Grand Parade Investments : Dividend declaration form

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TAX DECLARATION AND UNDERTAKING FORMS

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GRAND PARADE INVESTMENTS LIMITED

(Incorporated in the Republic of South Africa)

(Registration number 1997/003548/06 )

Share code: GPL ISIN: ZAE000119814

("GPI" or the "Company")

FORM I: REQUIRED DIVIDENDS TAX DECLARATION AND UNDERTAKING (IF YOU ARE EXEMPT FROM DIVIDENDS TAX)

This form is to be completed by the beneficial owner (of dividends, including dividends in specie ) in order for the exemptions from dividends tax referred to in s64F, read together with s64FA(1) or, 64G(2) of the Income Tax Act (No. 58 of 1962) (the "Act"). In order to qualify for an exemption this declaration and written undertaking should be submitted to GPI within the prescribed period as guided by the announcement. Failure to do so will result in the full 20% dividends tax being paid by GPI.

For completion by GPI Shareholders who are exempt from Dividends Tax (as indicated under Part C of this Form I). Please complete form II.

Note: Do NOT complete this Form I if you are subject to Dividends Tax at a reduced rate (including

1. reduced rate of 0%). Instructions:

Deliver this completed Form I to the Company on an urgent basis.

To be e-mailed to: [e-mail]

DIVIDENDS TAX: DECLARATION AND UNDERTAKING MADE BY THE BENEFICIAL OWNERS OF A DIVIDEND (EXEMPTION FROM DIVIDENDS TAX)

PART A - WITHHOLDING AGENT OR COMPANY DECLARING DIVIDEND

Registered name: GRAND PARADE INVESTMENTS LIMITED

Company registration number: 1997/003548/06

Dividends tax reference number: 9037038024

Address: 33 Heerengracht street, Foreshore, Cape Town, 8001

Contact details: [phone]

E-mail: [e-mail]

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PART B - BENEFICIAL OWNER

Full names and Surname OR Registered name:

Nature of person or entity (please tick box):

Individual

Listed company

Unlisted company

Trust (any type)

South African Government or Provincial Administration or Municipality

Retirement fund (pension or provident or benefit or retirement annuity)

Other (if this box is selected, please provide description of nature of person/entity below):

Identity number/Passport number/Registration number:

Income tax reference number:

Email address:

Telephone number:

Physical address:

Postal address:

Country of residence for tax purposes:

Number of shares held in the Company

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PART C - EXEMPTION

Please indicate the reason that the beneficial owner is exempt from the dividends tax as indicated in section

64F of the Income Tax Act (No.58 of 1962) (the "Act") (please tick box):

a company which is a resident; or

the government of the Republic in the national, provincial or local sphere; or

a public benefit organisation approved by the Commissioner in terms of section 30(3) of the Act; or

a trust contemplated in section 37A of the Act; or

an institution, board or body contemplated in section 10(1)(cA) of the Act; or

a fund contemplated in section 10 (1)(d)(i) or (ii) of the Act; or

a person contemplated in section 10(1)(t) of the Act; or

a holder of shares in a registered micro business, as defined in the Sixth Schedule of the Act, paying that dividend, to the extent that the aggregate amount of dividends paid by that registered micro business to all holders of shares in that registered micro business during the year of assessment in which that dividend is paid does not exceed the amount of R200 000; or

a small business funding entity as contemplated in section 10(1)(cQ) of the Act; or

a person that is not a resident and the dividend is a dividend contemplated in paragraph

(b) of the definition of "dividend" in section 64D of the Act; or

any person to the extent that the dividend constitutes income of that person; or

any person to the extent that the dividend was subject to the secondary tax on companies; or

any fidelity or indemnity fund contemplated in section 10(1)(d)(iii) of the Act; or

a natural person or deceased estate or insolvent estate of that person in respect of a dividend paid in respect of a tax free investment as contemplated in section 12T(1) of the Act.

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DECLARATION IN TERMS OF SECTION 64FA OF THE ACT

I, (insert full name and surname of the beneficial owner or duly authorised agent of the beneficial owner)

the undersigned, declare that dividends paid to the beneficial owner are exempt, or would have been exempt had such dividend not been a distribution of an asset in specie, from the dividends tax in terms of section 64F of the Act as indicated above.

Signature:Date:

(Duly authorised to do so)

Capacity of Signatory (if not the beneficial owner):

UNDERTAKING IN TERMS OF SECTION 64FA OF THE ACT

I, (insert full name and surname of the beneficial owner or duly authorised agent of the beneficial owner)

the undersigned, undertake to forthwith inform the Company in writing should the circumstances of the beneficial owner referred to in the declaration above change.

Signature:Date:

(Duly authorised to do so)

Capacity of Signatory (if not the beneficial owner):

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GRAND PARADE INVESTMENTS LIMITED

(Incorporated in the Republic of South Africa)

(Registration number 1997/003548/06 )

Share code: GPL ISIN: ZAE000119814

("GPI" or the "Company")

FORM II: REQUIRED DIVIDENDS TAX DECLARATION AND UNDERTAKING (IF YOU ARE SUBJECT TO DIVIDENDS TAX AT A REDUCED RATE)

This form is to be completed by the beneficial owner (of dividends, including dividends in specie ) in order for the exemptions from dividends tax referred to in s64F, read together with s64FA(2) and 64G(2) of the Income Tax Act (No. 58 of 1962) (the "Act"). In order to qualify for an exemption this declaration and written undertaking should be submitted to GPI within the prescribed period as guided by the announcement. Failure to do so will result in the full 20% dividends tax being paid by GPI.

For completion by GPI Shareholders who are subject to Dividends Tax at a reduced rate in terms of an agreement for the avoidance of double taxation ("Treaty") and only applicable to GPI Shareholders resident outside of South Africa for tax purposes.

Note: Do NOT complete this Form II if you are exempt from Dividends Tax as indicated in section 64F of the Income Tax Act (No. 58 of 1962) (the"Act"), i.e. if you are a taxpayer under Part C of Form I.

Instructions:

Deliver this completed Form II to the Company on an urgent basis

To be e-mailed to: [e-mail]

DIVIDENDS TAX: DECLARATION AND UNDERTAKING MADE BY THE BENEFICIAL OWNERS OF A DIVIDEND (REDUCED RATE OF DIVIDENDS TAX)

(ONLY APPLICABLE TO PERSONS RESIDENT OUTSIDE OF SOUTH AFRICA FOR TAX PURPOSES)

PART A - WITHHOLDING AGENT OR COMPANY DECLARING DIVIDEND

Registered name: GRAND PARADE INVESTMENTS LIMITED

Company registration number: 1997/003548/06

Dividends tax reference number: 9037038024

Address: 33 Heerengracht street, Foreshore, Cape Town, 8001

Contact details: [phone]

E-mail: [e-mail]

PART B - BENEFICIAL OWNER

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