BENEFICIAL-OWNERSHIP-DECLARATION-FORM-BO2.docx

BO2

ANNUAL CONFIRMATORY

BENEFICIAL OWNERSHIP(BO)

DECLARATION FORM

IN ACCORDANCE WITH THE COMPANIES AMENDMENT ACT NO.4 OF 2023, CLOSE CORPORATION AMENDMENT ACT NO. 5 OF 2023 & FINANCIAL INTELLIGENCE ACT 2012

COMPLETE FORM WITH BLACK INK IN BLOCK LETTERS – NO ABBREVIATIONS

PART A – ENTITY PARTICULARS

• ENTITY INFORMATION

• FULL LEGAL NAME OF ENTITY:

• ENTITY REGISTRATION NUMBER:

DECLARATION

1. I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT, ALL INFORMATION PROVIDED PREVIOUSLY, REMAIN THE SAME AND IS ACCURATE, ADEQUATE AND UP TO DATE.

NAME OF DIRECTOR/SHAREHOLDER/MEMBER/BENEFICIAL OWNER: ______________________________________________________

[DELETE WHERE NOT APPLICABLE]

SIGNATURE: DATE (DDMMYYYY):

OR

• I, UNDERSIGNED, FOR AND ON BEHALF OF THE REPORTING ENTITY CONFIRM THAT TO THE BEST OF MY KNOWLEDGE ALL

INFORMATION PROVIDED PREVIOUSLY REMAIN THE SAME AND IS ACCURATE, ADEQUATE AND UP TO DATE.

NAME OF ACCOUNTABLE INSTITUTION:

POSITION:

*IN THE CASE OF AN EXTERNAL COMPANY THE LOCAL MANAGER SHOULD SIGN.

NAME OF ACCOUNTABLE INSTITUTION:

POSITION:

*IN THE CASE OF AN EXTERNAL COMPANY THE LOCAL MANAGER SHOULD SIGN.

NAME OF AUTHORISED STAFF:

NAME OF AUTHORISED STAFF:

DATE (DDMMYYYY):

DATE (DDMMYYYY):

SIGNATURE:

SIGNATURE:

OFFICIAL USE ONLY [TO BE COMPLETED BY BIPA OFFICIAL]

NAME OF REGISTRATION OFFICER:

OFFICIAL USE ONLY [TO BE COMPLETED BY BIPA OFFICIAL]

NAME OF REGISTRATION OFFICER:

SIGNATURE:

SIGNATURE:

DATE (DDMMYYY):

DATE (DDMMYYY):