Declaration signed by Compliance Officer(s) submitting Compliance Report

Compliance report in terms of section 17(4) of the Act by compliance Officer(s) for the reporting period ____________ (insert date) until _____________ (insert reporting date).

I/We ________________________________________ compliance officer(s) hereby report as follows as regards compliance by _______________________________________ (insert full name of FSP and FSP number) and any representative of the FSP with the Act, for the reporting period.

Having completed the attached annual compliance report for the FSP, I/We hereby confirm that, to the best of my/our knowledge and ability all the information contained in the attached annual compliance report is true and correct.

I/We are aware that the information contained in the attached annual compliance report may be subject to verification by the Registrar of Financial Services Providers, and should I/we knowingly submit false, incorrect or misleading information to the Registrar, this may impact on my/our compliance with the fit and proper requirements with regard to personal character qualities of honesty and integrity as determined by section 8(1) of the Act.

Signed on ________ (day) of __________ (month) ___________ (year).

Name(s) of compliance officer(s): _____________________________

Signature(s): ________________________________