SID Number Nama Nasabah Customer Name Nomor CIF CIF Number Sales Name

  Nomor CIF CIF Number Nomor SID SID Number Nama Nasabah Customer Name Nama Sales Sales Name

  WTC 5, 9th Floor. Jl. Jend. Sudirman kav. 29, Jakarta 12920 Isilah dengan huruf cetak dan berikan tanda centang ( √ ) pada kotak yang sesuai.

  √) Please fill in block letters and tick ( the appropriate box.

I. INFORMASI NASABAH /

CUSTOMER INFORMATION

• 1. Nomor SID /
• * S

  ID Number

  2. Nama lengkap sesuai Kartu Identitas/ Name as stated ID Card 3.

  Nama Ibu Kandung sebelum menikah/ Biological Mother’s name before married

  Jenis kelamin/

   Sex 4.

  (Wajib diisi)

  5. Kewarganegaraan/ Nationality

  (Must be filled) 6.

  Tempat dan tanggal lahir/

  ,

   Place and date of birth

  7. Kartu Identitas/

  ID Card KTP/ Paspor/

   National ID Card Passport

  a. Jenis kartu identitas/ Identity card type KITAS/ KIMS/

  KITAP/ KITAP

KITAS/ KIMS

  b. No kartu identitas/ identity card number

  c. Berlaku sampai dengan/ Valid thru

   Yes No

  8. NPWP/ Ada/ Tidak/ Tax ID

  Nomor NPWP/ Tax ID Number Tanggal Registrasi/ Registration date

  9. Alamat sesuai kartu identitas/ Address as stated in ID CardTax ID

  Wajib diisi, jika nasabah sudah memiliki nomor SID/ * Must be filled, if customer have SID number.

• *

  10. Alamat korespondensi/ Mailing address

  11. Nomor telepon/ Telephone number

  12. Nomor faksmili/ Facsimile number

  13. Nomor telepon genggam/

  (Wajib diisi/ ) Must be filled

  Mobile phone number

  (Wajib diisi/ Must be filled )

  14. Alamat e-mail/ E-mail address

  15. Agama/ Religion

  16. Pendidikan terakhir/ Latest education

  17. Pekerjaan/ Occupation

  a. Nama perusahaan/ Company

  b. Bidang usaha/ Nature of business

  c. Jabatan/ Title

  d. Alamat perusahaan/ Office address

  e. No telp perusahaan/ Office phone number

  f. Nomor faksimili/ Facsimile office

  18. Penghasilan setahun/ Annualized income <Rp. 50.000.000,- <Rp. 500.000.000,- < Rp. 1.000.000.000

  Rp. 50.000.000,- < Rp.100.000.000,- Rp. 1.000.000.000,- < Rp. 5.000.000.000,- Rp. 100.000.000,- < Rp. 500.000.000,- >Rp. 5.000.000.000

  Hubungan/ Relationship

  19. Nama ahli waris/ Hibah/ 1.

  2. Heir’s name/ Grant

  20. Pihak keluarga tidak serumah yang dapat dihubungi dalam kondisi darurat/ The family was not the same home can be contacted in an emergency situation.

  a. Nama lengkap/ Full name

  b. Hubungan/ Relationship

  c. Alamat/ Address

  d. No telepon/ Phone number

  21. Identitas Pemilik Manfaat (jika ada)/ Beneficial Owner (If any).

  22. Sumber dana investasi/ Source of fund for investment

  23. Tujuan investasi/ Investment objectives

FAMILY INFORMATION

  KITAP/ KITAP

  <Rp. 500.000.000,- < Rp. 1.000.000.000 Rp. 1.000.000.000,- < Rp. 5.000.000.000,- >Rp. 5.000.000.000

  Branch <Rp. 50.000.000,- Rp. 50.000.000,- < Rp.100.000.000,- Rp. 100.000.000,- < Rp. 500.000.000,-

  Branch Cabang/

  Beneficiary Cabang/

  Nama bank/ Bank name Jenis rekening/ Account type Nama pemilik rekening/

  Nomor rekening Dollar AS/ USD account no

  Nama bank/ Bank name Jenis rekening/ Account type Nama pemilik rekening/ Beneficiary

  2. III. KETERANGAN BANK / BANK DETAIL Nomor rekening Rupiah/ Rupiah account no

  d. Alamat perusahaan/ Office address 1.

  c. Jabatan/ Title

  b. Bidang usaha/ Nature of business

  a. Nama perusahaan/ Company

  KITAS/ KIMS/

  Kartu identitas/

  Sumber penghasilan/ Source income No kartu identitas/ Identity card number Jenis kartu identitas/ Identity card type

  Penghasilan setahun/ Annualized income

  Pekerjaan/ Occupation

  Berlaku sampai dengan/ Valid thru

  Nama Pasangan/ Orang Tua/ Spouse/ Parent Name

  Status perkawinan/ Marital status

  6. II. INFORMASI KELUARGA /

  5.

  4.

  3.

  2.

  KTP/ National ID Card Paspor/ Passport 1.

  ID Card

KITAS/ KIMS

IV. KONFIRMASI DATA NASABAH / CONFIRMATION of CUSTOMER

  √ √) Pilih salah satu ( )/ Tick one only ( Harap kirim konfirmasi transaksi dan laporan bulanan ke : / Please send confirmation of transaction and monthly statement to:

  E-mail/ E-mail

  Lainnya/ Others

V. KETERANGAN TAMBAHAN / ADDITIONAL INFORMATION

  1. Apakah anda atau keluarga Anda sedang atau pernah memegang jabatan di pemerintahan ? Do you or any member of your close family currently hold(s) or have/has held a position in government ? a. Nama/ Name

  b. Nama Instansi/ Institution name

  c. Jabatan/ Position title

  d. Hubungan keluarga/ Family relation

  Apakah anda pernah / masih memiliki investasi di pasar modal ? / 2.

  Do you ever have / still have investment in capital market ? Jika Ya, Nama perusahaan/

  If Yes, Institution name Jenis investasi/

  Type of investment

  3. Apakah anda warga negara Amerika Serikat ?/ Do you US Citizen ? Apakah anda memiliki kartu penduduk tetap 4. Amerika Serikat ?/ Do you have US Green Card ? Apakah anda memiliki kewajiban pelaporan pajak 5. kepada pemerintah Amerika Serikat ?/ Do you have an obligation of reporting tax to government USA ?

  Jika anda memilih “Ya” pada salah satu pertanyaan pada nomor 3 dan 5 di atas, mohon mengisi Formulir Pernyataan

  Foreign Account Tax Compliance Act (FATCA) dan Form W.9 (Request for Tax Payer Identification Number and Certification) dan tuliskan Tax Payer Identification Number

  (TIN) /

  Social Security Number (SSN) anda./ If you choose “Yes” on one of the questions on number between 3 and 5 above, please fill declaration Form

  Foreign Account Tax Compliance Act (FATCA) and Form W.9 (Request for Tax Payer Identification Number and Certification) and write your Tax Payer Identification Number (TIN) / Social Security Number (SSN).

VI. PERNYATAAN NASABAH / CUSTOMER DECLARATION

  Dengan menandatangani formulir ini berarti / By signing this form, 1.

  Saya/Kami menyatakan bahwa semua data yang Saya/Kami isi adalah benar / I/We declare that all data that I/We declare are completely true.

  2. Saya/Kami telah bertemu dengan marketing officer PT Avrist Asset Management yang memiliki ijin WAPERD, dan telah membaca dan mengerti isi prospektus dan dengan ini menyatakan terikat pada persyaratan-persyaratan serta ketentuan yang tercantum dalam Prospektus, Kontrak Kolektif, dan Formulir ini. /

  I/we agree to use the information above for any other purposes including not I/we have met a marketing officer of PT Avrist Asset Management that has a WAPERD license, and have read and understood the prospectus and limited for the purposes of marketing or all possible and allowed by the applicable statutory provisions. In connection with the approval and use of declared binding on the requirements and conditions set forth in the Prospectus, Collective Investment Contract, and this form. the data was conducted by PT Avrist Asset Management, I/we hereby stated that have obtained the entire approval is needed, I/we guarantee and release PT Avrist Asset Management from any claims of third parties that may arise later.

  3. Informasi yang diberikan dalam Formulir Pembukaan Rekening Nasabah ini adalah benar dan lengkap. / The information provided in this Customer Account Opening Form is correct and complete.

  4. Nasabah akan segera memberitahukan PT Avrist Asset Management secara tertulis apabila terdapat perubahan atas informasi yang I/We have read, understood and dinyatakan dalam Formulir ini. / agreed to the Terms and Conditions of the Account Opening in the Company as written in this Account Opening Form, and I/we declare to be subject

  The customer will promptly notify PT Avrist Asset Management in writing if there are any changes in the information set forth in this form and bound to all provision stipulated (including to any possible amendment in the future) by the Company or regulation in Capital Market.

  5. Dengan demikian nasabah akan membebaskan PT Avrist Asset Management dari setiap klaim, gugatan, ganti rugi dan tanggung jawab hukum dalam bentuk apapun yang mungkin timbul apabila terdapat kekeliruan atau kesalahan dalam penanganan rekening nasabah di PT Avrist Asset Management sebagai akibat kelalaian atau kekeliruan nasabah dalam melakukan pengkinian data secara lengkap.

  Thus, customers will release PT Avrist Asset Management from any claims, lawsuits, damages and liability of any kind that may arise if there are errors or mistakes in handling of customer accounts in PT Avrist Asset Management as the result of customers negligence or mistake in updating data completely.

  6. Saya/Kami memahami bahwa investasi pada Reksa Dana dan/atau Kontrak Pengelolaan Portofolio Efek mengandung risiko sebagaimana telah diuraikan dalam Prospektus atau Kontrak Pengelolaan Portofolio Efek, dan menegaskan bahwa pihak PT Avrist Asset Management sebagai Manajer Investasi tidak memberikan jaminan, untuk itu saya/kami membebaskan pihak Manajer Investasi dari kerugian investasi yang mungkin akan timbul yang berkaitan dengan risiko yang telah dikemukakan.

  I am/We are aware that investing in this mutual fund and/or the securities portfolio management contract contains risks which are described in the prospectus and/or portfolio management contract, and fully understand that PT Avrist Asset Management, as the investment manager, has not given me/us any guarantee and hence will be not be liable for any loss incurred.

7. Saya/Kami setuju, untuk alasan keamanan, bahwa Manajer Investasi dapat meminta pernyataan tertulis dan/atau verifikasi dari Saya/Kami sebelum melaksanakan instruksi yang diberikan.

  For due diligence, I/We agree that the Investment Manager may request a written confirmation/verification statement before acting on an instruction for an order.

  8. Saya tidak akan menggunakan Rekening Investasi ini sebagai sarana untuk melakukan tindakan yang dapat dikategorikan sebagai pelanggaran hukum, termasuk tetapi tidak terbatas pada pencucian uang

  (Money Laundering). I will not use this Investment Account as a means to conduct actions that can be categorized as a violation of law, including but not limited to Money Laundering.

  9. Semua pembayaran atau penyetoran dana Nasabah hanya dapat ditransfer ke rekening Bank atas nama produk PT Avrist Asset Management, dan wajib menuliskan NAMA dan NOMOR TELEPON NASABAH (INVESTOR) pada Slip Setoran/Transfer tersebut, segera memberitahukan dan mengirim/menyerahkan copy slip setoran tersebut kepada perusahaan.

  All payments or fund deposits must be made to the bank account on behalf of PT Avrist Asset Management product, and must write CUSTOMER's NAME and TELEPHONE NUMBER on the Transfer Slip, then notify and send the copy or deposit slip to the company immediately.

  10. PT Avrist Asset Management tidak menerima pembayaran dalam bentuk uang tunai atau cek tunai. Semua pembayaran transaksi tidak dapat dititipkan melalui Agen, Rekening Nasabah lain, atau Karyawan PT Avrist Asset Management.

  PT Avrist Asset Management do not accept payments in cash or check. All payments can not be deposited through any Agents, other Customer Account, or employees of PT Avrist Asset Management.

  11. Saya/Kami menyetujui seluruh pengungkapan yang dilakukan PT Avrist Asset Management atas data/informasi sebagaimana tercantum dalam formulir ini kepada pihak ketiga yang merupakan rekanan usaha dan telah terikat dalam suatu perjanjian dengan Avrist Asset Management ataupun otoritas atau instansi yang berwenang di Indonesia. Sehubungan dengan pengungkapan data yang dilakukan oleh PT Avrist Asset Management tersebut, Saya/Kami dengan ini menjamin dan membebaskan PT Avrist Asset Management dari segala tuntutan dari pihak manapun yang akan timbul di kemudian hari.

   I/we agree to the entire disclosure conducted by PT Avrist Asset Management over the data/information as stated in this form to any third party which is a partner in this effort and has tied up an agreement with Avrist Asset Management or the authority or authorized agencies in Indonesia. With respect to the disclosure of data is carried out by PT Avrist Asset Management, I/we hereby guarantee and release PT Avrist Asset Management from any claims of third parties that may arise later.

  By signing this form, 12.

   I/We declare that all data that I/We declare are completely true.

  Saya/Kami menyetujui penggunaan data informasi tersebut diatas untuk segala keperluan lainnya termasuk tidak terbatas untuk tujuan pemasaran atau sepanjang dimungkinkan dan diperkenankan oleh ketentuan perundang-undangan yang berlaku. Sehubungan dengan Saya/Kami telah bertemu dengan marketing officer PT Avrist Asset Management yang memiliki ijin WAPERD, dan telah membaca dan mengerti persetujuan dan penggunaan data yang dilakukan oleh PT Avrist Asset Management, saya/kami dengan ini menyatakan bahwa telah memperoleh seluruh persetujuan yang dibutuhkan, saya/kami menjamin dan membebaskan PT Avrist Asset Management dari segala tuntutan dari pihak manapun yang akan timbul di kemudian hari. I/we agree to use the information above for any other purposes including not

  I/we have met a marketing officer of PT Avrist Asset Management that has a WAPERD license, and have read and understood the prospectus and limited for the purposes of marketing or all possible and allowed by the applicable statutory provisions. In connection with the approval and use of declared binding on the requirements and conditions set forth in the Prospectus, Collective Investment Contract, and this form. the data was conducted by PT Avrist Asset Management, I/we hereby stated that have obtained the entire approval is needed, I/we guarantee and release PT Avrist Asset Management from any claims of third parties that may arise later.

  The information provided in this 13. Customer Account Opening Form is correct and complete.

  Saya/Kami telah membaca, memahami dan menyetujui Syarat dan Ketentuan Pembukaan Rekening di Perusahaan sebagaimana tertera dalam Formulir Pembukaan Rekening ini, dan Saya/Kami menyatakan tunduk dan terikat pada semua ketentuan yang ditetapkan (termasuk untuk setiap kemungkinan perubahan di kemudian hari) oleh perusahaan atau peraturan di Pasar Modal. I/We have read, understood and agreed to the Terms and Conditions of the Account Opening in the Company as written in this Account Opening Form, and I/we declare to be subject

  The customer will promptly notify PT Avrist Asset Management in writing if there are any changes in the information set forth in this form and bound to all provision stipulated (including to any possible amendment in the future) by the Company or regulation in Capital Market.

  Thus, customers will release PT Avrist Asset Management from any claims, lawsuits, damages and liability of any kind that may arise if there are errors or mistakes in handling of customer accounts in PT Avrist Asset Management as the result of customers negligence or mistake in updating data completely.

  I am/We are aware that investing in this mutual fund and/or the securities portfolio management contract contains risks which are described in the prospectus and/or portfolio management contract, and fully understand that PT Avrist Asset Management, as the investment manager, has not given me/us any guarantee and hence will be not be liable for any loss incurred.

  Saya/Kami setuju, untuk alasan keamanan, bahwa Manajer Investasi dapat meminta pernyataan tertulis dan/atau verifikasi dari Saya/Kami For due diligence, I/We agree that the Investment Manager may request a written confirmation/verification statement before acting on an instruction for an order.

  Tanggal / Date

  (Money Laundering). I will not use this Investment Account as a means to conduct actions that can be categorized as a violation of law, including but not limited to Money Laundering.

  Nama & Tanda tangan nasabah/ Clients name & Signature

  All payments or fund deposits must be made to the bank account on behalf of PT Avrist Asset Management product, and must write CUSTOMER's NAME and TELEPHONE NUMBER on the Transfer Slip, then notify and send the copy or deposit slip to the company immediately.

  PT Avrist Asset Management do not accept payments in cash or check. All payments can not be deposited through any Agents, other Customer Account, or employees of PT Avrist Asset Management.

   I/we agree to the entire disclosure conducted by PT Avrist Asset Management over the data/information as stated in this form to any third party which is a partner in this effort and has tied up an agreement with Avrist Asset Management or the authority or authorized agencies in Indonesia. With respect to the disclosure of data is carried out by PT Avrist Asset Management, I/we hereby guarantee and release PT Avrist Asset Management from any claims of third parties that may arise later.

VII. DOKUMEN YANG DIPERLUKAN /

SUPPORTING DOCUMENT

  Fotokopi KTP / Paspor Copy of ID Card / Passport

  Fotokopi NPWP (Jika ada)/ Copy of tax ID (if any)

  Dokumen lainnya Other Documents

VIII. PERNYATAAN SALES /

SALES DECLARATION

  Saya telah melakukan verivikasi awal terhadap seluruh dokumen dan informasi yang diberikan oleh nasabah, termasuk informasi mengenai keberadaan beneficial owner. Saya menyadari PT Avrist Asset Management berhak melakukan verifikasi lanjutan dan dokumen pendukung lainnya atas informasi yang telah diberikan oleh nasabah./

  I have done a preliminary verification of all documents and information provided by the customer, including information about the existence of the beneficial owner. I realize that PT Avrist Asset Management reserves the rights to verify further and ask for other supporting documents for the information given by the customer.

IX. KOLOM PERSETUJUAN /

  APPROVAL

  PT Avrist Asset Management memiliki hak untuk menolak pembukaan rekening nasabah, dengan pertimbangan sendiri, tanpa memberikan penjelasan./ PT Avrist Asset Management has the rights to decline the opening of customer account, on its sole discretion, without any explanation. Sesuai Peraturan Bapepam Nomor IV.D2, Setiap Manager Investasi atau agen penjual Reksa Dana wajib mensyaratkan pemodal Reksa Dana untuk mengisi formulir pemodal Reksa Dana.

e.

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  40 WTC 5, 9th Floor. Jl. Jend. Sudirman kav. 29, Jakarta 12920 Telp. +6221 252 1662, Fax. +6221 252 2106, Email : cs.avram@avrist.com ₂₉₀₅₁₇