SJP Application Form - Ingenious Media

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APPLICATION FORM A 3. Adviser Details - to be completed by your adviser (if any). Title: Forename(s): Surname: Name of Firm: Firm Address: Postcode: Email: Phone Number: Firm FCA Number: Individual FCA Number: Adviser Confirmation I confirm that the Applicant is a customer of our firm and I have assessed the suitability of this investment for the Applicant. I confirm that any payment to me that the Applicant has required the Manager to facilitate is in relation to the provision by me of advice to the Applicant in respect of this application and the amount has been agreed by me with the Applicant in accordance with the rules on adviser charging and remuneration in COBS and is not a consultancy charge. Signature of Adviser: Date: DD / MM / YEAR Print Name: St James’s Place Partner Code: 4. Facilitation Payments - to be completed if you wish us to facilitate a payment from you to your adviser in respect of adviser charges. Facilitation Payment Amount Following the introduction of the Retail Distribution Review (effective from 31 December 2012), advisers must not solicit or accept commissions or certain other payments in connection with advice given to retail clients in respect of retail investments from product providers. However retail clients may in such circumstances pay an adviser charge in connection with such advice and a retail investment product provider, such as the Manager, may facilitate payments of adviser charges from the client to the adviser. Enter the total amount (in %) of any adviser charge (including VAT payment on such amount) that is required by the Applicant to be facilitated by the Manager (Facilitation Payment Amount): % In signing this Application Form I confirm that: a) the Facilitation Payment Amount is to be paid by the Custodian on the instructions of the Manager to my adviser; b) the Facilitation Payment Amount will not be invested in any Investee Companies and will not qualify for any EIS Reliefs; c) any subscriptions returned to me following any cancellation or withdrawal by me from the Fund will be returned net of the Facilitation Payment Amount and I acknowledge that there shall be no right of recovery in any circumstances from the Manager, any other Ingenious entity or the Custodian of any Facilitation Payment Amount; d) where amounts paid by me (by cheque or bank transfer) in respect of this application are less than the total amount subscribed for by me in this application plus any Facilitation Payment Amount the Manager may reduce the application subscription amount by that amount necessary to ensure the Manager has sufficient funds from me to be able to pay the Facilitation Payment Amount to my adviser; and e) the Facilitation Payment Amount (if any) is inclusive of any applicable VAT and I agree to reimburse the Manager for any VAT that is incurred by the Manager or any affiliated company or the Custodian on the Facilitation Payment Amount which is not recoverable by the incurring entity.
abc BROADCASTING EIS 2 5. Subscription to the Fund and Facilitation Payment (A) Gross investment (including any agreed Initial Advice Charge) £ (B) Agreed Initial Advice Charge (facilitation payment), if any (including VAT payable on such amount) £ (C) Net investment into the Fund (A-B), this needs to be a minimum of £10,000 £ Note: It is on this amount the investor should receive their tax relief Please indicate how you will pay your Subscription: by Cheque Bank Transfer Cheques should be made payable to Reyker Securities plc Client Account re: Ingenious Please note payments made by cheque will not be accepted after 18 July 2013 Bank transfer account details: Account Name: Sort Code: Account Number: Reference: Reyker Securities plc Client Account re: Ingenious 60 00 01 40482383 Applicant Surname and Initial(s) 6. Applicant Bank Account Details Please provide details of the bank account to which you would like any distributions credited. Where the account is in the name of a third party it will be necessary to identify that person for anti-money laundering purposes. Account Name: Account Number: Sort Code: Roll Number (if applicable): Bank Name: 7. Risk Factors Investment in the Service involves a high degree of risk, and may not be suitable for all investors. Therefore, it is important that you read and understand the detailed risk factors relating to an investment in the Service, as set out in the Brochure, which include the following: • share prices, their values and the income they generate through dividends can go down as well as up and investors may get back less than their original investment • past performance is not a guide to future performance; the extent and value of any tax advantages or benefits arising from the use of tax‐advantaged services such as ISAs, Junior ISAs, SIPPs and CTFs will vary according to the individual’s circumstances • the levels and bases of taxation may change • in compliance with the FCA rules, telephone calls will be recorded by the Custodian • early encashment may lead to some loss of capital
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Page 5 and 6: abc BROADCASTING EIS 2 8. Suitabili

SJP Application Form - Ingenious Media

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