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SUPPORTING INFORMATION CHECKLIST AND STATUTORY DECLARATION FINANCIAL MARKETS (Financial Markets Authority New Zealand)

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TRU2.1 Var
SUPPORTING INFORMATION CHECKLIST AND STATUTORY DECLARATION
INFORMATION FOR
LICENSING UNDER SECTION 16 OF THE
FINANCIAL MARKETS SUPERVISORS ACT 2011 (The Act)
Applicant company details:
1. Company nam
e (as registered):
2.
Company Financial Service Provider
(FSP):
Director/senior manager details:
Please complete and submit with this form a DIR1.1 Var form for each and every director and
senior manager as required by Section 16 of the Act.
3. Please identify the name and position of each director/senior manager submitting a DIR1.1 Var
form for your application by completing Appendix 1.
I confirm that all the required directors and senior managers have completed
DIR1.1 Var forms, and their names are listed in Appendix 1.
- Page 1 of 5 -
Date:
_______/_______/_______
Please initial here
TRU2.1 Var
Application document checklist:
4. To vary a licence, the applicant is required to provide a number of supporting documents. Please
confirm that you have supplied the required documents with this form by ticking the appropriate
boxes.
Provided with
Tru2.1 Var form
i. Business details
ii. Good character (DIR1.1 Var Forms)
iii. FSP (RDR) Act compliance
iv. Experience, skills and qualifications
v. Compliance controls
vi. Compliance monitoring
vii. Financial resources
viii. Other resources
ix. Independence
x. Governance
xi. Professional indemnity insurance
xii. Other matters
Please ens
ure that you use the cover pages provided in Appendix 2 to identify the
documents being submitted for assessment.
- Page 2 of 5 -
Date:
_______/_______/_______
Please initial here
Please refer to Part C of the ‘Guidance Note: Supervisor Licensing’ for help on providing the information
required under each of the heading.
TRU2.1 Var
Confirmation
I confirm that prior to completing this application I understand the entity’s obligations under the Act, and the
Financial Markets Supervisors Regulations 2014, and I have read and understood ‘Guidance Note: Supervisor
Licensing’ issued by the Financial Markets Authority.
I confirm (please tick those statements that are applicable):
Debt securities and/or registered schemes
The applicant is currently registered under the Financial Service Providers (Registration and
Dispute Resolution) Act 2008.
Retirement Villages:
The applicant is compliant with section 13 (a) of the Financial Service Providers (Registration
and Dispute Resolution) Act 2008.
Statutory declaration
I, _______________ _______________ _______________, of __________________________________________
solemnly and sincerely declare the following:
that I have been authorised to act on behalf of the above named applicant in the making of this
application,
that having conducted all necessary enquiries, I declare the information provided in this TRU2.1 Var
form is true and correct to the best of my knowledge,
Signature of person making declaration
Declared at this day of 20
before me:
Full name and desi
gnation of person to take statutory declaration
(Note: If you are making this declaration outside New Zealand, please ensure it is sworn in
accordance with section 11 of the Oaths and Declarations Act 1957).
- Page 3 of 5 -
Date:
_______/_______/_______
Please initial here
•
•
And I make this solemn declaration conscientiously believing the same to be true and by virtue of
the Oaths and
Declarations Act 1957.
TRU2.1 Var
Name
Role within applicant’s business
First name
Last name
- Page 4 of 5 -
Date:
_______/_______/_______
Please initial here
Appendix 1
TRU2.1 Var
Name
Role within applicant’s business
First name
Last name
- Page 5 of 5 -
Date:
_______/_______/_______
Please initial here
Appendix 2
TRU2.1 Var
TRU2.1 Var
1. Business detail
s
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provi
ded in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
2. Good character (DIR1.1 Var Forms)
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided
in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
3. FSP (RDR) Act compliance
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
4. Experience, skills and qualifications
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
5. Compliance controls
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
6. Compliance monitoring
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
7. Financial resources
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
8. Other resources
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
9. Independence
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
10. Governance
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
11. Professional indemnity insurance
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provided
in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
TRU2.1 Var
12. Other matters
Company name:
Company FSP number:
Number of pages in this section:
(excluding cover sheet)
The details provid
ed in this section are true and complete to the best of my knowledge:
Signed: Dated:
/ /
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SUPPORTING INFORMATION CHECKLIST AND STATUTORY DECLARATION FINANCIAL MARKETS (Financial Markets Authority New Zealand)

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Completed 15 November 2020

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