This form must be completed and submitted no later than the 31st January 2023. Failure to provide the information by this date will result in a suspension of your Network membership.

Email address *

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FCA Registered Company Name *

FCA Number *

Companies House Registration Number

(if applicable)

Date of Incorporation

(if applicable)

Please complete the below as accurately as possible. The FCA require actual turnover figures for 2022 for the legal entity that is authorised by Connect. Where the request relates to other business activities, this should only include activities that are transacted by the legal entity that is authorised by Connect, not other activities from other companies. For sole traders, this should include all activities conducted by the sole trader.

What is your company accounting year-end date? (ARD) *

TOTAL INCOME:

Confirm your actual total company turnover for 2022 You must include all income streams not just those derived from business via Connect agencies.

Total actual income from Jan 22 up to your ARD date in 2022. *

Projection of total income for the remainder of 2022. *

Projection of total income for 2023 for a calendar the year Jan-Dec. *

NON-CONNECT INCOME (Financial):

Of the total turnover confirm how much was from activities outside of Connect agencies that were activities of a financial services nature?

For example, pensions, investments, insurance, banking, lending, consumer credit, factoring, financial leasing, money transmission, payments, guarantees and commitments, foreign exchange, issuance of securities and other corporate finance, custodial, depository, trust services, financial information and data, asset finance, commercial mortgages, bridge finance, securities, currency etc or introductions/referrals of any of the above.

Actual non-Connect (financial) income from Jan 22 up to your ARD date in 2022. *

Projection of non-Connect (financial) income for the remainder of 2022. *

Projection of non-Connect (financial) income for 2023 for a calendar the year Jan-Dec. *

Please list those activities in order of largest first. *

NON-CONNECT INCOME (non-financial):

Of the total turnover, confirm how much was from activities outside of Connect agencies that were not of a financial nature?

For example, property sales or lettings, will writing, accountancy, consulting or any other non-connected business types etc.

Actual non-Connect (non-financial) income from Jan 22 up to your ARD date in 2022. *

Projection of non-Connect (non-financial) income for the remainder of 2022. *

Projection of non-Connect (non-financial) income for 2023 for a calendar the year Jan-Dec. *

Please list those activities in order of largest first. *

Is the company part of a group of companies? (e.g. some or all of its shares are owned by another company) *

Is the company registered office address or the group company owner address based in the UK? *

Declaration

WARNING: This information will be submitted to the FCA under the Section 165 request. Knowingly or recklessly giving the FCA information, which is false or misleading in a material particular, may be a criminal offence (sections 398 and 400 of the Financial Services and Markets Act 2000). SUP 15.6.4R requires an authorised person to take reasonable steps to ensure the accuracy and completeness of the information given to the FCA and to notify the FCA immediately if materially inaccurate information has been provided. Contravention of these requirements may lead to disciplinary sanctions or other enforcement action by the Regulator.

I confirm the information I have declared is true and to the best of my knowledge and that I have the appropriate authority on behalf of the Company to provide the information. I further understand that I may be required to evidence the information given.

Name of the company’s main controller. *

Signature *

Dated *

Data Collection – Section 165 – Controller

This form must be completed and submitted no later than the 31st January 2023. Failure to provide the information by this date will result in a suspension of your Network membership.

TOTAL INCOME:

NON-CONNECT INCOME (Financial):

NON-CONNECT INCOME (non-financial):

Declaration

IN ASSOCIATION WITH: