Appendix 8(i) Investor’s Statement (natural person)[1]

First name and surname:
Address of residence:
- country:
- town/city:
- street:
- house / apt. no.:
- postcode:
Identity card number or passport number:
Contact details:
- phone:
- e-mail address:

(hereinafter: “Private Investor”)

PRIVATE INVESTOR’S STATEMENT

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

  1. Status and authorisation 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 depend on 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).

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) The consent of the spouse for the financing of the private contribution is not required.

C) I have obtained the consent of the spouse for the 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 and warrant to provide a contribution to the VC Fund in the amount of PLN______[4]. I represent and warrant that I have sufficient funds to provide the financing of the private contribution to the VC Fund in connection with the Tender submitted by______[5].
  3. My earmarked funds as the private contribution declared for making in the VC Fund originate from my own funds and are not encumbered in any way and are free from any public support and/or state aid, and in particular they do not constitute public funds, as defined in the Act of 27 August 2009 on Public Finance.
  4. My earmarked funds as the private contribution declared for making in the VC Fund do not infringe, and their use does not infringe any provisions of the Act of 16 November 2000 on Preventing Money Laundering and Financing Terrorism (i.e. Journal Laws of 2016, item 299, as amended), including in particular the making of 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 Open InnovationsFIZ 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 VC Fund in the declared value. For that purpose, at the request of PFR Ventures, PFR Open InnovationsFIZ or their professional advisers, I undertake to provide PFR Ventures, PFR Open InnovationsFIZ 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 §12.1 of the Rules.
  5. I declare that I will immediately notify PFR Ventures of any circumstances constituting a conflict of interests leading to untruthfulness of the statement contained in point 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 procedural issues 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 Open InnovationsFIZ 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 Open InnovationsFIZ, at any time, of information about me, received by PFR Ventures and/or PFR Open InnovationsFIZ in connection with the Tender, to entities belonging to the capital group of which PFR Ventures and/or PFR Open InnovationsFIZ is a member, and to PFR TFI and Bank Gospodarstwa Krajowego, and the competent minister of regional development acting as a managing institution of the 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 Open InnovationsFIZ 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 2016, item. 922).
  11. The Private Investor represents that he or she is aware that:

a)the administrator of the personal data indicated in the Tender is PFR Ventures sp. z o.o. with its registered office in Warsaw, Ksiazeca Street 4 (5th floor),

b)personal data to be processed in accordance with the Act on protection of personal data for the purpose of Submission and Selection of Tenders for VC Funds through PFR Open Innovations FIZ,

c)the scope of the processed data includes the data indicated in the Tender i.e. name, surname, address, phone number, email, website, business information/name of company, description of professional experience,

d)the expected recipients of personal data are PFR Open InnovationsFIZ and entities authorized to control activities of PFR Ventures sp. z o.o. in the scope related to the management of portfolio of closed-end non-public assets investment fund (specifically KNF - Polish Financial Supervision Authority and PFR TFI) and in connection with agreement for financing under the Smart Growth Operational Programme 2014 - 2020 (in particular Ministry of Development and Bank Gospodarstwa Krajowego),

e)he or she has the right of access to and correction of its data, as well as right to object to the processing of personal data.

5.5.Any terms not defined herein have the meaning given in the Call Rules.

______
Signature
______
Date, place

1

[1] Where the Tender indicated more than 1 (one) Private Investor, Investor’s Statement must 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 statement is made.