Innovative Concepts AG — Client Onboarding & Identification

Establishment of the beneficial owner (AMLA Art. 4) and, for operating companies, of the controlling persons.

Beneficial ownership of the assets

I am the sole beneficial owner of the assets involvedOne or more third parties are the beneficial owner(s)

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For each beneficial owner: full name, date of birth, nationality and residential address

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Are you, or is any beneficial owner declared above, a US citizen or US tax resident (US person)?US citizenship, US tax residence, a US place of birth or a US address are relevant for FATCA purposes.

NoYes

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For each US person: full name, capacity (beneficial owner, controlling person, director, shareholder ≥25%) and country of tax residence. A Form W-9 will be requested separately during verification.

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Nature of the company

Operating company (active commercial activity)Domiciliary / holding company (no operating activity)

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Does any natural person hold, directly or indirectly, 25% or more of the company’s capital or voting rights?

YesNo

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For each controlling person (≥25%): full name, date of birth, nationality and residential address

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Identify the natural person(s) exercising control over the company in another manner, or — if none — the managing director

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Declaration of beneficial owner(s) of the assets: for each, full name, date of birth, nationality and residential address

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Is any controlling person, director or shareholder holding 25% or more a US citizen or US tax resident (US person)?US citizenship, US tax residence, a US place of birth or a US address are relevant for FATCA purposes.

NoYes

Please select an option.

For each US person: full name, capacity (beneficial owner, controlling person, director, shareholder ≥25%) and country of tax residence. A Form W-9 will be requested separately during verification.

Please complete this field.