Important Information About Becoming a Member

Version 01/20/2010

General

Membership Questionnaire

IMPORTANT INFORMATION ABOUT BECOMING A MEMBER

To help the government fight the funding of terrorism and money laundering activities, procedures have been established to obtain, verify and record information that identifies each entity that opens an account. When a firm applies for membership, we request information and documentation that allow us to identify the firm.

When required by applicable law, the Applicant/Participant shall procure the consent of any of its representatives from time to time to: (i) the processing of personal data by the Corporation (whether before, during or after the membership application); and (ii) the transfer of personal data out of the European Economic Area (the EEA) in each case for purposes in connection with the Applicant’s/Participant’s application for, and membership in, the Corporation. We may use the information about representatives (i) in conducting our business with the Applicant/Participant and to fulfill our regulatory obligations, as, for example, in determining individuals authorized to give instructions on behalf of the Applicant/Participant, and as contact information, and (ii) to confirm that the representatives are who they claim to be, and that senior officers of the company are fit and proper persons in accordance with our regulatory obligations. We may also collect other information about these representatives to confirm this. From time to time we may conduct investigations and research to ensure this information remains accurate. With respect to the transfer of personal data outside of the EEA, the data may be transferred to offices of the Corporation or its subsidiaries or to third parties (selected service providers who provide services in connection with the Corporation's products or services and regulatory authorities) located in countries that do not have such protective data protection legislation when compared to European law; by submitting personal data as set forth in this and similar forms related to the membership requirements of the Corporation, the Applicant/Participant agrees to the transfer, storing or processing of personal data outside of the EEA. If the Data Protection Act 1998 (the “Act”) applies, the Applicant/Participant hereby warrants that the transfer of personal data of any of its representatives to the Corporation for the purposes of processing personal data as is specified herein is in compliance with the Act. Please refer to the Corporation’s privacy policy at www.dtcc.com for additional information.

Please assist us to comply with the legal obligation to ensure that your information is kept accurate and up-to-date by ensuring that you inform us of any changes to your information.

New Member Application Existing Member Update*

*If a current member is changing its form of organization, ownership structure, or proposes changes to its business, the member may be required to complete an application for membership.

Full Legal Name of Applicant/Member:

Contact Person for this Questionnaire
Name: / Title:
Address Line 1:
Address Line 2:
City: / State: / Zip Code:
Country:
Telephone Number:
E-mail Address:

The Applicant/Member submitting this report and the person by whom it is executed represent hereby that all information reported therein is true, correct and complete.

Officer Responsible for Filing Questionnaire
Name: / Title:
Signature: / Date: / (m/d/yyyy)

Information as of Date: (m/d/yyyy)

General Information

Full Address of Registered Office
Address Line 1:
Address Line 2:
City: / State: / Zip Code:
Country:
Telephone Number:
Full Address of Chief Executive Office (if different from Registered Office)
Address Line 1:
Address Line 2:
City: / State: / Zip Code:
Country:
Telephone Number:
Full Address of Operations Office
Address Line 1:
Address Line 2:
City: / State: / Zip Code:
Country:
Telephone Number:
Legal Counsel Information
Counsel Name: / Title:
Internal External
Name of Firm (External only):
Business Telephone Number:
E-mail Address:

Government Issued Identification Number*:

*For U.S. Participants, a Tax Identification Number (“TIN”); and for non-U.S. Participants, a U.S. TIN (if available), a non-U.S. equivalent, a document bearing indicia of authenticity issued by a government other than the U.S. certifying the existence of the business or enterprise (with or without an ID number), or a government business registration number.

Company Website Address:

Contact Information

Primary Operations Contact
Name: / Title:
Business Phone: / E-mail Address:
Senior Business Contact
Name: / Title:
Business Phone: / E-mail Address:
Technical Contact
Name: / Title:
Business Phone: / E-mail Address:
Settlement - Main Contact
Name: / Title:
Business Phone: / E-mail Address:
Settlement - Contingency Contact
Name: / Title:
Business Phone: / E-mail Address:
Billing Contact
Name: / Title:
Business Phone: / E-mail Address:
Financial Reporting Contact
Name: / Title:
Business Phone: / E-mail Address:
Compliance Contact
Name: / Title:
Business Phone: / E-mail Address:

Form of Organization

Form of Organization – select from the table below: CorporationPartnershipLimited Liability CompanyOther
Type of entity - select the appropriate checkbox / Bank or Trust Company - Domestic
Bank or Trust Company - US Regulated Branch/Agency of Non-US Bank
Non-US Bank
Central Securities Depository
Broker Dealer - Domestic (US Registered/Regulated - Formed in the US)
Broker/Dealer – Non-US (US Registered/Regulated - Formed outside US)
Broker Dealer – Non-US (Non-US Registered/Regulated - Formed outside the US)
SEC Registered Clearing Agency
SEC Registered Transfer Agent
Futures Commission Merchant
Insurance Company
Registered Investment Advisor
Unregistered Investment Pool Incorporated in US
Unregistered Investment Pool Incorporated outside US
Investment Company Registered under the Investment Company Act of 1940 US Registered/Regulated – Formed/Incorporated in the US
Other (please describe below)
______
______
State of Incorporation/Formation:
Country of Incorporation/Formation:
Date of Incorporation/Formation: / (m/d/yyyy)
Date Applicant/Member commenced business: / (m/d/yyyy)
Please answer the questions below if you selected Corporation
Is the Applicant/Member publicly traded? / YesNo
If publicly traded, please list Exchanges:
Please answer the question below if you selected Partnership or Limited Liability Co.
Number of Partners/Members:
Please answer the question below if you selected Other
Please describe the form of your organization:

DUNS Number*:

*DUNS stands for "Data Universal Numbering System." It is a unique nine-digit numbering system that is used to identify a business. Please provide if you have one.

Ownership Structure

Owners are individuals or entities with a direct or indirect ownership of 10% or more in the applicant. Examples include Immediate, Intermediate and Ultimate owners.

Immediate Owners

Immediate owners, also called direct owners, include any individual or entity that owns, has the right to vote, to elect directors, or has the power to sell or direct the sale of a class of the businesses voting securities.

Intermediate Owners

Intermediate owners are persons or entities that stand in the ownership chain between immediate and ultimate owners.

Ultimate Owners

Ultimate owners, also called indirect owners or beneficial owners, include any person or entity that owns, has the right to vote, to elect directors or has the power to sell or direct the sale of a class of the businesses voting securities of an Intermediate owner.

Important Note: An applicant/member is not required to provide ownership information if it is a publicly traded company.

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Membership Questionnaire

Version 01/20/2010

For all owners that are entities with ownership of 10% or more of the Participant, provide the following information:

The Client hereby certifies that are no entities other than those listed with more than 10% ownership

Entities with Ownership of 10% or more
Full Legal Name / Type of Entity[1] / Type of Owner / Country of Incorporation/ Formation / Country
of Operations / Ownership Percentage / Is the Entity Regulated / If Regulated; Name and Country of Regulator / Is the Entity/
Owner Publicly Traded / If Publicly
Traded;
Name and
Country of
Exchange(s)
Immediate IntermediateUltimate
Immediate IntermediateUltimate
Immediate IntermediateUltimate
Immediate IntermediateUltimate
Immediate IntermediateUltimate
Immediate IntermediateUltimate
Immediate IntermediateUltimate
Immediate IntermediateUltimate
Immediate IntermediateUltimate

For all owners who are individuals with ownership of 10% or more of the Participant (including instances where a family collectively owns more than 10%), provide the following information:

The Client hereby certifies that are no individuals other than those listed with more than 10% ownership

Individuals with Ownership of 10% or more
Full Legal Name[2] / City, State/Territory and Country of Residence / Country of Citizenship / Is the owner a Politically Exposed Person (PEP)[3]; if yes, what is his/her position / Ownership Percentage

If Ownership total is less then 100% from the Entities and Individual sections of this form combined, please provide the number of Owners with an Ownership percentage of less then 10%:

Controlling Parties

For Participants who are privately held, the controlling parties are individuals or entities with direct or indirect control over the account or the Participant. For KYC purposes, controlling parties are defined as anyone with power of attorney, executive management (e.g., CEO, CFO, etc.), and parties with the ability to elect the Board of Directors and members of the Board of Directors, partners, general partners, managing members, etc.

For Participants who are publicly listed entities, the controlling parties are individuals or entities with direct or indirect control over the account or the Participant. For KYC purposes, controlling parties are defined as executive management (e.g., CEO, CFO, etc.) and any party listed on the Certificate of Incumbency (“COI”).

For all individuals identified as control parties, provide the following information:

Individuals Identified as Controlling Parties
Full Legal Name / Relationship to Customer[4] / Country of Citizenship / City, State/Territory and Country of Residence

Number of Back Office Operational Personnel:

Applicant/Member Total Number of Personnel:

Number of Branch Offices and State(s) Located:

Main Countries of Operations:

Regulatory Information

Primary Regulator Information
Primary Regulator/Designated Examining Authority:
Contact Name of Primary Regulator and Title:
District and Phone Number of Primary Regulator Contact:
Date of Last Inspection by Primary Regulator (m/d/yyyy)

Effective date of SEC Registration:

SEC Registration Number:

Financial Reporting Requirement
Types of Report(s):
Frequency of Filing(s):

List the type(s) of business that your firm is currently engaged in, including a list of products and services offered to your customers:

Briefly describe any changes contemplated during the next six (6) months in the Applicant’s/Member’s business activities:

Applicant/Member - Other Memberships

Clearing Corp/Depository/Exchanges / Type of Membership

Briefly describe any pending membership applications and recent membership changes, as well as those contemplated during the next six (6) months:

Financial Credit Information

Financials for Two Most Recent Fiscal Year-Ends, as Reported on the Audited Financials
Fiscal Year-Ended
(m/d/yyyy) / Net Worth ($)
(shareholder’s equity, etc.) / Excess Net Capital ($) (As per SEC Rule 15c3-1)

AML Regulatory Information

Is your company subject to AML Regulations? (Yes or No)

Does your company have risk-based Know Your Customer policy and procedures? (Yes or No)

From an AML perspective, does your company monitor your customer's transactions to identify unusual/suspicious activity? (Yes or No)

From an AML perspective, does your company monitor transactions which will flow through DTCC's proprietary systems? (Yes or No)

Does your company have 15% or more (cumulative) of your customers located in the following jurisdictions (see Appendix A)? (Yes or No)

Please submit the completed form to:

Attn: Account Administration

Depository Trust Company

55 Water Street, 1SL Floor

New York, NY 10041

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Membership Questionnaire

[1] Type of entity can be one of the following:

Bank or Trust Company – Domestic

Bank or Trust Company - US Regulated Branch/Agency of Non-US Bank

Non-US Bank

Central Securities Depository

Broker Dealer - Domestic (US Registered/Regulated - Formed in the US)

Broker/Dealer – Non-US (US Registered/Regulated - Formed outside US)

Broker Dealer – Non-US (Non-US Registered/Regulated - Formed outside the US)

SEC Registered Clearing Agency

SEC Registered Transfer Agent

Futures Commission Merchant

Insurance Company

Registered Investment Advisor

Unregistered Investment Pool Incorporated in US

Unregistered Investment Pool Incorporated outside US

Investment Company Registered under the Investment Company Act of 1940 US Registered/Regulated – Formed/Incorporated in the US

Other

[2] If a group of family members combined have an ownership interest of 10% or more, these individuals must also be listed in the table.

[3] PEP generally includes current or former senior political officials, their immediate family, and their close associates.

[4] e.g., CEO, CFO, Board Member, etc.