Example of Self-certify form for a High Net Worth Investor

I declare that in signing this form I am confirming my status as a self-certified High Net Worth Individual for the purposes of the Financial Services and Markets Act 2000 (Financial Promotion) Order 2001.

I confirm that at least one of the following applies to me:

1. 1. I had during the financial year immediately preceding the date below an annual income to the value of £100,000 (one hundred thousand pounds) or more;
   2. I held, throughout the financial year immediately preceding the date below, net assets to the value of £250,000 or more. Net assets for these purposes do not include:

– the property which is my primary residence or any loan secured on that residence;
– any rights of mine under a qualifying contract of insurance or pension which are payable on the termination of my service, or on my death or retirement, and to which I am (or my dependants are), or may be, entitled.

I understand that by being a self-certified High Net Worth Individual this means:

1. 1. 1. I can receive financial promotions that may not have been approved by a person authorised by the Financial Services Authority;
      2. the content of such financial promotions may not conform to rules issued by the Financial Services Authority;
      3. by signing this statement I may lose significant rights;
      4. I may have no right to complain to either of the following:

– the Financial Services Authority; or
– the Financial Ombudsman Scheme

I may have no right to seek compensation from the Financial Services Compensation Scheme. I understand that I can lose my property and other assets from making investment decisions based on financial promotions and I am aware that it is open to me to seek advice from someone who specialises in advising on this kind of investment.

Signature:____________________ Date__________

Name (BLOCK CAPITALS)______________________