Form 94-101F1
INTRAGROUP EXEMPTION

Type of Filing:

□ INITIAL

□ AMENDMENT

Section 1 – Information on the entity delivering this Form

1. Provide the following information with respect to the entity delivering this Form:

Full legal name:

Name under which it conducts business, if different:

Head office

Address:

Mailing address (if different):

Telephone:

Website:

Contact employee

Name and title:

Telephone:

Email:

Other offices

Address:

Telephone:

Email:

Canadian counsel (if applicable)

Firm name:

Contact name:

Telephone:

Email:

2. In addition to providing the information required in item 1, if this Form is delivered for the purpose of reporting a name change on behalf of the entity referred to in item 1, provide the following information:

Previous full legal name:

Previous name under which the entity conducted business:

Section 2 – Combined notification on behalf of counterparties within the group to which the entity delivering this Form belongs

1. For the mandatory clearable derivatives to which this Form relates, provide all of the following information in the table below:

(a)          the legal entity identifier of each counterparty in the same manner as required under the following instruments:

(i)           in Alberta, British Columbia, New Brunswick, Newfoundland and Labrador, the Northwest Territories, Nova Scotia, Nunavut, Prince Edward Island, Saskatchewan and Yukon, Multilateral Instrument 96-101 Trade Repositories and Derivatives Data Reporting,

(ii)          in Manitoba, Manitoba Securities Commission Rule 91-507 Trade Repositories and Derivatives Data Reporting,

(iii)          in Ontario, Ontario Securities Commission Rule 91-507 Trade Repositories and Derivatives Data Reporting, and

(iv)         in Québec, Regulation 91-507 respecting Trade Repositories and Derivatives Data Reporting;

(b)          whether each counterparty is a local counterparty in a jurisdiction of Canada.

Pairs	LEI of counterparty 1	Jurisdiction(s) of Canada in which counterparty 1 is a local counterparty	LEI of counterparty 2	Jurisdiction(s) of Canada in which counterparty 2 is a local counterparty
1

2. Describe the ownership and control structure of the counterparties identified in item 1.

Section 3 – Certification

I certify that I am authorized to deliver this Form on behalf of the entity delivering this Form and on behalf of the counterparties identified in Section 2 of this Form and that the information in this Form is true and correct.

DATED at ___________ this ________ day of ___________, 20 ___

__________________________________________

(Print name of authorized person)

__________________________________________

(Print title of authorized person)

__________________________________________

(Signature of authorized person)

__________________________________________

(Email)

__________________________________________

(Phone number)