KYC Form

Marital Status Required

Salutation Applicant

Name First Middle Last Required

Date of Birth Applicant Required
Employer Applicant
Phone Home Applicant
Phone Mobile Applicant Required
Email Applicant Required

Residential Address

This address will determine your place of residency for regulatory purpose.

Legal address Required

FINANCIAL ASSETS” VERSUS “NET ASSETS”

The Ontario Securities Commission (OSC) differentiates between “financial assets” and “net assets” as follows:
Financial assets include (i) cash, (ii) securities, or (iii) a contract of insurance, deposit or an evidence of a deposit that is not a security for the purposes of securities legislation. The value of an investor’s personal residence or other real estate is not included in the calculation of financial assets.By comparison, net assets include all of the investor’s assets, minus all of his or her liabilities, and so could include an investor’s personal residence and other real estate.

NET FINANCIAL ASSETS

Investment Knowledge Required
Risk Tolerance: Required

Investment Objectives What’s your objective of investment? Please indicate your preference for Income, Balance, and Growth

Rank first to Last (Three) Required
Rank first to Last (Three) Required
Rank first to Last (Three) Required
Required
Required
Required
Required
Time Horizon for whole portfolio Required
Risk Tolerance for Proposed Investment (Alternative Strategy) Required
Time Horizon for Proposed Investment (Alterantve Strategy) Required
Please select your institution
Pick select type of investment
Total invested $CAD
Other assets including home equity (House value - Mortgage), private equity, other investments.
Are you an officer or director of a company whose shares are traded on an Exchange or in the OTC Market? Required
Are you in a control position or part of a group in a control position of any such company? Required

POLITICALLY EXPOSED PERSON (PEP): CLIENT QUESTIONNAIRE

The Money Laundering Act of Canada as amended and effective June 23, 2008 now requires us as a financial institution to determine if our clients may be a Politically Exposed Person (PEP) or Head of an International Organization (HIO), and as such we are required to ask such clients the following questions

Do you or any members of your family hold or has held one of the following offices or positions in or on behalf of a foreign state? Family means Immediate Family including; Spouse or common law partner; Mother or father; Child; Brother, sister, half-brother or half-sister; or Spouse’s orcommon-law partner’s mother or father.

Please answer in Yes or No

(A) Head of state or head of government; Required
(B) Member of the executive council of government or member of a legislature; Required
(C) Deputy minister or equivalent rank; Required
(D) Ambassador or attaché or counselor of an ambassador; Required
(E) Military officer with a rank of general or above; Required
(F) President of a state-owned company or a state-owned bank; Required
(G) Head of a government agency; Required
(H) Judge; Required
(I) Leader or president of a political party represented in a legislature; Required
(J) Holder of any prescribed office or position. Required

THIRD PARTY DETERMINATION

In opening this account, are you acting on the instructions of or on behalf of a third party? Required

Head of an International Organization (HIO)

Are you or anyone you know the head of an international Organization (HIO) or close associate of an HIO? Required

If the answer to any of these questions is yes, please provide details of such positions and the parties involved (Plsease send us email with details).

By submiting this form, the Client(s) certify that all information disclosed in this form is complete and true and acknowledge that such information shall be deemed complete, true and unchanged until such time as Durham Asset Management Inc. is advised in writing by the Client(s) of any change pertaining thereto. The Client(s) certify that it is their responsibility to notify Durham Asset Management Inc. of any changes to the above information.