Pyrmont Bridge Road - Online Application Form

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Investor Type

Individual/Joint Investors/Sole Traders
Company
Trust/Superannuation Fund with Individual Trustee
Trust/Superannuation Fund with Corporate Trustee

I/we apply to invest in Units for the Pyrmont Bridge Road Mortgage Fund.

Amount: AUD @ $1.00 per Unit. *Minimum $1,000 AUD

Please tick the box beside your chosen payment method and complete the required details.

Bpay
Electronic Funds Transfer

Source of Investment Funds (we must collect this information as part of our AML/CTF obligations)

Please identify the source of your investable assets or wealth

Please fill this field if you selected "Other" from the Source of Investment Funds

Title

Given Names

Surname

Place of Birth

Country of Birth

Residential Address

Suburb

State

Postcode

Country

Mobile Number

Telephone

Occupation

Are you applying as a Joint Investor?

Title

Given Names

Surname

address investor

Tick this box if the address is same as investor 1

Residential Address

Suburb

State

Postcode

Country

Mobile Number

Telephone

Occupation

Politically Exposed Person (PEP)?

Yes, please provide description of PEP’s position
No

Are any of the Investors a PEP?

Yes, please provide description of PEP’s position.

Are you applying as a Sole Trader?

Full Business Name

Australian Business Number

If Principal Place of Business address is same as residential address given above, mark ‘As above’

Tick the box if Principal Place of Business address is same as residential address given above.

Address of Principal Place of Business (not a PO Box)

Suburb

State

Postcode

Country

Select one of the following options to verify each investor and Beneficial Owner.

Provide a certified copy of a driver’s license that contains a photograph of the license/permit holder
Provide a certified copy of a passport that contains a photograph and signature of the passport holder

Full Company Name

Country of Formation, Incorporation or Registration

ARBN

ACN/ABN

Tax File Number or Exemption Code

AFS License Number

Name of Regulator

Registered Business Address in Australia or in Country of Formation

Suburb

State

Postcode

Country

Same as above

Same as above

Principal Place of Business

Suburb

State

Postcode

Country

If an Australian Company, registration status with ASIC

Proprietary Company
Public Company

If a Foreign Company, registration status with the relevant foreign registration body

Private/Proprietary Company
Public Company
Other - Please Specify

Specify below if you selected "Other" for Foreign Company

Name of Relevant Foreign Registration Body

Foreign Company Identification Number

Is the Company Listed?

Name of Market/Stock Exchange

Is the company a majority-owned subsidiary of an Australian listed company?

Name of Australian Listed Company

Name of Market/Stock Exchange

Director 1 – Full Name

Director 2 – Full Name

Director 3 – Full Name

Director 4 – Full Name

Director 5 – Full Name

Director 6 – Full Name

Politically Exposed Person (PEP)

Yes, please provide description of PEP’s position.
No

Are any of the company directors a PEP?

Please provide description of PEP’s position.

Politically Exposed Person (PEP)

Yes, please provide description of PEP’s position.
No

Are any of the Beneﬁcial Owners a PEP?

Please provide description of PEP’s position.

Given Names

Surname

Postal Address

Suburb

State

Postcode

Country

Mobile Number

Telephone

Select one of the following options to verify the company.

Perform a search of the ASIC database (https://asic.gov.au/online-services/search-asic-s-registers/companies-and-organisations/)
Provide a certified copy of the certification of registration issued by ASIC or the relevant foreign registration body (must show full name of company, name of registration body, company identification number and type of company – private or public)

Select one of the following options to verify the Officeholders who have signed the Application Form and Beneficial Owners identified in Section 6.6.

Provide a certified copy of a driver’s license that contains a photograph of the license/permit holder
Provide a certified copy of a passport that contains a photograph and signature of the passport holder

Full Name of Trust/Superannuation Fund

Country of Establishment

Tax File Number or Exemption Code

Australian Business Number

TYPE OF TRUST

Type A: Regulated Trust (e.g. self-managed superannuation fund)
Type B: Government Superannuation Fund
Type C: Foreign Superannuation Fund
Type D: Other Type of Trust/Unregulated Trust

(Please tick ONE box from the list below to indicate the type of Trust and provide the required information)

Name of regulator

Registration/Licensing details

Name of the legislation establishing the fund

Name of Regulator

Registration/Licensing Details

Trust Description

SETTLOR OF THE TRUST

The material asset contribution to the trust by the settlor at the time the trust was established was less than $10,000.00.
The settlor of the trust is deceased.
Neither of the above is correct

Provide the full name of the settlor of the trust.

BENEFICIARY DETAILS

Do the terms of the Trust identify the beneficiaries by reference to a membership of a class?

Describe the class of beneficiaries below

Politically Exposed Person (PEP)

Are any of the beneficiaries a PEP?

Please provide description of PEP’s position.

For Trusts identified under 4.1 as Type A & Type B – select one of the following options to verify the Trust.

Perform a search of the relevant regulator’s website e.g. ‘Super Fund Lookup’ (unit registry to perform on behalf of the investor);
Provide a copy of an offer document of the managed investments scheme e.g. a copy of a Product Disclosure Statement; or
Provide a copy or relevant extract of the legislation establishing the government superannuation fund sourced from a government website.
Provide a certified copy or a certified extract of the Trust Deed containing the cover page, recitals and signature page;
Provide an original letter from a solicitor or qualified accountant that confirms the name of the Trust and full name of the settlor of the Trust; or
Provide a notice issued by the Australian Taxation Office within the last 12 months (e.g. a Notice of Assessment).

For Trusts identified under 4.1 as Type C & Type D – select one of the following options to verify the Beneficiaries and the Beneficial Owners identified in Section 6.6

Provide a certified copy of a driver’s license that contains a photograph of the license/permit holder; or
Provide a certified copy of a passport that contains a photograph and signature of the passport holder.

AND relevant identification documents for the trustee as specified in Section 2 or 3 (as applicable).

Bank/Institution

Branch

Account Name

The name of your nominated bank account must be the same as the Investor’s name.

BSB

Account Number

Country of Tax Residence 1

Taxpayer Identification Number 1

TIN Unavailable 1

TIN Unavailable

Country of Tax Residence 2

Taxpayer Identification Number 2

TIN Unavailable 2

TIN Unavailable

Country of Tax Residence 3

Taxpayer Identification Number 3

TIN Unavailable 3

TIN Unavailable

TIN Unavailable Explanation(s)

If any ‘TIN Unavailable’ box is checked, please provide an explanation.

I/We certify the tax residence countries provided represent all countries in which the Account Holder is considered a tax resident.

I/We certify the tax residence countries provided represent all countries in which the Account Holder is considered a tax resident.

If Account Holder has additional countries of tax residence, please email a statement to info@blackwall.com.au containing the Country and TIN for each such additional country.

IS THE ACCOUNT HOLDER A U.S. PERSON?

Yes (If 'Yes', the Account Holder’s U.S. country of residence and U.S. Tax Identification Number must be provided above.)
No

A U.S. person includes a U.S. citizen or resident alien of the U.S. even if residing outside the U.S.

Account Holder’s GIIN

Sponsoring Entity’s Name

If the Account Holder is a sponsored entity, please provide the sponsor’s GIIN.

Country of Tax Residence 1

Taxpayer Identification Number 1

TIN Unavailable 4

TIN Unavailable

Country of Tax Residence 2

Taxpayer Identification Number 2

TIN Unavailable 5

TIN Unavailable

Country of Tax Residence 3

Taxpayer Identification Number 3

TIN Unavailable 6

TIN Unavailable

TIN Unavailable Explanation(s)

If the Account Holder is a sponsored entity, please provide the sponsor’s GIIN.

I/We certify the tax residence countries provided represent all countries in which the Account Holder is considered a tax resident.

If Account Holder has additional countries of tax residence, please email a statement to info@blackwall.com.au containing the Country and TIN for each such additional country.

U.S PERSON CERTIFICATION

Yes (Provide a U.S. TIN below)
No

Is the Account Holder a specified U.S. person?

US Taxpayer Identification Number (TIN)

If No, complete the non U.S. Person certification

Select deemed-compliant category:

Trustee-Documented Trust (Provide GIIN and Trustee name in Section 6.2) Sponsored Investment
Vehicle (Provide GIIN and Sponsor’s name in Section 6.2) Registered-Deemed Compliant FFI
(Provide GIIN in Section 6.2)
Other Deemed-Compliant Category

Please provide the date the entity was organized

IS THE ACCOUNT HOLDER A FINANCIAL INSTITUTION?

Yes (If any tax residence country provided is not a participating CRS jurisdiction, then complete Section 6.6 – Controlling Persons.)
No

Financial Institution Is the entity an Investment Entity managed by an FI or other Financial Institution?

Non-Financial Entity (NFE)

Government Entity, International Organisation and Central Bank
A corporation the stock of which is regularly traded on an established securities market (or entity related to such a corporation)
Non-Reporting Financial Institution (includes Broad Participation Retirement Fund, Narrow Participation Retirement Fund, Exempt Collective Investment Vehicle, Trustee Documented Trust and Self-managed Superannuation Fund)
A Start-up Company formed in the past 24 months
Other Active NFE
Passive NFE (Complete Section 6.6 – Controlling Persons)
Other – describe the CRS Status

If the Account Holder is a Non-Financial Entity (NFE), select a classification that matches your CRS status:

Name of Securities Market:

Name of Related Entity:

Please provide the date the entity was organized:

First Name

Family Name/Surname

Current Residence Address

City/Town

State/Province

Postcode

Country

City/Town of Birth

Country of Birth

Country of Tax Residence 1

Taxpayer Identification Number 1

Country of Tax Residence 2

Taxpayer Identification Number 2

TIN Unavailable Explanation(s)

If TIN is not provided above, please provide an explanation.

*Please tick the box/es to select the role types that are relevant to you (i.e. Controlling Person 1/Beneficial Owner 1).

Controlling Person* / Legal Person* / Legal Arrangement – Trust* / Legal Arrangement – Other*
Beneficiary Type*

First Name

Family Name/Surname

Current Residence Address

City/Town

State/Province

Postcode

Country

City/Town of Birth

Country of Birth

Country of Tax Residence 1

Taxpayer Identification Number 1

Country of Tax Residence 2

Taxpayer Identification Number 2:

TIN Unavailable Explanation(s) – If TIN is not provided above, please provide an explanation.

*Please tick the box/es to select the role types that are relevant to you (i.e. Controlling Person 1/Beneficial Owner 1).

Controlling Person* / Legal Person* / Legal Arrangement – Trust* / Legal Arrangement – Other*
Beneficiary Type*

I/we wish to receive information regarding future investment opportunities. You may change your election at any time by contacting the Issuer.

I/we wish to receive information regarding future investment opportunities. You may change your election at any time by contacting the Issuer.

Communication Consent

I/we would like to receive all communications via post

Full Name

Tick capacity (mandatory for companies):

Sole Director and Company Secretary
Director
Secretary

Full Name

Are you applying via a financial adviser?

Please provide access to information and send copies of all transaction confirmations to my/our financial adviser. You may change your election at any time by contacting the Issuer.

Please provide access to information and send copies of all transaction confirmations to my/our financial adviser. You may change your election at any time by contacting the Issuer.

Please select the relevant option below:

I have attached the verification documents that were used to perform the CID for this investor and/or the beneficial owners
I have not attached the verification documents but will retain them in accordance with the AML/CTF Act and agree to provide them to the Issuer or its agents with access to these documents upon request. I also agree that if I become unable to retain the verification documents used for this application in accordance with the requirements of the AML/CTF Act I will forward them to the Issuer

I agree to provide the Issuer or its agents with any other information that they may require to support this Application.

Financial Adviser Name

Financial Advisor Name

Financial Advisor Number

Contact Person

AFSL Number

ABN

Suburb

State

Postcode

Country

Office Telephone

Certifying a Document

Certifying a Document

PEP

PEP questions

Beneficial Owner

Beneficial Owner questions

Do you accept that you have no right to withdraw your money for the term of the Fund?

Do you accept the capital value of your investment is not guaranteed?

The income paid by this Fund is not guaranteed and may vary over time. Do you accept that you should not invest if you are reliant on the income you receive from this fund to meet your day to day living requirements and cannot bear any fluctuations in your income distributions?

Diversification is an important principal of investing. Do you accept that you should not invest all your savings in a single investment or asset type and this investment should form part of a broader investment portfolio?

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Pyrmont Bridge Road - Online Application Form

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