ANNEXURE

DISCLOSURE BY SHAREHOLDERS OF ASSOCIATES

(Disclosure in terms of Section 22 of the South African Reserve Bank Act as read with the Regulations)

Please state as follows-

1.

Full name of shareholder as it appears on the share certificate and total number of shares held:

______________________________________________________

______________________________________________________

2.

If the person mentioned in (1) is acting as a nominee, the full names and addresses of the holders of a beneficial interest in the shares ("beneficial shareholders")

______________________________________________________

______________________________________________________

3.

Disclosure of associates:

Name of associate* of the shareholder/beneficial

Manner in which related to the shareholders*

Number of shares owned by associate

*Refer to the definitions of "associate" and "close relative" in section 1 of the Act.

I_____________________________, acting in my capacity as_________________

Declare that the content of this disclosure is true to the best of my knowledge and belief and accurately reflects the particulars of all my associates.

Signature

Date

I know and understand the contents of this declaration. I have no objection to taking the prescribed affirmation/oath.  I consider the prescribed affirmation/oath to be binding on my conscience.

Deponent

Date

I certify that the deponent has acknowledged that he/she knows and understands the contents of this declaration. This declaration was affirmed/sworn to before me and the deponent’s signature was placed thereon in my presence at __________________________

on __________________________________________________

__________________________

Commissioner of Oaths

__________________________

Date

Full name of Commissioner

__________________________

Designation:

__________________________

Business Address:

__________________________

__________________________

__________________________

__________________________

__________________________

__________________________

Area for which he/she holds appointment:

__________________________

Office held if he/she holds this appointment ex officio:

_________________________