mail (info@dnb.nl).