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CERTIFICATES REPRESENTING EQUITY SECURITIES IN PUBLIC HANDS STATEMENT INFORMATION PROVIDED ON THIS FORM MUST BE TYPED OR PRINTED ELECTRONICALLY. To: The FSA Date: _________________20__ Name of applicant: Description of security: Total number of securities to be admitted: Name of advisor* (if applicable): Summary of holdings: Percentage of issued certificates representing equity securities Certificates representing equity securities in public hands (EEA States): Certificates representing equity securities in public hands (nonEEA States)** Certificates representing equity securities not in public hands:*** TOTAL Where less than 25% of the certificates representing equity securities are in public hands, has prior approval been obtained from the FSA? 100% Yes / No * - If this confirmation is being submitted by an advisor to the issuer, then a letter of appointment is required with this schedule (unless this has been previously provided to the UKLA) ** - see LR18.2.9 *** - see LR18.2.8(4) SIGNED BY _____________________________________________ Duly authorised officer for and on behalf of: _______________________________________________ Name of advisor or name of applicant If you knowingly or recklessly give false or misleading information you may be liable to prosecution.
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