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Annual Economic Substance Notification

Please complete this form, on behalf of the below named entity, with this information relating to Section 7(2) of the International Tax Co-Operation (Economic Substance) Law 2018 (“ES Law 2018”) to the Department for International Tax Cooperation.

* Denotes Required Inputs

I,

, on behalf of

acknowledge that by submitting this form I hereby confirm that I am an authorised signatory of the entity, and I acknowledge that Genesis Trust & Corporate Services Ltd. ("Genesis") will make a submission to the Cayman Islands Tax Information Authority, based on the information provided in this form. I acknowledge that there are sanctions as outlined in Section 13(2) of the ES Law 2018 for providing inaccurate information and I confirm that the entity will indemnify Genesis for any liability that may result from the submission of inaccurate information. I also acknowledge that Genesis will make the submission without undertaking any investigation or verification of the information I am providing.

By submitting this form, I further confirm that I, or another authorised signatory of the entity, will immediately advise Genesis should any of the information submitted, as required by Law and/or the regulations, cease to be true.