Hedge Fund Subscription Procedure Page 21
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23In the box below, please provide the name, address and U.S. TIN of any U.S. person(s) who are controlling person(s)1 of the entity.
Alternatively, an IRS W tax form can be completed for each U.S. person who is a controlling person of the entity.
Person 1
Person 2
Person 3
Person 4
Name
Address
U.S. TIN
__ __ __ - __ __ - __ __ __ __
__ __ __ - __ __ - __ __ __ __
__ __ __ - __ __ - __ __ __ __
__ __ __ - __ __ - __ __ __ __
(Attach a separate page if more space is required)
Number of additional sheet(s) attached?
__________________________________
Certification
I declare that the information I have provided on this form is, to the best of my knowledge and belief, correct and complete. I agree to notify AGF
Investments Inc. within 30 days if there are any changes in circumstances that cause any information provided on this certification to become
incomplete, inaccurate, false or misleading, and to provide AGF Investments Inc. with a new Tax Self-Certification form upon request. I
acknowledge that information contained in this form and information regarding my account(s) with AGF Investments Inc. (including information
on account balances and payments received) may be reported to the CRA, and that the CRA may provide this information to the IRS.
Name:
Title:
Signature:
Date:
Name:
Title:
Signature:
Date:
Name:
Title:
Signature:
Date:
Please note that the information contained in this form should not be construed as tax or legal advice. Please consult with your own tax or legal advisors for
information regarding your own circumstances.
Selected definitions for Entity Self-Certification
The definitions provided herein are for information purposes only and should not be construed as legal or tax advice. You should consult with
your legal or tax advisor and should not base your decisions on information provided in this form. For the complete definitions in the Canadian
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