Foreign Account Tax Compliance Act (FATCA) REQUIREMENT

I hereby apply to purchase twenty permanent shares in the Dennery community Credit Co-operative Society Ltd. I agree to conform to the by-laws of the Credit Union and Co-operative Act.

I hereby nominate the following person(s) to whom or to whose credit the interest or the value of such share or interest held by me in the said Society shall in the event of my death be paid or transferred (in the proportions respectfully shown hereunder).

1.

2.

3.

If beneficiary is a minor (under the age of 16) you are required to name a legal guardian.

Please note than upon minors reaching the age of 16 years, the above named guardian would be considered null and void.