None of the Above. If none of the above condition(s) were checked, (i.e., inpatient care, pregnancy) no additional information is needed. Go to page 4 to sign and date the form. Employee Name:
None of the Above. If none of the options above pertain, a committee of two employees from Human Resources and two SEIU CEC members will meet and decide where seniority should be credited.
None of the Above. You hereby represent that you (i) are not required to be an NFA member and/or to be registered with the CFTC pursuant to the Commodity Exchange Act and the rules thereunder, and, if applicable, (ii) have complied with all conditions of any exclusion or exemption from such registration. If you cannot make this representation, please contact the Fund. iv. Please answer the following questions, to your knowledge, with regard to the person that is the ultimate beneficial owner of your interest in the Fund (i.e., the individual that has the ultimate economic benefits and burdens of the investment in the Shares, looking through any intermediate entities). (a) To your knowledge, is the ultimate beneficial owner of your Shares also the ultimate beneficial owner of any other Shares? ☐ Yes ☐ No (b) To your knowledge, is the ultimate beneficial owner of your Shares “related” to another ultimate beneficial owner of Shares? For this purpose, persons are “related” only if they are members of the same family (i.e., a whole or half-brother or sister, spouse, ancestor, or lineal descendant) or partners in a partnership. ☐ Yes ☐ No (c) If you answered “Yes” to either (a) or (b) directly above, please provide the following information regarding the ultimate beneficial owner of your Shares. Name: Relation: $ Amount: By completing this Subscription Agreement, you are also agreeing to notify the Fund (via mail or courier to your Financial Advisor) if your response to either of the above questions (a) or (b) changes or becomes inaccurate in the future. The Fund and its affiliates do not intend to provide this information to the IRS or any other tax authority, unless requested to do so in the context of an audit or as otherwise required by law, in which case this information may be disclosed to the IRS or another tax authority in the context of such audit or other legal requirement. v. Check all that apply. In connection with the Fund’s obligations relating to Disqualifying Events pursuant to Rule 506(d) under the Securities Act, please indicate below whether any of the following (which are Disqualifying Events as provided in Rule 506(d) under the Securities Act) have occurred with respect to you or any person that directly or indirectly will have voting or dispositive power over your interest in the Fund.
None of the Above. Initials
None of the Above o The Subscriber is a legal entity located outside of the United States, but none of the above apply to the Subscriber. * * If the Subscriber checked the box immediately above, please indicate the jurisdiction in which the Subscriber is located _ Depending on the jurisdiction indicated, the Partnership may require additional documentation or representations from the Subscriber. ACTIVE/83648739.2 ATTACHMENT L FATCA SELF-CERTIFICATION Instructions for Completion The Partnership may be obligated to collect certain information about each Subscriber and its interest and submit reports to the Cayman Islands Tax Information Authority (the "TIA") in accordance with the Tax Information Authority Law (as amended), the Regulations) and related Guidance Notes, as well as intergovernmental agreements ("IGAs") entered into separately between the Cayman Islands and the u.S. and United Kingdom (collectively "FATCA"). This form only addresses the FATCA due diligence and reporting rules implemented by the Regulations so as to give effect to the Cayman-UK IGA (referred to herein as "UK FATCA"). Please complete the sections below and provide any additional information that is requested. Please note that in certain circumstances the Partnership may be obligated to share this information with relevant tax authorities. Terms referenced in this form shall have the same meaning as applicable under FATCA. Consistent with the terms of Sections 5.2 and 9 of this Subscription Agreement, if any of the information below changes in the future, the Subscriber shall promptly notify the Partnership of such changes. If the Subscriber has any questions about how to complete this form, please contact your legal counsel and/or tax adviser. Please note that where there are joint account holders, each investor is required to complete a separate form.
