Dear Sir / Madam

FICA REQUIREMENTS FOR AN INDIVIDUAL / NATURAL PERSON

You are kindly requested to provide us with the following documents which are required in
terms of the Financial Intelligence Centre (FICA) Act 38 of 2001:

ID Book - A certified copy of your barcoded identity document (if a South African
resident) or passport (if a foreign national)

Proof of Residency - Original or certified recent documentary evidence of your

residential address (e.g. utility bill, telephone account, motor vehicle license or bank
statement)

SARS Tax Certificate - Original or certified documentation from SARS reflecting your
tax registration number

Completed “Know Your Client” (KYC) form, attached hereto

PLEASE NOTE:

All documents must be either original, original certified or original sighted.

A Commissioner of Oaths must certify each document and the following details must
appear together with the Commissioner's signature:

Full name of the Commissioner of Oaths

Title of Commissioner of Oaths
Date of certification
Signature of Commissioner of Oaths
Wording must stipulate: "Certified a true copy of"
If the document being commissioned is more than one page, the stamp/full
commission must appear on either the front or back page and the Commissioner
must initial every page of the document in between.

Your urgent attention hereto will be highly appreciated.

Regards,

COUZYN HERTZOG & HORAK INCORPORATED

Email: fica@couzyn.co.za
Couzyn Hertzog & Horak Incorporated (1997/001019/21)
321 Middel Street Brooklyn Pretoria PO Box 2509 Brooklyn Square 0075 Docex 50 Brooklyn
Tel (Int): +27 12 460 5090 Fax (Int): +27 12 460 5320 E-mail: pretoria@couzyn.co.za Website: www.couzyn.co.za
Directors: Hans Oosthuizen Amanda Booysen Jan Sterk Jan Kruger Derick Nel Werner Bruyns Horace Kotsokoane Mariana Vorster
Ferdie Trüter Marinus Steenkamp Bennie Marais Associates: Derik van der Linde Petri de Clercq Professional Assistants: Stefan Oosthuizen Henrike
Putter Mudzunga Nemaranzhe Wikus Hertz Administrative Manager: Jolandie Augustyn Accountant: Anel Denysschen
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KNOW YOUR CLIENT (KYC) FORM – INDIVIDUAL / NATURAL PERSON

1. Full Name and Surname:

______________________________________________________________________

2. Contact Number and e-mail adress:

(h) ____________________________ (s) ________________________________

(f) ____________________________ (e-mail) _____________________________

3. Occupation:

______________________________________________________________________

4. Identity Number and Date of Birth:

__________________________________________________________________

5. Income Tax Registration Number:

______________________________________________________________________

6. Residential and Postal Address (if different):

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

7. Bank Account Details:

______________________________________________________________________

______________________________________________________________________

Please note that if the client or business partner is a minor or person without legal capacity all the
guardian / curator / parent's details must be supplied as per the above as well as the client or
business partner's details. Where a person acts on behalf of the client or business partner proof of
the authority must be attached together with the details as required above for the client and person
authorised to act.
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Declaration by client / business partner

I declare and warrant that:

• the information supplied above is correct.

• the funds to be used in the transaction do not constitute the proceeds of unlawful
activity, including but not limited to tax evasion and breach of exchange control
regulations.

• I am aware that certain Companies are obligated by law to report money laundering
suspicions and certain defined transactions to the Financial Intelligence Centre.

• I have been advised to consult with an attorney should I require further clarification
concerning this document.

Signed at_____________________on the_____day of______________________ 20_____

_________________________________________________________________________
Prospective client (Full names and signature)