EFTA00237364.pdf

UBS lt nt Revised 2/12 Sofa Bade Alternative Investments US - Additional Subscription Form ALPHAKEYS MILLENNIUM FUND LLC Please return this form to your Financial Advisor The undersigned hereby wishes to contribute additional capital to the above-named fund (the 'Fund"). Please indicate amount of additional capital contnbution m USS The undersigned confirms that the amount conuibuled is consistent with the Fund's minimum additional investment requirements. The undersigned acknowledges: (i) that the undersigned is making an additional capital contribution on the terms and conditions contained in the Confidential Memorandum of the Fund previously received by the undersigned, the governing documents of the Fund as currently in effect and the Subscription Agreement or Investor Application previously executed by the undersigned and accepted by the Fund (the 'Investor Application'), and (ii) that the representations and warranties of the undersigned contained in the Investor Application are true and correct in al respects as of the date set forth below. In addition, the undersigned acknowledges that a placement fee of 2% of the capital contribution will be charged if the undersigned invests through a brokerage account. However, in limited circumstances the placement fee may be waived by UBS Financial Services Inc, as placement agent. This placement fee is in addition to, and will not reduce, the undersigned's capital contribution. THE UNDERSIGNED AGREES TO NOTIFY THE FUND PROMPTLY SHOULD THERE BE ANY CHANGE IN ANY OF THE FOREGOING INFORMATION. The Investor hereby authorizes the debit of funds for the capital contribution, plus any applicable placement fee, and any applicable amount required to satisfy a tax obligation of the Fund. By signing below the undersigned acknowledges, represents and agrees that: (a) it has carefully read and is familiar with the Investor Application and the Fund's governing documents (collectively, the "Agreements"), including the pre-dispute arbitration clause which appears in the Agreements and (b) it hereby confirms that with respect to the information maintained by UBS Financial Services Inc. regarding the undersigned's portfolio held at UBS Financial Services Inc., the investment objective and risk profile applicable to the investment in this Fund are respectively. "capital appreciation" and `aggressive" and that this objective and risk profile is applicable only to this investment and may differ from the investment goals and risk tolerance for the overall portfolio and the brokerage account in which this Investment is held. Client Signatures (please sign below): , \wee Daze Aostonar wiper Si:theism leg ant gnaw Pao GNStaine Ravnielk not mew era rine hereeninnoste For Financial Advisors and Branch Managers I. Investor Suitability and /*A Byline 1101: With regard to the proposed investment of the alogementioned client n the Fund, I, as Financial Advisor so the client, by Signing Wow, coney that I have: :I; informed the client of ail pertinent facts relating to the ,thadty and transferability or the Fund, including the obhgaton to ma mart sufficient liquidly to meet ongong capital calls (if the Fund has a capital cad stnsture} on potentiary short notce and that the Mourner* may impact the thent's future ithiclity, ;21 reasonable grounds to believe (on the basis of information °Planed from the dent concerning tie client's age. twestment objectives, investment wrierence, name, net worth, liturgist situation and needs, other investments and any otter nrcernation known by me, including the attached CAI) that (a) the Fund being subsc'ibed for iS suitable and appropriate for the clent (b) the client meets all app cable minenum income, net worth. Kiwi assets and other obit:the suitability standards, (c) the client can reasonably benefit (including realizing any intended tax benefit if applicable) lion the Fund based on the client's financial position. overall investment obµctives and portfolio structure; the dent can bear the economic risks or the investment n the Eyre tel the client's goals are consistent with the time frame of the wieurnent, and (0 the client appears to have an understanding of: 01 the fundamental risks of the Find ',including that the client may Ilse his or her entire investrmnd (e) the restrictions on the liqu dity and transferability or the Fund, ( the oackground and qualifications of the sporsonsi and investment manages: of the hind, and ferl the tax Consequences with respect to an irveStrnent rz the Find, obtained a wigs and duly completed Form thr-9 or W.8, as applicable, or successor form thereto, signed under penalties of penury by the client and I nave Properly placed such form on Me pursuant to internal Les PolicY. and (4) confirmed, with reasonable due floury, texhideo my rearm of relevant aCCOsest CCCUreentatiCr. that the client's representations provided in the NFA Bylaw 1101 Certification (if appaCahlth Regarding Item 2(b) above, in the event that the client d an ent ty isqrh as a trust a partnership; :hat does not itself meet the minimum nwstment requirements (suer' as net won!') I have ascertained from the approprate parties :such as the client's trustee or general partner) that all of the client's beneficial owners meet such requrements Will the investment result in the client boron; --ore than 3C% of his net worth as evidenced on CAI in Alternative Investments' K Yes 0 No By signing below. the undersigned FA acknowledges that the undersigned k nags *redly of his or tier own knowledge that the Fund's cpwrning documents have been previously delivered to the investor IL Investor qualification for Offshore Fund offerings oar I have remewed the 'Country qualifications' appendix to tne Memorandum or kAncription Agreement and in any applicable Peopkment to the Menwandum or set forth in the instnections on the UBS otraret. and I certify that I have reasonable grounds to believe that the dent is qualified, under the law of its country of residence, as described them to lowest in the Fund in ackitios, it is onrul that Financial ACMSors review and understand the Ras of the Road ['ROW). with specific locos CO *Wilbert investments. for each country in WhiCh the Financial Advisor expects to conduct cross border lossiness and I hereby onion that I have reviewed, understand and have complied with the applicable R0TR. CONFIDENTIAL UBSTERRAMAR00001730 EFTA00237364 Form W .lie (RIN. December 2014) Depaileient of the Treasury Internal Revenue Serum Request for Taxpayer identification Number and Certification Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. I Name (as shown on your income tax Mum). Name is required on the WC do not have this lee Monk- Ghislaine Maxwell 2 Business name/disregarded entity name. d different from above 3 Check appropriate box kr federal tax classikcation; check only one of the follovAng seven boxes: a 0 C Con 0 Incavickallsole proprietor xration 0 SCaPOratkin 0 Petrie:SI* single-member LW 0 United liability company. Enter the tax cLassrlicaton pc corporation. $-S corporation. Is-partnership) Note. Fa a single-member LLC that is disregarded, do not cher* LLC: check the appropriate box in the tax classification of the single-member owner. 0 Other (see instructions) la 0 Trust/estate ii 4 Exemptions certain entities. instnicticris Exempt payee Exemption code Of any) tAnme• ii esc...nto (codes apply only to not individuals: see on page 3): code (if any) from MICA worth!) the line above for Staittal MISS S. USA 5 Address (number, street, and apt. or suite no.) 116E 65th Street Requesters name and address (optional) 6 City, state, and ZIP code New York. NY 10065 7 last account nurnber(s)here (optional) taim Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individualS, this is generally your social secwity number (SSN). However, for a resident alien, sole proprietor. or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter. Part II Social security number 1 3 3 Or 7 8 4 8 8 3 Employer Identification number Certification Under penalties of perjury. I certify that: 1. The number shown on this form Is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I an not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below): and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have tailed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contnbutions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the SVuetons on page 3. J Signature& U.S. person * Date* General Instructions Section references we to the [Memel Revenue Code unless Otherwise noted. Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release a) a at www.irs.govitw9 Purpose of Form An individual or entity (Form W-9 requester) who is required to file an intimation return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number ISSN). individual taxpayer identification number (ITN). adoption taxpayer identification number (ATIN), or ompnyer identification number (EIN). to report on an Information return the amount paid to you. or other amount reportable on an information return. Examples of information returns include, but are not finned to. the following: • Form 1099-24T (merest earned or paid) • Form 1099.0Iv (dividends. including those from stocks or mutual funds) • Form 1099-MISC (various types of income. prizes. awards. or gross proceeds) • Form 1099-B (stock a mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactional • Fonn 1099-K (merchant card and third party network transactions) • Form 1098 thome mortgage interest 1098-E (student loan interest). 1098-T Ninon) • Form 1099-C (canceled debt) • Form 1093.A (acquisition or abandonment of secured properb) Use Form W-9 only if you area U.S. person (including a resident alien), to provide you correct 11N. It you do not maim Form W-9 to die requester with a TW, you might be sublet( to backup withhOhang. See What u backup bearworceng? on page 2. Sy signing the filed-out tom,. you: 1. Certify that the TIN you are giving is coned (a you afe wading for a number to be issued). 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable. you are also certifying that as a U.S. person. you allocable share of any partnership income from a U.S. trade a busyness is not subject to the withholding tax on Weir partners' share of effectively connected income, and 4 Certify that FATCA code(S) entered on this form (if any) indicating that you are exempt from tho FATCA reporting. is correct. See what is FATCA reporong9 on page 2 Ice further information. Cat. No. 1023IX Form W-9 (Rev. 12-2014) CONFIDENTIAL UBSTERRAMAR00001731 EFTA00237365