Notification of Cessation of Registered Director Status

in a Special Purpose Entity

CAPITAL MARKET AUTHORITY

(Confidential)

NOTIFICATION OF CESSATION OF REGISTERED DIRECTOR STATUS IN A SPECIAL PURPOSE ENTITY

SECTION 1: SPE DETAILS

  1. Full name of SPE:
  1. License Number:
  1. SPE’s Contact Personand Job Title:
  1. E-mail address:
  1. Telephone number:

SECTION 2: PERSONAL INFORMATION FOR THE WITHDRAWING DIRECTOR

2.1Name

Surname / First / Mid / Grandfather

2.2GenderMaleFemale

2.3Date of birth

Day / Month / Year

2.4Place of birth

2.5Nationality

2.6National Identification Number For Saudis

2.7Passport number For Non Saudis

2.7.1Date of expiration

Day / Month / Year

2.7.2Passport issuing country

SECTION 3: CONTACT INFORMATION FOR THE WITHDRAWING DIRECTOR

Please provide thedirector’s residential address, telephone and e-mail address.

3.1Permanent Residential Address:

Address
Street No. & Name
District & City
State
Postal Code,(if any)
Telephone Number
e-mail

3.2Job title withinSPE and office address:

3.3Cessation date of directorship

Day / Month / Year

3.4Please indicate the reason(s) for withdrawal of the above Director.

Change of responsibilities
End of contract
Resignation
Redundancy
Withdrawal of offer of employment*
Dismissal, termination of employment/contract or requested to resign*
Suspension*
Other*
* If the reason is one of these please provide an explanation below:

3.5Are there any circumstances which have led the SPE to believe that the Director is no longer fit and proper?

Yes / No
If Yes, please provide your rationale for this conclusion below:

SECTION 4: DECLARATIONOF THE WITHDRAWINGDIRECTOR

Name of the withdrawingdirector

I certify and represent that the information in this notification (including all supplements and attachments) is complete, true and correct.

I understand that the CMA may take any disciplinary or regulatory action against a person who has made a false or misleading representation in this notification.

I undertake that if any information in this notification changes before this notification is finalised, I will notify the CMA in writing immediately of the changes.

I acknowledge that the CMAhas the power to make any enquiries it considers appropriate of any person, request more detailed information or take steps to verify any information provided in this notificationshould it be deemed necessary to assess my fitness and propriety adequately. I consent to the CMAcontacting any previous employers, educational institutions, professional organisations or any other organisation, to verify any information contained in this notification.

I consent to the CMA using or disclosing any information I have provided in this notification or may provide in the future, for purposes of carrying out its responsibilities.

______//

SignatureDate

SECTION 5: SPE DECLARATION

To be completed by the SPE.

I declare that[Name of SPE]has reviewed the information provided in this notification (including all supplements and attachments).

I declare that [Name of SPE] shall maintain a register of Directors in accordance with Article 9 of the standard form by-laws for a Special Purpose Entity and that the details of the withdrawing director shall be removed from this register on cessation of the directorship of thewithdrawing director.

I declare that, to the best of my knowledge and belief, having made due enquiry into the withdrawing director’s background and qualifications, the information given in this notification is complete and correct. I understand that it is an offence to provide to the Regulator any information which is false, misleading or deceptive or to conceal information where the concealment of such information is likely to mislead or deceive the Regulator.

I confirm that I have the authority to make this notification, to declare as specified above and sign this form for, and on behalf of, the SPE.

Name of SPE:

______//

Name of director Signature and stamp Date

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