ANNUAL RETURN CLIENT INFORMATION FORM

DETAILS OF FIRM

ICATT Firm ID No.:

No. of Owners/ Partners/ Directors:

Type of Firm:

Sole Practitioner
Partnership
Body Corporate

Number of Employees at Firm:

Contact Person

- - Listed

Name

First

Middle

Last

Office:

Mobile:

Fax:

Email Address

Main Office Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mailing Address: (if different from above)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Other Branch(es)/Address Location(s):

Name(s) of owners / partners / directors (members / non-members).

Click the + button to insert additional names.

Owner Name

Name(s) of auditing or practising members:

Click the + button to insert additional names.

Practising Members

No. of ICATT members who are auditing or practising executives employed at firm:

(1) In the current year stated did the firm engage in any of the following public practice assignments:

(a) Audit

(b) Practising

(2) If you ticked Yes to 1 (a), please submit the following details:

NUMBER OF CLIENTS

(Based on the number of reports signed)

PIE* clients:

Banks or similar financial institutions:

Credit Unions:

Insurance Companies:

Listed Companies:

Mutual funds that take third porty risk or funds:

Non - PIE clients:

*A Public Interest Entity (PIE) Is defined as a listed company, bank or similar financial lnstitution,credit union, Insurance company or a mutual fund which takes third party risks or funds.

(3) If you ticked Yes to 1 (b), please submit the following details:

Accountancy - Type of Non-PIE Clients

Accountancy - Type of PIE Client

(Bank, Credit Union, Insurance, Listed Cos & Mutual Funds)

Accountancy - Number of Clients

(Based on the number of reports signed)

Insolvency- Type of Non-PIE Clients

Insolvency - Type of PIE Client

(Bank, Credit Union, Insurance, Listed Cos & Mutual Funds)

Insolvency - Number of Clients

(Based on the number of reports signed)

Taxation - Type of Non-PIE Clients

Taxation - Type of PIE Client

(Bank, Credit Union, Insurance, Listed Cos & Mutual Funds)

Taxation - Number of Clients

(Based on the number of reports signed)

Information Technology - Type of Non-PIE Clients

Information Technology - Type of PIE Client

(Bank, Credit Union, Insurance, Listed Cos & Mutual Funds)

Information Technology - Number of Clients

(Based on the number of reports signed)

Other- Type of Non-PIE Clients

Other - Type of PIE Client

(Bank, Credit Union, Insurance, Listed Cos & Mutual Funds)

Other - Number of Clients

(Based on the number of reports signed)

4) In the coming year does the firm intend /will continue to engage in public practice assignments:

CONFIRMATION

On behalf of my firm, I confirm that the Information given In this form Is true, accurate to the best of my knowledge and belle/ offer making all reasonable
enquiries. I understand that a false declaration on this form may lead to disciplinary action being token against me and/or my firm. I further confirm that neither
I nor the firm nor any of Its partners/dlrectors/responslble lndlvlduals have been subject ta any criminal, dlsclpllnary, regulatory or any other matters which may
hove been contrary to the Rules and Regulations ol lCATT, the Code of Ethics, and/or relevant accounting and auditing stondords as adopted by ICATT that may
coll Into doubt my firm's ellglblllly lo hold an auditing certltlcote, which hove not already been brought lo the attention of ICATT's Investigations Committee. I om
aware of, and will abide by, my continuing obllgotlon to draw any such matters to ICATT's attention.

Date