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Certificate of Status of Beneficial Owner for
Identification of Beneficial Owner

Name of organization that is the beneficial owner: Themes & Variations Inc

Country of incorporation or organization: Canada

Name of disregarded entity receiving the payment (if applicable):

Chapter 3 Status (entity type):

• Corporation
• Disregarded entity
• Partnership
• Simple trust
• Grantor trust
• Complex trust
• Estate
• Government
• Central Bank of Issue
• Tax-exempt organization
• Private foundation
• International organization

If you entered disregarded entity, partnership, simple trust, or grantor trust above, is the entity a hybrid making a treaty claim? If ‘Yes’ complete Part II:

Chapter 4 Status (FATCA status):

• Nonparticipating FFI
• Participating FFI
• Reporting Model 1 FFI
• Reporting Model 2 FFI
• Registered deemed-compliant FFI
• Excepted nonfinancial group entity
• Sponsored FFI
• Certified deemed-compliant nonregistering local bank
• 501(c) organization
• Certified deemed-compliant FFI with only low-value accounts
• Publicly traded NFFE
• Active NFFE
• Passive NFFE
• Certain investment entities that do not maintain financial accounts

Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address):

3 4664 Riverside Drive

City or town, state or province. Include postal code where appropriate: Red Deer, AB T4N 6Y5 Canada

Mailing address (if different from above):

US taxpayer identification number (TIN), if required:

GIIN: N/A

Foreign TIN: 13051 1132

Reference number(s) (see instructions):

Note: Please complete remainder of the form including signing the form in Part XXX.

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• Government
• Company that meets the ownership and base erosion test
• Tax exempt pension trust or pension fund
• Company that meets the derivative benefits test
• Other tax exempt organization
• Company with an item of income that meets active trade or business test
• Publicly traded corporation
• Favorable discretionary determination by the U.S. competent authority received
• Subsidiary of a publicly traded corporation
• Other (specify Article and paragraph):

• Is an investment entity;
• Is not a QI, WP (except to the extent permitted in the withholding foreign partnership agreement), or WT; and
• Has agreed with the entity identified above (that is not a nonparticipating FFI) to act as the sponsoring entity for this entity.

• Is a controlled foreign corporation as defined in section 257(a):
• Is not a QI, WP, or WT;
• Is wholly owned, directly or indirectly, by the U.S. financial institution identified above that agrees to act as the sponsoring entity for this entity; and
• Shares a common electronic account system with the sponsoring entity (identified above) that enables the sponsoring entity to identify all account holders and payees of the entity and to access all account and customer information maintained by the entity including, but not limited to, customer identification information, customer documentation, account balance, and all payments made to account holders or payees.

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Form W-8BEN-E (Rev. 7-2017)

Certified Deemed-Compliant Nonregistering Local Bank

1. Certify that the FFI identified in Part:
• Operates and is licensed solely as a bank or credit union in its country of incorporation or organization;
• Engages primarily in the business of receiving deposits from and making loans to retail customers unrelated to such bank;
• Does not solicit account holders outside its country of organization;
• Has no fixed place of business outside such country;
• Has no more than $175 million in assets on its balance sheet;
• Does not have any member of its expanded affiliated group that is a foreign financial institution.

Certified Deemed-Compliant FFI with Only Low-Value Accounts

1. Certify that the FFI identified in Part:
• Is not engaged primarily in the business of investing or trading in securities;
• No financial account maintained by the FFI has a balance or value in excess of $50,000;
• Neither the FFI nor the entire expanded affiliated group has more than $50 million in assets.

Certified Deemed-Compliant Sponsored, Closely Held Investment Vehicle

1. Name of sponsoring entity
2. Certify that the entity identified in Part:
• Is an FFI solely because it is an investment entity;
• Is not a QI, WP, or WT;
• Will have all of its due diligence, withholding, and reporting responsibilities fulfilled by the sponsoring entity;
• 20 or fewer individuals own all of the debt and equity interests in the entity.

Certified Deemed-Compliant Limited Life Debt Investment Entity

1. Certify that the entity identified in Part:
• Was in existence as of January 17, 2013;
• Issued all classes of its debt or equity interests to investors on or before January 17, 2013;
• Is certified deemed-compliant because it satisfies the requirements to be treated as a limited life debt investment entity.

EU Certain Investment Entities that Do Not Maintain Financial Accounts

1. Certify that the entity identified in Part:
• Is a financial institution solely because it is an investment entity;
• Does not maintain financial accounts.

Part X Owner-Documented FFI

Note: This status only applies if the U.S. financial institution has agreed that it will treat the FFI as an owner-documented FFI.

1. All owner-documented FFIs check here
2. Certify that the FFI identified in Part:
• Does not act as an intermediary;
• Does not accept deposits in the ordinary course of a banking or similar business;
• Does not hold financial assets for the account of others;
• Is not an insurance company that issues payments with respect to a financial account;
• Is not owned by or in an expanded affiliated group with an entity that accepts deposits;
• Does not maintain a financial account for any nonparticipating FFI;
• Does not have any specified U.S. persons that own an equity interest in the FFI.

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Form W-8BEN-E (Rev. 7-2017)

Part X: Owner-Documented FFI

Check box 24b or 24c, whichever applies.

I certify that the FFI identified in Part I:

• Has provided, or will provide, an FFI owner reporting statement that contains:
1. The name, address, TIN (if any), chapter 4 status, and type of documentation provided (if required) of every individual and specified U.S. person that owns a direct or indirect equity interest in the owner-documented FFI (looking through all entities other than specified U.S. persons);
2. The name, address, TIN (if any), and chapter 4 status of every individual and specified U.S. person that owns a debt interest in the owner-documented FFI that constitutes a financial account in excess of $50,000;
3. Any additional information the withholding agent requests in order to fulfill its obligations with respect to the entity.

Has provided, or will provide, valid documentation meeting the requirements of Regulations section 1.1471-2(b)(6)(i) for each person identified in the FFI owner reporting statement.

I certify that the FFI identified in Part I has provided, or will provide, an auditor’s letter, signed within 4 years of the date of payment, from an independent accounting firm stating that the firm has reviewed the FFI’s documentation with respect to all of its owners and debt holders and that the FFI meets all the requirements to be an owner-documented FFI.

Check box 24d if applicable (optional, see instructions).

I certify that the entity identified on line 1 is a trust that does not have any contingent beneficiaries or designated classes with unidentified beneficiaries.

Restricted Distributor

All restricted distributors check here

I certify that the entity identified in Part I:

• Operates as a distributor with respect to debt or equity interests of the restricted fund;
• Provides investment services to at least 30 customers unrelated to each other;
• Is required to perform AML due diligence procedures under the anti-money laundering laws of its country of organization;
• Operates solely in its country of incorporation or organization;
• Does not solicit customers outside its country of incorporation or organization;
• Has no more than $175 million in total assets under management and no more than $7 million in gross revenue on its income statement for the most recent accounting year;
• Is not a member of an expanded affiliated group that has more than $500 million in total assets under management;
• Does not distribute any debt or securities of the restricted fund to specified U.S. persons.

Check box 25b or 25c, whichever applies.

I further certify that with respect to all sales of debt or equity interests in the restricted fund:

• Has been bound by a distribution agreement that contained a general prohibition on the sale of debt or securities to U.S. entities;
• Is currently bound by a distribution agreement that contains a prohibition of the sale of debt or securities to any specified U.S. person.

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Nonreporting IGA FFI

I certify that the entity identified in Part I:

• Meets the requirements to be considered a nonreporting financial institution pursuant to an applicable IGA between the United States and
• The applicable IGA is a Model 1 IGA or a Model 2 IGA; and
• is treated as a under the provisions of the applicable IGA or Treasury regulations.
• If you are a trustee documented trust or a sponsored entity, provide the name of the trustee.
• The trustee is: U.S. or Foreign
• Foreign Government, Government of a U.S. Possession, or Foreign Central Bank of Issue

I certify that the entity identified in Part I is the beneficial owner of the payment, and is not engaged in commercial financial activities of a type engaged in by an insurance company, custodial institution, or depository institution with respect to the payments, accounts, or obligations for which this form is submitted.

EU International Organization

Check box 28a or 28b, whichever applies.

• I certify that the entity identified in Part I is an international organization described in section 7701(a)(18).
• I certify that the entity identified in Part I:
• Is comprised primarily of foreign governments;
• Is recognized as an intergovernmental or supranational organization under a foreign law similar to the International Organizations Immunities Act or that has in effect a headquarters agreement with a foreign government;
• The benefit of the entity’s income does not inure to any private person; and
• Is the beneficial owner of the payment and is not engaged in commercial financial activities of a type engaged in by an insurance company, custodial institution, or depository institution.

Exempt Retirement Plans

Check box 29a, b, c, d, e, or f, whichever applies.

• I certify that the entity identified in Part I:
• Is established in a country with which the United States has an income tax treaty in force (see Part II if claiming treaty benefits);
• Is operated principally to administer or provide pension or retirement benefits; and
• Is entitled to treaty benefits on income that the fund derives from U.S. sources or would be entitled to benefits.
• I certify that the entity identified in Part I:
• Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former employees of one or more employers in consideration for services rendered;
• No single beneficiary has a right to more than 5% of the FFI’s assets;
• Is subject to government regulation and provides annual information reporting about its beneficiaries to the relevant tax authorities;
• Is generally exempt from tax on investment income under the laws of the country in which it is established or operates due to its status as a retirement or pension plan;
• Receives at least 50% of its total contributions from sponsoring employers;
• Does not permit or penalizes distributions or withdrawals made before the occurrence of specified events related to retirement, disability, or death;
• Limits contributions by employees to the fund by reference to earned income of the employee or may not exceed $50,000 annually.
• I certify that the entity identified in Part I:
• Is organized for the provision of retirement, disability, or death benefits (or any combination thereof) to beneficiaries that are former employees;
• Has fewer than 50 participants;
• Is sponsored by one or more employers each of which is not an investment entity or passive NFFE;
• Employee and employer contributions to the fund are limited by reference to earned income and compensation of the employee;
• Participants that are not residents of the country in which the fund is established or operated are not entitled to more than 20% of the fund’s assets;
• Is subject to government regulation and provides annual information reporting about its beneficiaries.

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Form W-8BEN-E (Rev. 7-2017)

Exempt Retirement Plans (continued)

I certify that the entity identified in Part I is formed pursuant to a pension plan that would meet the requirements of section 401(a), other than the requirement that the plan be funded by a trust created or organized in the United States.

I certify that the entity identified in Part I is established exclusively to earn income for the benefit of one or more retirement funds described in this part or in an applicable Model 1 or Model 2 IGA, or accounts described in Regulations section 1.1471-5(b)(2)(A) (referring to retirement and pension accounts), or retirement and pension accounts described in an applicable Model 1 or Model 2 IGA.

I certify that the entity identified in Part I:

• Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section 1.1471-6) or an exempt beneficial owner described in an applicable Model 1 or Model 2 IGA to provide retirement, disability, or death benefits to beneficiaries or participants that are current or former employees of the sponsor (or persons designated by such employees); or
• Is established and sponsored by a foreign government, international organization, central bank of issue, or government of a U.S. possession (each as defined in Regulations section 1.1471-6) or an exempt beneficial owner described in an applicable Model 1 or Model 2 IGA to provide retirement, disability, or death benefits to beneficiaries or participants that are not current or former employees of such sponsor, but are in consideration of personal services performed for the sponsor.

I certify that the entity identified in Part I:

• Is an FFI solely because it is an investment entity;
• Each direct holder of an equity interest in the investment entity is an exempt beneficial owner described in Regulations section 1.1471-6 or in an applicable Model 1 or Model 2 IGA;
• Each direct holder of a debt interest in the investment entity is either a depository institution (with respect to a loan made to such entity) or an exempt beneficial owner described in Regulations section 1.1471-6 or an applicable Model 1 or Model 2 IGA.

Has provided an owner reporting statement that contains the name, address, TIN (if any), chapter 4 status, and a description of the type of documentation provided to the withholding agent for every person that owns a debt interest constituting a financial account or direct equity interest in the entity; and

Has provided documentation establishing that every owner of the entity is an entity described in Regulations section 1.1471-6(b), (c), (d), (e), and/or (g) without regard to whether such owners are beneficial owners.

I certify that the entity identified in Part I is a financial institution (other than an investment entity) that is incorporated or organized under the laws of a possession of the United States.

I certify that the entity identified in Part I:

• Is a holding company, treasury center, or captive finance company and substantially all of the entity’s activities are functions described in Regulations section 1.1471-5(e)(6)(C) through (E);
• Is a member of a nonfinancial group described in Regulations section 1.1471-(e)(5)(B);
• Is not a depository or custodial institution (other than for members of the entity’s expanded affiliated group); and
• Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or any investment vehicle with an investment strategy to acquire or fund companies and then hold interests in those companies as capital assets for investment purposes.

I certify that the entity identified in Part I:

• Was formed on (or, in the case of a new line of business, the date of board resolution approving the new line of business) (date must be less than 24 months prior to date of payment);
• Is not yet operating a business and has no prior operating history or is investing capital in assets with the intent to operate a new line of business other than that of a financial institution or passive NFFE;
• Is investing capital into assets with the intent to operate a business other than that of a financial institution; and
• Does not function (or hold itself out) as an investment fund, such as a private equity fund, venture capital fund, leveraged buyout fund, or any investment vehicle whose purpose is to acquire or fund companies and then hold interests in those companies as capital assets for investment purposes.

I certify that the entity identified in Part I:

• Filed a plan of liquidation, filed a plan of reorganization, or filed for bankruptcy on;
• During the past 5 years has not been engaged in business as a financial institution or acted as a passive NFFE;
• Is either liquidating or emerging from a reorganization or bankruptcy with the intent to continue or recommence operations as a nonfinancial entity; and
• Has, or will provide, documentary evidence such as a bankruptcy filing or other public documentation that supports its claim if it remains in bankruptcy or liquidation for more than 3 years.

Form W-8BEN-E (Rev. 7-2017)

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Form W-8BEN-E

501(c) Organization

I certify that the entity identified in Part I is a 501(c) organization that:

• Has been issued a determination letter from the IRS that is currently in effect concluding that the payee is a section 501(c) organization;
• Has provided a copy of an opinion from U.S. counsel certifying that the payee is a section 501(c) organization.

Nonprofit Organization

I certify that the entity identified in Part I is a nonprofit organization that meets the following requirements:

• The entity is established and maintained in its country of residence exclusively for religious, charitable, scientific, artistic, cultural or educational purposes;
• The entity is exempt from income tax in its country of residence;
• The entity has no shareholders or members who have a proprietary or beneficial interest in its income or assets;
• Neither the applicable laws of the entity’s country of residence nor the entity’s formation documents permit any income or assets of the entity to be distributed to, or applied for the benefit of, private person or noncharitable entity other than pursuant to the conduct of the entity’s charitable activities or as payment of reasonable compensation for services rendered or payment representing the fair market value of property which the entity has purchased;
• The applicable laws of the entity’s country of residence or the entity’s formation documents require that, upon the entity’s liquidation or dissolution, all of its assets be distributed to an entity that is a foreign government, an integral part of a foreign government, a controlled entity of a foreign government, or another organization that is described in this part or escheats to the government of the entity’s country of residence or any political subdivision thereof.

Publicly Traded NFFE or NFFE Affiliate of a Publicly Traded Corporation

Check box 37a or 37b, whichever applies.

I certify that:

• The entity identified in Part I is a foreign corporation that is not a financial institution; and
• The stock of such corporation is regularly traded on one or more established securities markets.

I further certify that the entity identified in Part I has no substantial U.S. owners or has provided the name, address, and TIN of each substantial U.S. owner.

Active NFFE

I certify that:

• The entity identified in Part I is a foreign entity that is not a financial institution;
• Less than 50% of such entity’s gross income for the preceding calendar year is passive income; and
• Less than 50% of the assets held by such entity are assets that produce or are held for the production of passive income.

Passive NFFE

I certify that the entity identified in Part I is a foreign entity that is not a financial institution and is not certifying its status as a publicly traded NFFE or other NFFE types.

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Form W-8BEN-E (Rev. 7-2017)

,

Excepted Inter-Affiliate FFI

,

I certify that the entity identified in Part I:

,

,
• Is a member of an expanded affiliated group;

,

• Does not maintain financial accounts (other than accounts maintained for members of its expanded affiliated group);

,

• Does not make withholdable payments to any person other than to members of its expanded affiliated group;

,

• Does not hold an account (other than depository accounts in the country in which the entity is operating to pay for expenses) with or receive payments from any withholding agent other than a member of its expanded affiliated group;

,

• Has not agreed to report under Regulations section 1.1471-4(d)(2)(i)(C) or otherwise act as an agent for chapter 4 purposes on behalf of any financial institution, including a member of its expanded affiliated group.

,

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Sponsored Direct Reporting NFFE

,

Name of sponsoring entity:

,

I certify that the entity identified in Part I is a direct reporting NFFE that is sponsored by the entity identified on line 42.

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Substantial U.S. Owners of Passive NFFE

,

As required by Part XXVI, provide the name, address, and TIN of each substantial U.S. owner of the NFFE. Please see the instructions for a definition of substantial U.S. owner. If providing the form to an FFI treated as a reporting Model 1 FFI or reporting Model 2 FFI, an NFFE may also use this part for reporting its controlling U.S. persons under an applicable IGA.

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Name Address TIN

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Certification

,

Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:

,

,
• The entity identified on line 1 of this form is the beneficial owner of all the income to which this form relates, is using this form to certify its status for chapter 4 purposes, or is a merchant submitting this form for purposes of section 6050W;

,

• The entity identified on line 1 of this form is not a U.S. person;

,

• The income to which this form relates is: (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax