Section 12B Commitment Form — Meridian Capital Group

Applicant Type

Applicant Details

Individual Information

Title *

Full Name *

Resident Status *

Nationality *

Country of Birth *

Place of Birth *

RSA ID Number * Leave blank if using a foreign ID / passport

Foreign ID / Passport Number Required if no RSA ID

Tax Reference Number

Reason if No Tax Reference

Registered Entity Name *

Company / Trust Registration No. *

SA Entity or Foreign Entity *

SA Tax Reference Number

Authorised Signatory (Full Name) *

Additional Persons / Trustees

Email Address *

Contact Number *

Investment Details

Capital Committed (ZAR) *

Minimum commitment: R 500,000

Fund / Product *

Financial Advisor / IFA Name

Advisor FSP Number

FATCA & AML Declarations

Are you a US Person for FATCA purposes? *

No Yes

Source of Funds *

Are you a Politically Exposed Person (PEP)? *

No Yes

I confirm that all information provided in this form is true, accurate, and complete to the best of my knowledge.

I understand that this commitment is made under Section 12B of the Income Tax Act and that the investment qualifies for the applicable tax incentive.

I have read and agree to Meridian Capital Group's investment terms, risk disclosure, and privacy policy.

Signature

Draw your signature below

Place of Signature *

Date *

Signature *

Sign here using your mouse or touchscreen

This signature will be embedded in the generated PDF commitment document.

By submitting this form, a completed commitment PDF will be automatically generated and filed with Meridian Capital Group. You will receive a confirmation email once processed.

✓ Your commitment has been submitted. We will be in touch within 1 business day.

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