BENEFICIAL OWNERSHIP DECLARATION

Pursuant to Section 7 (f) (ii)

of the Petroleum Industry
Act. 2021

Notice of Persons with Significant Control

What this form is for What this form is NOT for For further information
You may use this form to You cannot use this fom1 Please: refer to our
give notice of person with to give notice of change of guidance: at
significant control (PSC)- details of PSC- Natural www.nuprc.gov.ng
Natural Person. PSC- Person or Legal Entity
legal Entity and details of
the interest(s) held (used
by both entities and
natural persons)

Notification - Natural Person

O n e copy should be filled out for each natural person who i s a person with significant control

Details of the person with significant control

Submission Date _ _-_ _ _-_ _ _ _ The date on which this

information was
day-month-year submitted

Input month as
abbreviated text e.g
30-Jan-2020

Title
First Name This should be the
current legal name of the
PSC
Surname The family names of the
PSC
Other Name(s) The given names of the
PSC used to distinguish
the individual within the
family.

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Former name(s) The patronymic name of
the PSC (where used).
City
Nationality/nationalities The nationalities held by
the PSC
Country of residence
Identification number
Identification type Means of identification
e.g. international
passport. National ID
card. Driver’s License.
Permanent Voter’s Card
Gender
Email
Phone number
Address service Building The service address of the
name/number PSC
Street
City
State
Country

Address - home The home address of the PSC (not

Building for publication)
name/number Individual’s residential address
You can state: 'Same as service
address· in this section if the usual
residential address is same as the
service address.
You cannot state ·Same as service
address· if the service address is
not stated as the Company's
Registered Office:·. You will need
to complete the address in full.
This address cannot be a P O Box
number.
Street
City
State
Country

Tax residency A jurisdiction or

jurisdiction in which the

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 PSC is resident for tax
purposes
Date of Birth _ _-_ _ _-_ _ _ _ Input month as
abbreviated text e.g
day-month-year 30-Jan-2020

B. Alternative name forms

One copy should be filled out for each alternative name the person of significant control
is known, or has been known, by.

Name type Choose from:

• "Translation" -
translation of a
name.
• "Former" - former
name (for example. a
maiden name).
• “Alias" -an alias.
• "Nick" - a nickname.
• "Birth” - the name of
the PSC at birth.
Full Name The PSC's full name
Family Name The family name(s) of the
PSC
Given Name The given name(s) of the
PSC used to distinguish the
individual within the family.
Patronymic name The patronymic name of the
PSC (where used).

C. Notification - Legal Entity

Submission Date _ _-_ _ _-_ _ _ _ The date on which this
information was submitted
day-month-year
Input month as abbreviated
text e.g 30-Jan-2020

Name of entity
Legal form Choose from:
• Private registered
company

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 • Public registered
company
• Limited liability
partnership
• Other legal entity
(e.g government
department)
• Trust
• Legal arrangement
Country of Registration The country in which this
legal enti1y is registered. if
any.
Legal entities that have a
unique registration must
provide a jurisdiction.
register and identifier.
Register The register in which this
legal entity is registered.
Registration Number The Registration number' for
this legal entity.
E.g., a company number
provided by a central
business register.
Governing law The governing law to which
this legal entity is subject.
Address - registered Building The registered address of the
name/number legal entity
Street
City
State
Country

D. Details of the interest(s) held

Date this person _ _-_ _ _-_ _ _ _ Input month as abbreviated

became a person with text e.g 30-Jan-2020
day-month-year
significant control

Interests held

Shares in a company or interest in a limited liability partnership

Yes/No

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Docs the PSC directly Percentage held If ·Yes·. state the
or indirectly hold at directly percentage held directly
Percentage held and indirectly.
least 5% of the shares
or interest in a company indirectly
or limited liability
partnership?
Name of legal Name(s), Share (%) Where some part of the
Owner(s) of shares or jurisdiction(s), interest is held indirectly.
and company the name of the legal owner
interest in the Register
number(s) of through which this interest
and the percentage of legal owner(s) is held should be provided.
the PSC's overall where the PSC holds the
interest held through interest through a
them. combination of legal
owners in the Register. all
relevant legal owners
should be listed.
Where the legal owner is a
natural person. the name
should be as it appears on
the Register. Where the
legal owner is an entity. the
company number and
jurisdiction should also be
provided.

Voting rights in a company or limited liability partnership

Does the PSC directly or Yes/No If ·Yes·. state the percentage

indirectly hold at least Percentage held directly and indirectly.
5% of the voting rights held directly
in a company or limited
liability partnership?
Percentage
held indirectly
Name of legal Name(s), Voting right If the names and
owner(s) of voting jurisdiction(s), (%) percentages of the legal
rights in the Register and company owners are the same as the
number(s) of shares and interest
and the percentage of legal owner(s) declaration. then this
the PSC's overall section can be left blank.
interest held through
them. Where some part of the
interest is held indirectly·.
the name of the legal owner
through which this interest
is held should

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 be provided.
Where the PSC holds the
interest through a
combination of legal owner
in the Register. all relevant
legal owner.; should
be listed.
Where the legal owner is a
natural person, the name
should be as it appears on
the
Register. Where the legal
owner is an entity, the
company number and
jurisdiction should also be
provided

The right to appoint or remove a majority of the directors or partners

Docs the PSC directly Yes/No

or indirectly hold the
right to appoint or
remove a majority
of the directors or
partners in a
company or limited
liability partnership?

Significant influence or control over a company or limited partnership

Docs the PSC otherwise Yes/No

have the right to
exercise or is actually
exercising significant
influence or control
over a company or
limited liability
partnership?

Significant influence or control whether or not the PSC is a legal entity, but
would itself satisfy any of the first four conditions if it were an individual.

Does the PSC have the Yes/No Natural persons should

right to exercise, or always answer “No”
actually exercise
significant influence or

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 control over the
activities of a trust or
furn. whether or not it
is a legal entity, but
would itself satisfy any
of the first four
conditions if it were an
individual?

Term Definition
"person with significant control" means any person:

• directly or indirectly holding at least 5% of the

shares or interest in a company or limited liability
partnership;
• directly or indirectly holding at least 5% of the
voting rights in a company or limited liability
partnership;
• directly or indirectly holding the right to appoint or
remove a majority of the directors or partners in a
company or limited liability partnership;
• otherwise having the right to exercise or actually
exercising significant influence or control over a
company or limited liability partnership; or
• having the right to exercise, or actually exercising
significant influence or control over the activities of
a trust or firm whether or not it is a legal entity, but
would itself satisfy any of the first four conditions if
it were an individual.'

Presented for filing by:

Name
Address Street
City/Area/District
City/Town/Village
Local Government
Postal code
State
Country
Phone Number

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 Email Accreditation
Number
(where
applicable:)
Signature Date

NOTE:
Petroleum Industry Act, 2021. Section 230.
Subject to the provision of Section 230 (a), (b),( c) and e) any person who fails or
refuses to furnish, return or supply information to the Commission or Authority
or any other lawful authority at the time and in the manner prescribed, furnishes
a false or incomplete return, supplies false or incomplete information, or conceals,
fails or refuses, without reasonable cause, to supply information required by the
Commission or Authority or any duly empowered lawful authority at the time and
in the manner prescribed or when required to do so, commits an offence and is
liable:
a) on conviction by a court of competent jurisdiction is liable to a term of
imprisonment and
b) be liable to a fine as prescribed by the Regulations where such offence is
repetitive or continues after having been so informed in writing by the
Commission.
Nothing in this section shall affect the provision of any enactment imposing
penalties in respect of perjury in force in Nigeria