| I, [................................ full name ....................] Passport Number [...............] |
| of [................................ please state full address ........................................] |
| do solemnly and sincerely declare as follows— |
| 1. | That I am a citizen of [..................................] |
| 2. | That *I have never been convicted of an offence under the Laws of Saint Lucia or of any other State. *(except for minor traffic offences). |
| 3. | That I am of good character. |
| 4. | That I have never been the subject of any refusal in any related application for registration, licence, recognition or authorization by any regulatory authority in any country or jurisdiction. |
| 5. | That I have never been the subject of any suspension, cancellation or revocation of registration, licence, recognition or authorization by any regulatory authority in any country or jurisdiction. |
| 6. | That no judgment has been rendered against me nor any suit or proceedings are pending against me in any country or jurisdiction which has been based in whole or in part on fraud, theft, deceit, misrepresentation or similar conduct. |
| 7. | I have never been charged, indicted or convicted in any country or jurisdiction for any offence in any criminal or civil proceedings relating to fraud or theft arising out of operating or dealing in mutual funds, collective investment schemes/funds, securities, banking or insurance business. |
| 8. | I have never been declared bankrupt nor have I been a party to bankruptcy or insolvency proceedings. |
| 9. | I have never been subject to proceeding relating to winding-up, dissolution, creditors' arrangement, creditors' compromise or receivership. |
| I make this Declaration conscientiously believing the same to be true and in accordance with the Statutory Declaration Act, and that I am aware that if there is any statement in this Declaration which is false, or which I know to be false or do not believe to be true, I am liable to imprisonment. |
| DECLARED before me |
| at |
| this | day of | __________________ |
| Declarant |
| ________________ |
| Notary Royal |