Download Appendix 6(ii) Investor`s Statement (legal person) First name and

Appendix 6(ii) Investor’s Statement (legal person)
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First name and surname:
Address of residence:
- country:
- town/city:
- street:
- house / apt. no.:
- postcode:
Identity card number or passport
number:
Contact details:
- phone:
- e-mail address:
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Ultimate Beneficial Owner’s details to be filled. Where the Investor has more than one Ultimate Beneficial
Owner, please fill in details of all the Ultimate Beneficial Owners. In such case, the statement should be
completed and signed separately by all the Ultimate Beneficial Owners.
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PRIVATE INVESTOR’S STATEMENT2
I, the undersigned, being the Ultimate Beneficial Owner3 (“Ultimate Beneficial Owner”) / I/We, the
undersigned, representing4 the Private Investor operating business under the corporate name of
_______________________________5 (“Investor”) hereby represent and warrant that:
1. Ultimate Beneficial Owner status6
1.1. I am the Ultimate beneficial Owner due to the fact that7:
2. Status and authorisation of the Investor
2.1. The Investor was duly incorporated and operates under the governing law of the place of its
incorporation and/or registration.
2.2. The Investor has full capacity and authorisation to fulfil the commitment to make a private
contribution under the SG OP
2
Where the Tender indicated more than 1 (one) Private Investor, Investor’s Statement must be completed and
signed separately by each Private Investor.
3
Ultimate Beneficial Owner means:
1) a natural person or natural persons who own or control the Investor,
2) a natural person or natural persons who are members or shareholders or hold voting rights at the
shareholders’ meeting in excess of 50% in the legal person concerned, including through bearer share
holdings, other than companies whose securities are traded on organised venues, subject to or
applying laws and regulations of the European Union concerning the disclosure of information, as well
as entities providing financial services within the territory of a Member State of the European Union or
an equivalent state - in the case of legal persons,
3) a natural person or natural persons who control at least 50% of the assets - in the case of entities
entrusted with the administration of assets and distribution of such assets, except for entities
performing portfolio management activities, where the portfolios consist of one or more financial
instruments.
Where in each case, the persons concerned are natural persons who ultimately, directly or through other
entities, finance and control the Investor’s activities (in particular in the case of Investors registered in
countries where, in accordance with the law, direct shareholders are trust funds, acting on behalf of and for the
benefit of individual natural persons not disclosed in the register files of such Investors as bodies controlling or
financing their activities).
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To be filled by the persons authorised to represent the Investor, where there is no situation of control over
the Investor referred to in footnote 3 and the Investor finances the Contribution to the Financial Intermediary
in whole from funds generated from their own business and not from funds raised from natural persons being
the owners of the Investor and in control of the Investor.
5
Please enter here the corporate name of the Private Investor, name of the register/registry in which the
Private Investor is entered, as well as the number of entry of such Private Investor in the register/registry.
6
To be filled only by an Ultimate Beneficial Owner
7
Please describe the basis on which the person concerned is deemed to be the Ultimate Beneficial Owner
within the meaning of footnote 3 to this statement (e.g. I have the Ultimate Beneficial Owner status within the
meaning of footnote 3 to this statement due to the fact that I exercise control over the Investor by holding the
controlling interest in the Investor).
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2.3. A) the fulfilment of the Investor’s commitment to make a private contribution does not
depend on the Investor’s obtaining any consent, approval, notice or registration by any
public, self-government administration authority or any other authority and/or third party
(including under any contract or agreement).
B) Except for the following, the fulfilment of the Investor’s commitment to make a private
contribution does not require the Investor’s obtaining any consent, approval, notice or
registration by any public, self-government administration authority or any other authority
and/or third party (including under any contract or agreement).
2.4. The Investor is not subject to liquidation or bankruptcy, nor have public collective insolvency
proceedings been initiated against the Investor for the purpose of rescue, adjustment of
debt, reorganisation or liquidation within the meaning of Article 1. 1 (without the last
sentence) of EU Regulation 2015/848.
2.5. The Investor meets the definition of an independent private investor within the meaning of
Article 2 (72) of Commission Regulation (EU) No 651/2014 of 17 June 2014 declaring certain
categories of aid compatible with the internal market in application of Articles 107 and 108
of the Treaty.
2.6. The structure of the Investor’s owner forms Exhibit A hereto.8
3.
Investor’s private contribution
3.1. The Investor will provide a private contribution to the Financial Intermediary in the amount
of ________9. The Investor has the necessary resources sufficient to finance the Investor’s
private contribution to the Financial Intermediary on the terms of the Tender submitted by
________10.
3.2. The Investor’s earmarked funds as the private contribution declared for making in the
Financial Intermediary originate from the Investor’s own funds and are free from any public
support and/or state aid, and in particular they do not constitute public funds, as defined in
the Act of 27 August 2009 on Public Finance.
3.3. The Investor’s earmarked funds as the private contribution declared for making in the
Financial Intermediary originate from sources that do not infringe, and their use does not
infringe any provisions of the Act of 16 November 2000 on Preventing Money Laundering
and Financing Terrorism (i.e. Journal Laws of 2016, item 299, as amended), including in
particular the making of private contribution in the declared amount does not constitute
money laundering or serve the purposes of financing terrorism.
8
To be filled by Investors the control over which is not exercised by Ultimate Beneficial Owners, as referred to
in footnote 3.
9
Enter the value of the declared contribution to the Financial Intermediary.
10
Please enter here the details of the Tenderer, in connection with whose Tender this statement is made.
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4.
Consent to due diligence in the event the Tender is selected through the Call
4.1. The Ultimate Beneficial Owner/Investor undertakes to allow, prior to signing the Investment
Agreement, PFR Ventures, PFR Starter FIZ and/or their professional advisers to conduct due
diligence of the Investor in order to verify its legal and financial capacity to provide the
private contribution to the Financial Intermediary in the declared amount, and in terms of
the correct determination/indication of the ultimate beneficial owner of the Investor or
members/shareholders of the Investor. To this end, the Ultimate Beneficial Owner
undertakes to cause that both the Ultimate Beneficial Owner and the Investor, on demand of
PFR Ventures and/or PFR Starter FIZ or their professional adviser, deliver to PFR Ventures
and/or PFR Starter FIZ or their professional advisers, in particular, any and all documents
confirming that the Investor is in possession of the private contribution and indicating the
ownership structure of the Investor.
5. Conflict of interest
5.1. The Ultimate Beneficial Owner/ Investor represents and warrants that there is no conflict of
interest regarding the Ultimate Beneficial Owner or the Investor/ members of their managing
and supervisory bodies and arising for any of the reasons set out in §13.1 of the Rules.
5.2. The Ultimate Beneficial Owner/ Investor undertakes to immediately notify PFR Ventures of
any circumstances constituting a conflict of interests leading to untruthfulness of the
statement contained in point 5.1 above.
6.
Other statements
6.1. In connection with the repayable financing provided by PFR Starter FIZ for Investments to be
made by the Financial Intermediary, for which the Investor (together with the Tenderer) may
apply under the Call, the Ultimate Beneficial Owner/ Investor represents and warrants that
with regard to the contributions provided by the Ultimate Beneficial Owner / Investor there
will be no double financing, in part or in whole, in accordance with the guidelines on
eligibility of expenditure within the framework of the European Regional Development Fund,
the European Social Fund and the Cohesion Fund for the years 2014-2020.
6.2. The Ultimate Beneficial Owner/ Investor is aware that the financial support provided by PFR
Starter FIZ represents state aid within the meaning of Article 107 (1) TFEU and is subject, in
particular, insofar as its allocation and settlement is concerned, to the provisions of the Act
of 30 April 2004 on procedural issues concerning state aid (Journal of Laws of 2007, No 59,
item, 404, as amended), and therefore the Ultimate Beneficial Owner/ Investor
acknowledges that upon entering into the Investment Agreement the Investor will have the
status of a state aid beneficiary.
6.3. The Ultimate Beneficial Owner/ Investor consents to the processing of the Ultimate
Beneficial Owner’s personal data contained in this statement by PFR Ventures and/or PFR
Starter FIZ and by other authorised entities for purposes related to the analysis of the
Tender, in compliance with the Act of 29 August 1997 on protection of personal data (Journal
of Laws No. 133, item 883).
6.4. The Ultimate Beneficial Owner/ Investor consents to the disclosure by PFR Ventures and/or
PFR Starter FIZ, at any time, of information about the Ultimate Beneficial Owner, received by
PFR Ventures and/or PFR Starter FIZ in connection with the Tender, to entities belonging to
the capital group of which PFR Ventures and/or PFR Starter FIZ is a member, and to TFI BGK
and the Beneficiary, and the competent ministry responsible for the management of the SG
OP (the managing institution).
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6.5. Any terms not defined herein have the meaning given in the Call Rules.
___________________________________________________________
Signature
___________________________________________________________
Date, place
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Exhibit A to the statement of the Private Investor being a legal person, which is not controlled by
ultimate beneficial owners in the manner indicated in footnote 3 in the Form
Name of the
member/shareholder*

Number of shares/stocks
% of the Investor’s capital
In the case of members/shareholders registered in countries where, in accordance with the
law, direct shareholders are trust funds, acting on behalf of and for the benefit of individual
natural persons not disclosed in the register files of such Investors as bodies controlling or
financing their activities, natural persons in control of such member/shareholder must also
be indicated.
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