MOVENTUM

Know Your Customer Questionnaire for single accounts, jOint accounts and minor accounts Dotaznfk: Poznejte sveho zakaznfka pro samostatne Lilty, spolelne Licty a Lilty pro nezletile

'For your COII~II;tn(t. the dolo rhol we hoYt on our Iiles havt bun prtpopulottd 1/ any o[ the daro ort mCOfftCl pleost PflnI rile corrf!ct dOlo In I~ r~/ds provided 0(1 fi,e last poge. Please note thol In such a WSt lilt may (on/oa you to request supportlllg dCKu~nrs.I' Pro usnodn~nl bYo/ pl tdvyplneny informore. kttri m6mt v zdznomech. Pokud jsrw nlkteri In/ormoa: ~pravni, ~dft foskovi sprdvni ;n/ormoc:r tiskod m pismem II' /co/on/t:6ch no posltdni stroni. UPOlO,nuftTne, it v tOkowm p iipadi Vas mulemt kOnlOktOllOf a poiodovut podklody.

Account Number I tislo uttu 4556889

1" Account Holder 1

1. majitel uctul

lenka Tomeckova

Kuncicky u Basky 417

73901 Kuncicky u Basky

Czech Republic

Dale of birth (dd.mm.yy) :

Datum narozeni (mm.dd.rm) :

23 .07 .1958

Place of birt h: Frydek·M istek

M islO narOlen! :

2"' Account Holder I

2. majitel uctu l

Date of bi rth (dd.mm.yy):

Datum narozen! (mm.dd.rrrr):

Place of birt h:

M fsto narOl eni :

Count ry ot birth: Czech Hepublic Country of birth : _________________ _

Zeme narozen !: Zeme narOlen!:

Nationali ty: Clech R:e~p~u=b:!;:c ____________________ _ Nationalitv: __________________ _

Cbb nst .. f: Obcanshli:

1 2 Source of funds I ZdroJe penez

Please proYlde details on how you haye acquired the money to be invested . I Uvedte prosim podrobnosti, jakjste zlskali penize, ktere se maji investovat.

1.2.1 Savings f rom salary/wages/commissions/royalties I Uspory z platu/mzdy/ provizflhonoraru

1 Sl account holder occupation: Name of employer: [ [ Povolani 1. majitele ucru : Nazev zam~stnaYatele:

2nd account holder occupation: Name of employer:

Poyolani 2. majitele ut tu: Nazev zam~stnavatele:

The amount of my/our annual disposable net assets amounts to approximately I vy~e meho/na~eho rocnmo disponibilnmo cisteho jmeni dosahuje p7ibll!ne:

0- 24.999 EUR 25.000 - 49.999 EUR 50.000 - 99.999 EUR 100.000 - 149.999 EUR

If you are self·employed please provide more details of your business background/activiry: Pokud pracujete j ako OSVt, wedte laskav~ vice podrobnosti 0 Va~em podnikani/cinnosti:

If you are not working at present or are retired please provide details of your preViOUS profeSSiOn{s)lfunction{s): Pokud v soucasnosti nepracujete. nebo jste v duchodu, uvedte laskave vice podrobnosti 0 VaWich pi'edchozi/ch profesi(ich)/ funker(ich):

1.2.2 Proceeds from sales I vynosy z prodeje

Type of sale I Druh prodeje (pltost lick· mull/pit onSWtfS pouiblt} (mo/nosr lotkrtnour vlCt odpovid/)

o Financial investments/participations/shares Financni investice/ucasti/ ak(le

o Properties Nemovi tosti

o Sale of Company Prodej spolecnosti

o Other sales Ostatni prodej

Proceeds / Vynosy Remarks I Pozn~mky

' 50.000 EUR or more I nebo vic

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KYC QuestIOnnaire / Dotaznik: Poznejte sveho zakaznika Page 1 of4/5trana 1 z4 February / unor 2018

1.2.3 0 Other I Ostatnf

Other income I Ostatnf pfijem (please lick·multlple answers possible) (molnose za$knnoul VIU odpO'ddf)

o Insurance pay-out V}iplata pojistneho

o Inheritance DedictVf

o Donation Dor

o Compensation Nahrada

o Rental income Prijem z pronajmu

o Gain from shareholding in a company Pffjem z akcioveho podnu ve firme

Business activity/commercial or industrial revenues o Pffjmy z podnikani, obchodni ci prumyslove einnosti

o Retirement income/d isability pension Starobnf duchod/invalidnf duchod

o Other Ostatnf

1 3 US Persons I Amenlti obcane

Additiona l information I Dopli'iujfd informace:

Kind of benefit Druh benefitu

Relationship of deceased to the account holder Vztah zemfeleho k majiteli uctu

Relationship of donor to the account holder Vztah darce k majiteli unu

Nature of the compensation Druh nahrady

Number of rented properties [ Pocet pronajatYch nemovitostf

Name of the company Nazevfi rmy

Business model/activity r

Obchodni modelRinnost F

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1.3.1 1N1/e hereby confirm that I/we am not/are not a US Person(s)* and am not/are not acquiring units on behalf of, or for the benefit of a US Person{s) nor do we Intend to sell or trclnsfer any units which I/we may purchase to any person(s) who is/are a US Person(s). *US persons are natural or legal persons who, irrespective of the source of their income, (i) possess US citizenship. (ii) have their place of residence in the USA, (iii) are in possession of a Green Card, (iv) in the last three years have stayed in the USA for several consecutive days and thus fulfil the Substantial Presence Test or (v) any corporate entity, private company or corporation which is organised in or according to the laws of the United States of America or one of its political subdivisions, or any goods or trusts which are subject to the federal income tax laws of the United Srates of America. In particular this includes all citizens of the United States of America who fall under the area of application of the regulations of the Foreign Account Tax Compliance provisions of the US Hiring Incentives to Restore Employment Act enacted in March 2010 (~FATCA~). Timto potvrzuji, ie nejsem americkou osobou (Timto potvrzujeme, ie nejsme americk}imi osobami)* a ie nezfskavam/e podny jmenem, nebo ve prospech americke osoby (americkych osob), ani nezamyslim/e prodat nebo pf evest iadne podily, ktere mohu/muieme koupit zadne osohe, ktera je americkou osobou (zadnym osobam, ktere jsou americk}imi osobami). *Americke osoby jsou fyzicke nebo pravnicke osoby, ktere. bez ohledu na zdroj j ejich pi'ijmu, (i) maj i americke obeanstvi, (ii) maji misto bydliste v USA, (iii) jsou dr!iteli Zelene karty, (iv) v poslednfch tfech letech byli nekolik po so be nasledujicfch dnu v USA a tim sphluji Test podstatne pi'ftomnosti (Substantial Presence Test) nebo (v) je to jakakoliv pravnicka osoba, soukroma spoleenost nebo korporace, ktera je zaloiena v USA. nebo jedne z jejich politicky-ch uzernnfch jednotek ci v souladu s jejich zakany, anebo jakekoliv zboii nebo trusty. ktere pod lehaji zakonum USA a federalni dani z pfijmu. Toto konkretne zahmuje vSechny obeany Spojenych statu americk}ich, na ktere se vzrahuje uplat~ovanr predpisu ustanovenf ohl. dadriovani dafiovych pi'edpisu u zahranicnich uctu ("the Foreign Account Tax Compliance,,) americkeho zakona a pobfdkach pro obnoveni zamestnanosti (~ US Hiring Incentives to Restore Employment Act") pfijateho v bfeznu 2010 (MFATCA").

o I/we confirm that I am/we are not a US Person(s) / Potvrzuji, Ie nejsem americkou osobou (Potvrzujeme, Ie nejsme americky-mi osobami) o IIwe confirm that I am/we are (a) US Person(s) I Potvrzuji, ie jsem americkou osobou (Potvrlujeme, zejsme americkYml osobami)

1.4 BenefiCial Owner ship I Skutecne vlastnlctvl

In accordance with its legal obligations. Moventum must identify the beneficial owner(s) of the assets of the account. The benefiCial owner(s) is/are the effective ultimate beneficiary{ies) of the assets held on the account. The law defines the beneficial owner as one or more natural persons who ultimate ly, directly or indirectly, own/s or control/s, de facto or de jure. a legal person or legal arrangement. This may be the case even if the minimum shareholding or control requirements as indicated in Article 1 (7) (a) and (b) (i) and iii) of the Law of 12 November 2004 have not been attained. I V souladu se svymi pravnimi zavazky rnusf spoleenost Moventum identifikovat skutecne/ho vlastnikalky aktiv uCtu. Skutecny vlastnik je (skutecni vlastnici jsou) fakticti konecnf prijemci aktivvedenych na ucte. Zakan definuje skutecneho vlastnikajako jednoho nebovice fyzick}ich osob. ktere v konecnem efektu. primo nebo nepffmo, vlastni nebo kontroluji de facto nebo de jure, pravnickou osobu nebo pravnf usporadani. Tak tomu muie b}it i v pfipade, ie nebyto dosaieno minimalnich poiadavku na akcie nebo kontrolu podle (I. 1 odst. 7 plsm. a) a b) (i) a (Hi) zakona ze dne 12. listopadu 2004.

1.4.1 Account for natural persons I Ucet pro fyzicke osoby l{We declare, that I amlwe are the sole beneficial owner(s) of all current and future assets held on the account. I/we undertake to use only the account registered in my/our own name(s).1 Prohlasuji, fe jsem vyhradnfm skutecnym vlastnikem (Prohla~ujeme, ie jsme vyhradnimi skutecnymi vlastniky) vSech soueasnych a budoucich aktiv vedenych na uctu. Zavazuji/eme se pouiivat pouze ueet vedeny na moje/nase vtastnf jmeno/a.

o yes/ano

1.5 Remarks/add lttonallOformatlon I Poznamky/ doplnuJ id IOformace

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1 6 Country of Fiscal Residence} Zeme danoveho domlCllu

1 Please stale lile country OfYOUlPiCOI reSidence ond t0x Idemlficollon Nurnbet (TIN}. If you do nOl hOile TIN, pleose speCl{y Ihe reason (eg. /he counfly / Jur/sdK/IOII ofrOllr flscol les/delICt does nol/s5IJe TIN /0 mdlvlduols. you are nOI ttqwred fO ob/om TIN, you are unable fO ob/om TlNJ./ lJvedte lodlCl'd svrij donovj domkil 0 donovi idemifikolnllfslo (OIC}. Pokud DIC nem6!e. IIpfes/llre laskovl dWod (nopf. zem~ I jUflsdlkce Va!eho donovUIO dornkilu nevysravuje ole {yzickjm osobOrn. nejSfe povinen DIC zfskot OIC zlsko! nemu}elej.

1" Account Holder 11. Majitel "ftu Fiscal Residence 1 Danovj domicil 1

TIN f Dlt Reason of no TIN Duvod absence Dlt

2 ..... Account Holder 12. Majltel uftu Fiscal Residence 1 Danovj domicil 1 TIN I Dlt Reason of no TIN Duvod absence OIL

1 7 Additional Countries of Fiscal Residence 3} Dal~f zeme danoveho domlCllu 1

J Generally. on mdwldu(J1 has only one fiscal I'eSldenCt. If. however, you have more ilIOn one fiscal (t5ldence, please s/ole all counffies ofyaur fiscal (esldence and ploVide I'eleva/ll TINs In Ihe fields below. , Fyzicko osoba rnd obIIykle POUlt jeden donovj domicil. Pokud orl'em mote vice nel jeden dai'tovj domkil wed/e loskavi rl'echny zem~ dafloodho domicilu a uvedte pflslu!ndlis/a Dltv kolonkdch nfle.

1" Account Holder 11 . Majitel Liltu Fiscal Residence 2 DanoyY domicil 2 TIN lOlL Reason of no TIN Duvod absence OIL

Fiscal Residence 3 Dai'\ovy domicil 3 TIN I Dlt Reason of no TIN Duvod absence OIL

2 .... Account Holder /2. Majitel uftu Fiscal Residence 2 DanovY domicil 2 TIN I Dlt Reason of no TIN Duvod absence OIL

Fiscal ReSidence 3 DafiovY domicil 3 TIN I Dlt Reason of no TIN Duvod absence Dlt

KVC Questionnaire / Dotaznik: PozneJte sveho zakaznfka

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February I Dnor 2018

1 8 Tax compliance statement 4 1 Prohl,Henf 0 dodrzovanf dariovYch predplsti 4

• Please nole that licking "No~ meallS your account is re)ecled. ,. Upozorfluj eme, I t zaIkrtnuffWe· znamtn6, I e V6f utet bude zamftnul.

I/we hereby confIrm that I/we comply with all and any legal, regula cory or other obligations incumbent upon me/us (such as but not limited to my/our tax obligations in the country(ies) in which I/we have to pay taxes in relation to the assets deposited with or managed by Moventum). / Timto potvrzuji/eme, ze sp li'\uji/eme jakekoliv pravni, regulaeni ei j ine povinnosti, ktere pro me/nas vyplyvaji Oako jsou napffklad, ale nejen me/na~e danove povinnosti v zemi(ich), v ktere/rYch musim/e platit dane vzhledem k aktivum uloi:enym u spolel nosti Moventum, nebo touto spo]elnosti spravovanych).

o Yes/ Ano D No / Ne

I/we hereby acknowledge and understand that should IIwe fail to (om ply with such obligations, IIwe shall be exclUSively responsible for all consequences thereof (including possible financial or criminal sanctions) and Moventum sha ll not bear any responsibility wha tsoever in that respect. The same obligations shall apply with respect to the beneficia l owner(s) of any account held in the books of Moventum. I/we sha ll consult relevant legal or other advisers in case of doubt as to the exact obligations incumbent upon me/us. I/we hereby acknowledge and understand that additional information and documents may be requested in order to justify my/our tax compliances. / Timto uznavam/e a rozumfm/e, ze kdybych/om nesplnil/i tyto povinnosti, za ~echny dusledky takoveho nesplnen f (ve. moznych finanlnich a trestnfch sankc!) jsem/ jsme zodpovedny/i pouze jil/my a Moventum v tomto oh ledu nenese zadnou odpovednost. Stejne povinnosti se vztahujl na skutelneho vlastnlka (skuteene vlastniky) jakehokoliv uCtu vedeneho v uletnictvi spoleenosti Moventum. V pfipade pochyb ohledne pfesnych povinnosti pro me/nas vyplyvajicfch, budu/eme toto konzultovat s prislu~nymi pravnfmi l i jinymi poradci. Timto uznavam/e a rozumfm/e, i e mohou byr vyzadovany dal~ i informace a dokumenty pro ueely oduvodneni meho/na~eho dodr1ovani dai'\oyYch p?edpisu.

D Yes / Ano D Nol Ne

1.9 DeclaratIon 1 Prohlaseni

IflNe declare that the above information provided is true and complete. IflNe agree to provide Movemum with any furthe r information or documentary proof upon request. IflNe further agree to Moventum's contacting any third party to obtain additional information on the investments, if req uired. Prohlasuji/eme, ze yY~e uvedene informace jsou pravdive a uplne. Souhlasim/e, ie spolecnosti Moventum na vyzadani poskytnu/eme jakekoliv dagi informace ei doklady. Dale souhlasim/e, ze spolelnost Moventum muze v prfpade potreby kontaktovat jakoukoliv aeti stranu kvuri zfskani dopli'\ ujfdch informaci 0 investicich.

1" Account Holder or Parents/Guardians on behalf of the Minor or other Account Holders 1. majitel ultu nebo rodile/opatrovnki jmenem nezletileho nebo dalsl majitele ultu

Signature 1 Podpis Place / Misto

2 ..... Account Holder 12. Majiteructu

Signacure I Podpis Place 1 Misto

If the prepopulated data in Section 1 are incorrect, please provide the correct data in the fields below. Jsou·li predvyplnene informace v·lasti 1 nespravne. uvedte prosfm spravne informace v kolonkach nile.

1" Account Holder 11. Majltel ultu

Family Name: P7ijmenf:

Street: Ulice:

Postal Code: psC:

country: Zeme:

Date of birth (mm.dd.yyyy): Datum narozeni (mm.dd.rrrr):

country of birth: Zeme narozeni:

2 ..... Account Holder 12. Majitel ultu

Family Name: P7fjmeni:

Street: Ulice:

Postal Code: psC:

Country: Zeme:

Date of birth (mm.dd.yyyy): Datum narozen! (mm.dd.rrrr):

Country of birth: Zeme narczeni:

Date (dd.mm.yyyy) Datum (dd.mm.rrrr)

Date (dd.mm.yyyy) Datum (d d.mm.rrrr)

Moventum S.C.A . • Societe en commandite par actions' B.P. 12S7, L·1012 Luxembourg· Registered office: 12, rue Eugene Ruppert, l·2453 luxembourg Chairman of the Board of Directors of the General Partner: John Keffe r ' Execut ive Management: Roman Lewszyk, Michael Jensen, Sabine Sa id

RCS Luxembourg B 75930 ' VAT Registration LU 218S2934· www.moventum.lu· info@moventumJu

KYC Questionnaire I Dotaznik: Poznejte sveho zakaznika Page 4 of 4/ Strana 4 z 4 February I unor 2018