FORM SEC 6A5

(To be completed in duplicate)

SECURITIES AND EXCHANGE COMMISSION (SEC)

NIGERIA

APPLICATION FORM FOR AUTHORIZATION AND REGISTRATION OF INFRASTRUCTURE FUNDS IN

ACCORDANCE WITH THE PROVISIONS OF SECTIONS 13 (h); 160 (1) – (4); 161 (1) – (5) OF THE
INVESTMENT AND SECURITIES ACT, NO. 29, OF 2007, AND THE DRAFT RULES ON INFRASTRUCTURE
FUNDS

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Instructions for Completion of Form

i. All questions must be answered in the space provided and not left blank. Where a
question is not applicable please indicate by writing N/A in the space provided.

ii. All entries made in this form must be typed. Hand written entries will result in rejection of
application

ii. Information supplied/entered in the application form must be valid and correct as at a
date not earlier than 30 days preceding the date of this application.

iii. In the event of any material change to the information provided in this application prior
to the authorization of the scheme, the applicant shall notify the Commission of such
change (s) immediately.

iv. Any false/misleading information found to have been supplied herein shall attract
appropriate sanction(s) / penalty (ies) in line with the requirement of SEC Rules and
Regulations.

Date of Submission of Application

Reference/Processing Application No.
Cheque No.

v. The form should be sworn to by a notary public.

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 1. APPLICANT/REGISTRANT

a) Name………………………………………………………………………………….
(Exact name as in certificate of incorporation)
b) Head Office ………………………………………………………………………….
(Principal Office Address)
c) Branch Office (i)……………………………………………………………………...

d) Branch Office (ii)…………………………………………………………………….

e) Other Address, if any (iii)...…………………………………………………….........

f) Telephone Number……………………………………………………………………
2. THE SCHEME/FUND

a) (i)Name of Proposed Scheme:……………………………………………………..

(ii)Proposed Date of Commencement:…………………………….……………….

b) Objective of the Scheme:…………………………………………………………...

………………………………………………………………………………………
………………………………………………………………………………………

c) Industry or Geographical focus of the Fund:………………………………………

……………………………………………………………………………………..

……………………………………………………………………………………
d) Investment Criteria for Target Portfolio Companies:……….………..…………..

…….………………………………………………………………………………

…………………………………………………………………………………....

e) (i) Total Capital Commitment:……………………………………………………

(ii) Net Target Investment Return:……………………………………………….

(iii) Distribution of Proceeds and Sharing Ratio:…………………………………

g) Fees and Charges connected with investment in the Fund: ………………………

………………………………………………………………………………….

………………………………………………………………………………….
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 h) Provision for admission of new and withdrawal of existing investors:…………….

………………………………………………………………………………………

………………………………………………………………………………………

i) Exit Routes from Investments:……………………………………………………..

………………………………………………………………………………………

j) Management participation in the Fund:……………………………………………

………………………………………………………………………………………

k) Repayment of Capital:……………………………………………………………...

l) Duration of the Fund and extension:………………………………………………..

3. DETAILS OF MANAGEMENT COMPANY/ GENERAL PARTNER1

(a) Names:……………………………………………………………………………...

(b) Address:……………………………………………………………………………

(c) Date of Incorporation ………….…………………………………………………...

(d) Date of Commencement of business:………………………………………………

4. SHAREHOLDING STRUCTURE OF THE MANAGEMENT COMPANY/

GENERAL PARTNER

a) Name(s) of Substantial Shareholders (5% and above)

Name No. of Amount %
Shares

Nigeria

Foreign

b) Names of beneficial owners of nominee shareholding of at least 5% of the ordinary share

capital apart from pension funds (state the percentage in each case)

………………………………………………………………………………………………
1. Details of General partner applies if fund is setup as a partnership, otherwise fill in details of Fund Manager

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 c) State of business (where appropriate) and percentage contribution from each line
(projected)
No. Description % Contribution to
Turn over Net Profit
1.
2.
3.
4.
5.

d) Details of Affiliates as follows: (if applicable)

(i) Name of Affiliate:………………………………………………………………………

(ii) Address: ………………………………………………………………………………..

(iii)Nature of Affiliate:……………………………………………………………………...

e) Management and Principal Officers.

Name Educational Address Share % Shareholding in Remarks
Qualification Qualification relation to total share
capital

f) Details of Management of other Schemes in the last five (5) years

Name of Scheme Nature of Business Year of floatation Current status

f) Details of contingent liabilities (if any) & estimate probability of an outflow of

resources resulting from contingent liabilities……………………………………………..
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

g) (i) Are you a member of any Trade Association? If yes please give de

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 (ii) Have you ever been found guilty of any misdemeanor breach of the rules of any
such association?.......................................................................................................

h) (i) Is any investment advisory contract subsisting between your company and any other?
(ii) Details of any such investment Advisers stated below:

Name & Address Pertinent Fund Basis of Remuneration

………………… …………………. ……………………..
………………… …………………. …….……………….
………………… ………………….. …………………….
i) (i) Are your officers covered by a Fidelity guarantee Insurance?
(ii) If yes give details:

Name & Insurer Insured Valued Date Last Previous Claims

Premium paid (if any)

……………………. ……………… …………….…… ………………….

…………..……....... ..……………. ………………… ………………….
……………………. ……………… …………………. …...…………….
…………………… ………………. …………………. …...…………….

j) Details regarding previous claims relating to (i)(ii):……………………………………….

………………………………………………………………………………………………
……………………………………………………………………………………………....
………………………………………………………………………………………………
………………………………………………………………………………………………
k) Any subventions/source of funding for investment purposes.
l) Details of Subventions.
m) Five year financial summary (including management account as at immediate quarter
preceding submission of application)

5. MANAGEMENT COMPANY/ GENERAL PARTNER’S FINANCIALS:

Five year financial statement or such number of years the company has been in
existence if less than 5years.
Year 5 Year 4 Year 3 Year 2 Year 1
N’000 N’000 N’000 N’000 N’000

ASSET:
Cash at bank and in hand
Propriety investments
Account receivables and other assets
Financial Assets
Non-current assets

TOTAL ASSETS:

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 LIABILITIES:
Bank Overdraft
Accounts payables
Financial liabilities
Tax payable
Dividend Payable
Deferred Taxation

TOTAL LIABILITIES:

FUNDS UNDER MANAGEMENT

NET ASSETS

CAPITAL RESERVES:
Share Capital
Share premium
Reserve
Retained Earnings

Profit before tax

Taxation
Profit after tax
Earnings per share
Dividend per share

6. DETAILS OF TRUSTEE2

a) Name of Proposed Trustee………………………………………………………………….

b) Date & place of incorporation………………………………………………………………

c) Relationship of Trustee with Management company………………………………………

d) Authorized Capital…………………………………………………………………………

e) Amount of issued & paid up share capital………………………………………………….

2. Please note that details of Trustee only applies if the Infrastructure fund to be registered is structured as a Trust

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 f).Management and principal officers of Trustee
Name Educational Position held Address Units of Remark
Qualifications scheme held

g).Details of Trusteeship of other Schemes within the last 10 years

Name of Scheme Year trusteeship Current status Reason for cessation (if
commenced applicable)

h). Remuneration/charges of Trustee (with respect to this application)……………………….

i). State basis of remuneration………………………………………………………………….

7. TRUSTEE’S FINANCIALS:
Five year financial statement or such number of years the Trustee has been in
existence if less than 5years.
Year 5 Year 4 Year 3 Year 2 Year 1
N’000 N’000 N’000 N’000 N’000
ASSET:
Cash at bank and in hand
Propriety investments
Account receivables and other assets
Financial Assets
Non current Assets

TOTAL ASSETS:
LIABILITIES:
Bank Overdraft
Financial Liabilities
Other Liabilities
Tax payable
Dividend Payable
Deferred Taxation

TOTAL LIABILITIES:

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NET ASSETS

CAPITAL RESERVES:
Share Capital
Share premium
Reserve
Retained Earnings

Profit before tax

Taxation
Profit after tax
Earnings per share

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SIGNATURES AND CERTIFICATION
Pursuant to the requirements of the Investment and Securities Act 2007 and the Rules and
Regulations made there under, the Applicant/Registrant has duly caused this application form to
be signed on its behalf by the undersigned hereunto duly authorized.

………………………………….
Applicant/Registrant

Date:………………………………………….Signature:………………………………….............

………………………………………………………………………………………………………
(Full Name and Title)

I certify that to the best of my knowledge and belief that the information set-forth in this
application form is true, complete and correct.

………………………………………. ………………………………………………
Date Signature

………………………………………………………………………………………………………
(Full Name and Title

NB:
*This form should be notarized*