South African Reserve Bank Act, 1989 (Act No. 90 of 1989)

ANNEXURE

DISCLOSURE BY SHAREHOLDERS OF ASSOCIATES

(Disclosure in terms of Section 22 of the South African Reserve Bank Act as read with the Regulations)

Please state as follows—

1.

Full name of shareholder as it appears on the share certificate and total number of shares held:

______________________________________________________

______________________________________________________

2.

If the person mentioned in (1) is acting as a nominee, the full names and addresses of the holders of a beneficial interest in the shares ("beneficial shareholders")

______________________________________________________

______________________________________________________

3.

Disclosure of associates:

Name of associate* of the shareholder/beneficial

Manner in which related to the shareholders*

Number of shares owned by associate

*Refer to the definitions of "associate" and "close relative" in section 1 of the Act.

I_____________________________, acting in my capacity as_________________

Declare that the content of this disclosure is true to the best of my knowledge and belief and accurately reflects the particulars of all my associates.

Signature

Date

I know and understand the contents of this declaration. I have no objection to taking the prescribed affirmation/oath.  I consider the prescribed affirmation/oath to be binding on my conscience.

Deponent

Date

I certify that the deponent has acknowledged that he/she knows and understands the contents of this declaration. This declaration was affirmed/sworn to before me and the deponent’s signature was placed thereon in my presence at __________________________

on __________________________________________________

__________________________

Commissioner of Oaths

__________________________

Date

Full name of Commissioner

__________________________

Designation:

__________________________

Business Address:

__________________________

__________________________

__________________________

__________________________

__________________________

__________________________

Area for which he/she holds appointment:

__________________________

Office held if he/she holds this appointment ex officio:

_________________________