JPF Form

Jersey Private Fund (JPF)

Application form for authorisation (JPF Form)

This JPF Form should be completed and submitted by the relevant designated service provider (DSP) (or on behalf of the relevant DSP, signed by the relevant DSP)by email in readable pdf format to:

Note:
This JPF Form and the 48 hour streamlined JPF authorisation process can only be used by a JPF which meets all of the eligibility criteria for a JPF set out in detail under Part D of the Jersey Private Fund Guide (Guide) published by the Jersey Financial Services Commission (JFSC).

1.DSP*details:

1.1Name of DSP:

*A DSP must not be a “managed entity” for FSB purposes.
Please note that in the event that the JFSC requires further information from the DSP regarding this JPF Form, the JFSC will contact the DSP’s compliance contact of record.
Please note that fee invoices for the JPF will also be sent to the DSP’s compliance contact.

2.JPF details:

2.1Name of JPF:

2.2Legal form of JPF:

/ Please choose from:CompanyLimited partnershipLimited liability partnershipUnit trust

2.3In the case of a unit trust / limited partnership / limited liability partnership, please insert the name(s) of the trustee/ general partner/managing partner

2.4Registered office address:

2.5Jurisdiction of establishment / incorporation / registration:

2.6Date of establishment / incorporation / registration:

/

//

2.7Will the JPF be an “Alternative Investment Fund” (AIF) (within the meaning of Regulation 3 of the Alternative Investment Funds (Jersey) Regulations 2012)?

Please choose from:YesNo
Note:
Where a JPF is also an AIF, the application timescale and fee attaching to the relevant AIFMD Form(s) shall be separate from the application timescale and fee attaching to this JPF Form.

2.8Please confirm that the activity of the JPF will be in compliance with the principles set out in the Commission’s sound business practice policy?

Confirmed
2.9Under what Article(s) is the ‘relevant consent’(within the meaning of Part A of the Guide) sought for the purpose of this application?
Please choose from:Art 1: Non-JSY Company issuing sharesArt 2: JSY Company issuing sharesArt 3: Non-JSY Company hold registerArt 4: Company issuing securities (except shares)Art 9(1)(a): Unit Trust issuing unitsArt 9(1)(b): Unit Trust JSY Law/hold registerArt 10(1)(a): JSY LP issuing interestsArt 10(1)(b): LP Create interests/hold registerArt 10(1)(c): Non-JSY LP circulating offerArt 11(1)(a): JSY LLP issuing interestsArt 11(1)(b): LLP Create interests/hold register Art 11(1)(c): Non-JSY LLP circulating offer
Please choose from:Art 1: Non-JSY Company issuing sharesArt 2: JSY Company issuing sharesArt 3: Non-JSY Company hold registerArt 4: Company issuing securities (except shares)Art 9(1)(a): Unit Trust issuing unitsArt 9(1)(b): Unit Trust JSY Law/hold registerArt 10(1)(a): JSY LP issuing interestsArt 10(1)(b): LP Create interests/hold registerArt 10(1)(c): Non-JSY LP circulating offerArt 11(1)(a): JSY LLP issuing interestsArt 11(1)(b): LLP Create interests/hold register Art 11(1)(c): Non-JSY LLP circulating offer
Please choose from:Art 1: Non-JSY Company issuing sharesArt 2: JSY Company issuing sharesArt 3: Non-JSY Company hold registerArt 4: Company issuing securities (except shares)Art 9(1)(a): Unit Trust issuing unitsArt 9(1)(b): Unit Trust JSY Law/hold registerArt 10(1)(a): JSY LP issuing interestsArt 10(1)(b): LP Create interests/hold registerArt 10(1)(c): Non-JSY LP circulating offerArt 11(1)(a): JSY LLP issuing interestsArt 11(1)(b): LLP Create interests/hold register Art 11(1)(c): Non-JSY LLP circulating offer
Please choose from:Art 8: Non-JSY CompanyArt 8: Non-JSY Unit Trust circulating offer with a‘relevant connection’ to Jersey.
Note:
This question allows for the option to choose up to 4 different Articles.

2.10May a discretionary investment manager acquire an interest in the JPF, either directly or indirectly on behalf of persons who are not professional investors (see paragraph 5 of Annex A of the Guide)?

Please choose from:YesNoNot known at this stage
If so, please disclose the name(s) of the discretionary investment manager(s):

2.11In relation to the JPF, will there be 50 or 15 or fewer offers and professional and/or eligible investors.

Please choose from:1550

2.12Where there is a minimum initial investment in or commitment to the JPF please confirm the amount(s)in the relevant currency per investor:

Minimum investment amount(s):

2.13What asset class will the JPF invest in?

Please identify the most applicable investment policy code using the list provided in AppendixA to this JPF Form.
Investment policy code:

2.14Will the JPF be a “professional investor regulated scheme” (PIRS) (within the meaning of the Financial Services (Investment Business (Restricted Investment Business – Exemption)) (Jersey) Order 2001 and the Financial Services (Trust Company Business(Exemptions No.5)) (Jersey) Order 2001 (together, the PIRs Orders))?

Please choose from:YesNo

2.15Please confirm the anticipated launch date of the JPF?

/ / or if not known please tick here

3.Jersey service provider details (other than the DSP named in 1.1 above):

3.1Are there any Jersey service providers to the JPF?

Please choose from:YesNo

3.2If yes, please provide the following details in respect of each. If the DSP named in 1.1 above will be providing any of the services listed below, please enter ‘DSP’ in the second column.

Type / Name / PIRs Exemption
Administrator
Manager
Registrar
Investment Manager
Investment Adviser
Distributor
Prime Broker
Trustee/Custodian/ Depositary
Member of Partnership (except a LP)
Auditor
Other (please specify role)[1]

3.3Are any Jersey service providers to the JPF relying on the PIRS Orders to exempt them from the requirement to register under the FSJL to carry on ‘trust company business’ and/or ‘investment business’ within the meaning of the FSJL (PIRS Exemption) to the extent that they may be carrying on either financial service business?

Yes No

If yes, please confirm by ticking the third column in 3.2 abovewhich Jersey service providers are relying on the PIRS Exemption.

3.4Are any Jersey service providers to the JPF relying on any other FSJL exemption?

Yes No

If yes, please provide details of which Jersey service providers and which other FSJL exemption:

Issued: 15 March 2017Page 1 of 6

Effective From: 18 April 2017

VPPF Form

Declaration from DSP in its capacity as DSP to the JPF

Acting in our capacity as DSP to the JPF, we declarethat:
›Having made all reasonable enquiry, the information provided in this JPF Form is complete, true and accurate to the best of our knowledge and belief and we are aware of our obligations under Article 28 of the Financial Services (Jersey) Law 1998, to not knowingly or recklessly provide any information that is false or misleading.
›Having made all reasonable enquiry, we are satisfied that the JPF will,on its establishment, meet all of theeligibility criteria referred to under part D. of the Guide
›We have carried out all necessary due diligence on the JPF and its promoter and will ensure that the promoter puts in place appropriate measures to ensure that all service providers to the JPF are fit and proper and can fulfil the tasks in a responsible, professional and suitable manner.
›All documents relating to our due diligence enquiries will be readily retrievable in Jersey and, if kept otherwise than in legible form, will be maintained by ourselves so as to be readable at a computer terminal in Jersey so that they may be produced in legible form without delay.
›We will ensure compliance with all necessary Jersey AML/CFT requirements applicable to the JPF.
›We will not cease to act as DSP to the JPF without the prior approval of an officer of the JFSC.
›We willin our capacity as DSP to the JPF and having made all reasonable enquiry, complete a JPF Returnin each relevant year.
›We will notify the JFSC,in writing by completing and submitting a JPF notice of change or event (JPF Notice of Change or Event), as soon as reasonably practicable, and for the avoidance of doubt within 28 calendardays’, in the event of any of the circumstances referred to in Part G, paragraph 6(vi) of the Guide.
Acting in our capacity as DSP to the JPF, we hereby request on behalf of the JPFthat any relevant consent to be issued for the purposes of this application should (i) replace any previous relevant consent issued to or in relation to the JPF pursuant to COBO and (ii) be issued with immediate effect.

This declaration is signed for and on behalf of the DSP by any two directors of the DSP.

Director: / Director:
FullName: / FullName:
Signature: / Signature:
Date: / // / Date: / //

Issued: 15 March 2017Page 1 of 6

Effective From: 18 April 2017

Appendix A:codesfor investment policy

Please use the code and description that most closely matches the investment policy of the fund.

Specialist

S01 Specialist-Venture Capital/Private Equity- Emerging Markets

S02 Specialist-Venture Capital/Private Equity- Other

S03Specialist-Real Property

S04 Specialist-Derivatives

S05 Specialist-Traded Endowment Policies

S06 Specialist-Hedge/Alternative Investment Funds

S07 Specialist-Other

Equity

E01 Equity-UK

E02 Equity-Europe (Including UK)

E03 Equity-Europe (Excluding UK)

E04 Equity-US (North America)

E05 Equity-Japan

E06 Equity-Far East (Including Japan)

E07 Equity-Far East (Excluding Japan)

E08 Equity-Global Emerging Markets

E09 Equity-Global Equity

E10 Equity-Other

Bond

B01 Bond-Global

B02 Bond-UK Debt

B03 Bond-US Debt

B04 Bond-Europe

B05 Bond-Other

Money Market

M01 Money Market-Sterling

M02 Money Market-US Dollar

M03 Money Market-Euro

M04 Money Market-Swiss

M05 Money Market-Other

Mixed

X01Mixed-Mixed Equity and Bond

Issued: 15 March 2017Page 1 of 6

Effective From: 18 April 2017

[1] If other, and registered for ‘trust company business’ or ‘investment business’ within the meaning of the Financial Services (Jersey) Law 1998 (FSJL), please include details of class.