Financial Capital Operation Form

FINANCIAL CAPITAL OPERATION FORM

Section 1 — Request Summary

Requestor Name:   Department:

Request Date:   Reference ID (internal):

Section 2 — Operation Type

Select the nature of the capital operation (select all that apply):

Capital injection / equity contribution     Capital call / drawdown     Debt issuance / loan draw

Repayment / redemption     Intercompany transfer     Other (specify below)

Section 3 — Financial Terms

Amount:   Currency:   Exchange Rate (if applicable):

Effective Date:   Expected Settlement Date:

Section 4 — Accounts and Settlement Instructions

Section 5 — Breakdown of Allocation (if applicable)

Provide line-item allocation of the requested funds

Section 6 — Compliance, Representations, and Indemnity

By submitting this form, the Requestor represents and warrants that: (a) the Requestor is duly authorized to initiate this capital operation on behalf of the named entity; (b) the funds to be transferred are from lawful sources and the transaction will not violate applicable anti-money laundering, sanctions, or currency control laws; (c) this transaction complies with the entity's organizational documents and any applicable financing agreements; and (d) all information provided on this form is true, complete, and accurate to the best of the Requestor's knowledge.

The Requestor further acknowledges that the initiating entity shall indemnify, defend, and hold harmless the treasury function and its agents for any claims, losses, taxes, penalties, or expenses arising from incorrect instructions, failure to obtain necessary approvals, or material misstatements on this form. The Requestor accepts responsibility for any bank fees, exchange costs, or intermediary charges incurred in connection with settlement unless otherwise agreed in writing.

KYC / Beneficial ownership verified     Sanctions and PEP screening completed     Legal/Contract review completed

Section 7 — Internal Approvals

Treasury Manager — Name:

Chief Financial Officer — Name:

Board or Committee Approval (if required) — Resolution Ref:

Section 8 — Certification and Authorization

The undersigned certifies that they have authority to request the foregoing capital operation on behalf of the named entity; that all required internal approvals will be obtained prior to settlement; and that the entity will comply with any reporting, withholding, or tax obligations arising from this transaction. The undersigned further authorizes the treasury function and designated banks to act on these instructions and to rely on the representations contained herein.

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