Appendix 6(i): Private Investor’s Statement (Natural Person)[1]

First name and surname:
Address of residence:
- country:
- town:
- street:
- building No/ unit No:
- postcode:
Identity card number or passport number:
Contact details:
- phone:
- email address:

(hereinafter: “Private Investor”)

PRIVATE INVESTOR’S STATEMENT

I, the undersigned, acting as Private Investor, hereby represent that:

  1. Status and authority of the Private Investor
  2. I have full legal capacity and authority to make a private contribution in the declared amount.
  3. [2]A) The fulfilment of the commitment to make a private contribution does not require me to obtain any consent, approval, notice or registration by any public administration, local government or any other authority and/or third party (including under any agreement or arrangement).

B) Except for the following, the fulfilment of the commitment to make a private contribution does not require my obtaining any consent, approval, notice or registration by any public, self-government administration authority or any other authority and/or third party (including under any contract or agreement).

1.3. [3]A) I am not married.

B) Consent of my spouse to the financing of the private contribution is not required.

C) I have obtained by spouse’s consent to financing of the private contribution.

1.4.I meet the definition of an independent private investor within the meaning of Article 2 (72) of Commission Regulation (EU) No 651/2014 of 17 June 2014 declaring certain categories of aid compatible with the internal market in application of Articles 107 and 108 of the Treaty.

  1. Private Investor’s private contribution
  2. I represent that I declare to make a contribution to the Financial Intermediary in the amount of PLN ______[4]. I represent that I have the necessary resources sufficient to finance a private contribution to the Financial Intermediary in connection with the Tender submitted by ______[5].
  3. The funds I have earmarked as private contribution declared to be made to the Financial Intermediary come from my own resources, and they are not encumbered in any form and are free from any public support and/or state aid, in particular they do not constitute public funding within the meaning of the Act of 27 August 2009 on public finance.
  4. The funds I have earmarked as private contribution declared to be made to the Financial Intermediary do not breach, nor does the use thereof breach, any provisions of the Act of 16 November 2000 on the prevention of money laundering and terrorist financing ( Journal Laws of 2016, item 299, as amended), including in particular the making of a private contribution in the declared amount does not constitute money laundering or serve the purposes of financing terrorism.
  1. Consent to due diligencein the event the Tender is selected through the Call
  2. I grant my consent to the conduct, prior to the signature of the Investment Agreement, by PFR Ventures, PFR Starter FIZ or their professional advisers, of due diligence for the purposes of verification of my legal and financial capacity to make the private contribution to the Financial Intermediary in the declared value. For that purpose, at the request of PFR Ventures, PFR Starter FIZ or their professional advisers, I undertake to provide PFR Ventures, PFR Starter FIZ or their professional advisers with, in particular, any documents confirming my possession of the private contribution.
  3. Conflict of interest
  4. I declare that no conflict of interest arises for me due to any of the reasons specified in §12 of the Call Rules.
  5. I declare that I will immediately notify the PFR Ventures of any circumstances constituting a conflict of interest rendering untrue the statement contained in Section 4.1 above.
  6. Other statements
  7. The information contained in this statement concerning state aid, including de minimis aid, is in compliance with the provisions of the Act of 30 April 2004 on proceedings concerning state aid (Journal of Laws of 2007, No 59, item 404, as amended) and with the provisions of the relevant aid scheme.
  8. I am aware that the financial support provided by PFR Starter FIZ represents state aid and is subject, in particular, insofar as its allocation and settlement is concerned, to the provisions of the Act of 30 April 2004 on procedural issues concerning state aid (Journal of Laws of 2007, No 59, item, 404, as amended), and therefore I acknowledge that upon entering into the Investment Agreement I will have the status of a state aid beneficiary.
  9. I consent to the disclosure by PFR Ventures and/or PFR Starter FIZ, at any time, of information about me, received by PFR Ventures and/or PFR Starter FIZ in connection with the Tender, to entities belonging to the corporate group of which PFR Ventures and/or PFR Starter FIZ is a member, and to TFI PFR, Bank Gospodarstwa Krajowego and the competent ministry in charge of regional development acting as Managing Authority under SG OP.
  10. I consent to the processing of my personal data contained in any documents submitted in connection with the Tender (including the data contained in this statement) by PFR Ventures and/or PFR Starter FIZ and by other authorised entities for purposes related to the analysis of the Tender, in compliance with the Act of 29 August 1997 on protection of personal data (Journal of Laws No 2016, item. 922).
  11. I represent that I am aware that:

a)the administrator of the personal data stated in the Tender is PFR Ventures sp. z o.o. with its registered office in Warsaw, ul. Książęca 4 (Floor 5),

b)personal data are processed in accordance with the Act on personal data protection for the purposes of the submission and selection of tenders for Financial Intermediaries under PFR Starter FIZ,

c)the scope of the data processed includes the data stated in the Tender, i.e. first name, surname, address, telephone number, email address, website address, information on the business pursued, description of professional experience,

d)the expected recipients of personal data are PFR Starter FIZ and entities authorised to audit the activities of PFR Ventures sp. z o.o. with regard to the management of closed-end investment funds of non-public assets (in particular, the Polish Financial Supervision Authority and TFI PFR SA) and in connection with financing agreements under the Smart Growth Operational Programme 2014-2020 (in particular, the Ministry of Development and Bank Gospodarstwa Krajowego),

e)I have the right to access and correct my data as well as the right to object against the processing of personal data.

5.5.Any terms not defined herein shall have the meaning assigned to them in the Call Rules.

______
Signature
______
Date, place

1

W/11/2017

[1] If more than one Private Investor has been named in the Tender, the statement should be completed and signed separately by each Private Investor.

[2] Delete as appropriate.

[3] Delete as appropriate.

[4] Please enter here the amount of the declared contribution of the Private Investor.

[5] Please enter here the details of the Tenderer in connection with whose Tender this declaration is made.