Form K

FORM K

Declaration of Controlling Person for Non-Listed Entities (K)

CLIENT NUMBER

ACCOUNT / SECURITIES ACCOUNT NUMBER

(FOR OPERATING LEGAL ENTITIES AND PARTNERSHIPS THAT ARE CONTRACTING PARTNER AS WELL AS ANALOGOUSLY FOR OPERATING LEGAL ENTITIES AND PARTNERSHIPS THAT ARE BENEFICIAL OWNERS)

ESTABLISHING OF THE CONTROLLING PERSON OF OPERATING LEGAL ENTITIES AND PARTNERSHIPS BOTH NOT QUOTED ON THE STOCK EXCHANGE

CATEGORY (WHERE APPROPRIATE)

Contracting partner

CONTRACTING PARTNER

PURSUANT TO ARTICLE 20 OF THE AGREEMENT ON THE SWISS BANKS’ CODE OF CONDUCT WITH REGARD TO THE EXERCISE OF DUE DILIGENCE (CDB 20), THE CONTRACTING PARTNER(S) HEREBY DECLARE(S)

(TICK THE APPROPRIATE BOX)

THE PERSON(S) LISTED ON THE RIGHT-HAND SIDE IS/ARE HOLDING 25% OR MORE OF THE CONTRACTING PARTNER’S SHARES (CAPITAL SHARES OR VOTING RIGHTS); OR

IF THERE ARE NO CAPITAL SHARES OR VOTING RIGHTS OF 25% OR MORE, THAT THE FOLLOWING PERSON(S) LISTED BELOW IS/ARE CONTROLLING THE CONTRACTING PARTNER IN OTHER WAYS; OR

IN CASE NO PERSON(S) EXIST(S) WHO EXERCISE(S) CONTROL OVER THE CONTRACTING PARTNER IN A DIFFERENT CAPACITY, THE CONTRACTING PARTNER HEREBY DECLARES THAT THE PERSON(S) LISTED BELOW IS/ARE THE MANAGING DIRECTOR(S)

f

FIRST NAME(S), LAST NAME(S)/ENTITY

ACTUAL ADDRESS OF DOMICILE / REGISTERED OFFICE (INCL. COUNTRY)

STREET

HOUSE NUMBER

CITY

POSTAL CODE

COUNTRY

FIDUCIARY HOLDING OF ASSETS

(TICK THE APPROPRIATE BOX)

YES → THE RELEVANT INFORMATIONREGARDING THE BENEFICIAL OWNER HAS TO BE OBTAINED BY FILLING IN A SEPARATE FORM A, S, OR T.

THE CONTRACTING PARTNER(S) HEREBY UNDERTAKE(S) TO AUTOMATICALLY INFORM THE BANK OF ANY CHANGES.

PLACE

DATE

SIGNATURE

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IT IS A CRIMINAL OFFENCE TO DELIBERATELY PROVIDE FALSE INFORMATION ON THIS FORM (ARTICLE 251 OF THE SWISS CRIMINAL CODE, DOCUMENT FORGERY)