Beneficial Owner Declaration Of Status Form - Computershare
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1
2
3All correspondence to
Computershare Proprietary Limited
Reg No 2000/006082/07
Dividends Tax Ref No 9390046143
PO Box 62212 Marshalltown
2107 South Africa
Telephone +27 11 373 0004
All Holders should complete Part A, resident holders seeking exemption from Dividends Tax should also complete Part B
and non-resident holders who qualify for a reduced rate should complete Part C
Dividends Tax – Beneficial Owner Declaration of Status Form
This form is to be completed by the person entitled to the benefit of the dividend attaching to a security.
Please complete and return to Computershare (Pty) Ltd.
Use a black pen. Print in CAPITAL letters inside the boxes.
Beneficial Owner details
A
Full name(s) of Holder:
Trading Name (if applicable):
Please mark this block with an “X” if you are a regulated intermediary and provide us with your tax reference number below:
Nature of person/entity:
Listed
Unlisted
RSA Government
Retirement /
Individual
Company
Company
Trust
Department
Pension Fund
(if selected please provide a description/
Other
explanation of nature of entity)
Identity number/Passport number/Registration number:
Income tax reference number (RSA):
Date of Birth/Inception:
Email address
(* Refer to note 1 below)
Country in which resident for tax purposes:
Cell phone number/Contact telephone number:
Physical Address:
Postal Address:
Post code
Post code
I hereby confirm that the above information is correct.
Signature:
Date:
*Note 1: Computershare may use the email address you provide for investor communication purposes. The full terms and conditions of the electronic
communication service may be viewed on our website .
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