Type of Claim



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Datum22.08.2016
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Bonds

This form is suggested for creditors wishing to make general claims in respect of bond issues. If you wish to claim priority, security or there are other issues relevant to your claim, you MUST provide details (and relevant documentation). If you do not, those issues may not be taken into account when your claim is assessed. If the form is not appropriate or does not provide enough space, you do not have to use the form at all. If it helps, you can append information to the form. You must make your claim in writing so that it can be clearly understood.







Type of Claim

Check the appropriate box.
 New Claim  Amends and updates a previously filed claim.
Reference number (if known): ___________________________________________________________________________________________











If you are amending a previously filed claim, provide a reference number (if known) or any other details related to the previously filed claim.

Claimant information










Name of Claimant













Name of the individual or entity that is submitting the claim (the "Claimant"), including company registration number (if available).







Address













Registered address of the Claimant. If the Claimant operates from another address, please also enter this address and clarify which address should be used for correspondence.







Email













Email address of one or more individuals at the Claimant which can be used for queries about this claim.







Bond information










ISIN/CUSIP of Bond













The International Securities Identification Number (ISIN) or the Committee on Uniform Security Identification Procedures number (CUSIP), or other identification number, for each Glitnir Bond issue to which this claim relates. If you are filing this claim with respect to more than one Glitnir Bond issue, you may attach a schedule with the ISINs and/or CUSIPs for the Glitnir Bonds issue to which this claim relates.







Maturity date













Date the bond is due for settlement in full under the terms of the contract.







Currency of Bond













Currency in which the bond is denominated.





































Claim










Principal amount claimed (in currency of bond)













Set out the principal amount on the Glitnir Bonds to which this claim relates.













Total interest claimed up to and including 22 April 2009 (in currency of bond)













Set out amount and basis of calculation, including rate used.







Total interest claimed post 22 April 2009 (in currency of bond)













Set out amount and basis of calculation, including rate used.







Total costs claimed up to and including 22 April 2009 (in currency of bond)













Set out amount and basis of calculation, including a full breakdown.







Total costs claimed post 22 April 2009 (in currency of bond)













Set out amount and basis of calculation, including a full breakdown.





The Winding-Up Board will convert the principal, interest and costs claim amounts into Icelandic Krona (ISK). In accordance with Icelandic law, the rate that will be used is the Central Bank of Iceland’s selling rate on 22 April 2009.

Interest and costs can be claimed as part of your main claim up to and including 22 April 2009. Thereafter you can still claim interest and costs, but this part of your claim will often be deferred.



Provide details of the amount claimed in the table below:

Claim Type

Principal Claimed

Interest Claimed
up to and including
22 April 2009


Interest Claimed
Post 22 April 2009


Costs Claimed
up to and including
22 April 2009


Costs Claimed
Post 22 April 2009


Total

Unsecured







N/A




N/A




Deferred

N/A

N/A




N/A







Total



















Note: State amounts in the currency of the bond. Claim type refers to articles 109-115 of The Bankruptcy Act No. 21 of 1991. Definitions of claim types can be found in the FAQ son http://www.glitnirbank.com.
Enclose copies of any documents that support your claim type and statements above, including, without limitation, documents providing evidence of costs claimed. To support any claim of legal fee costs, include a statement from your legal representative and invoices for legal costs.







Any further claim details













Details of any factors that the Claimant believes might affect the claim amount or priority. Where the Claimant believes that the claim has priority treatment under Icelandic law, state the basis for this.
Enclose copies of any documents that support your statements above.







Any setoff rights

Check the box below if you believe you have a right of setoff and provide the additional requested information.


  • Right of Setoff



Describe: _________________________________________________________________________________________
Amount of setoff right: _______________________________________________________________________________











Where the Claimant believes that there is a setoff right related to this claim, state the basis for this and include all relevant details and provide documentation in evidence of the transaction and the right of setoff. Under Icelandic law, if your right of setoff arises from a transaction more than three months period prior to the reference date (15 November, 2008), i.e. prior to 15 August, 2008, you may provide proof of ownership and claim a right of setoff. The Winding-Up Board will consider any setoff claim on a case by case basis.
Enclose copies of any documents that support your statements above, including proof of ownership, such as an account statement or a confirmation of purchase or transfer.


Accountholder Information

Clearstream Participant Account Number of Your Accountholder: ___________________________________________


OR
DTC Participant Account Number of Your Accountholder: _________________________________________________
OR
Euroclear Participant Account Number of Your Accountholder: _____________________________________________
OR
Other Depository Name: ________________________________________________________________________________ and
Participant Account Number: ___________________________________











The Clearstream Bank, Euroclear Bank, DTC or other depository participant account number related to the Glitnir Bond issue for which you are filing this claim. You must acquire the relevant Clearstream Bank, Euroclear Bank, DTC or other depository participant account number from your accountholder (i.e. the bank, broker or other entity that holds such securities on your behalf). Beneficial holders should not provide their personal account numbers.







Blocking Number (Mandatory for ISINS beginning in “XS” or “US”)

Blocking Number:











The Clearstream Bank Blocking Number, Euroclear Bank Electronic Reference Number, DTC VOI Number, or other depository blocking reference number, as appropriate (each, a “Blocking Number”) for each Glitnir Bond issue for which you are filing a claim. You must acquire a Blocking Number from your Accountholder (i.e., the bank, broker or other entity that holds such securities on your behalf). If you are filing this claim with respect to more than one Glitnir Bond issue or position, you may attach a schedule with the Blocking Numbers for each Glitnir Bond issue or position to which this claim relates.

This section is NOT needed for claims related to ISINS beginning in “XS” or “US”
Payment Instructions for any future payment (in cash)



Wire transfer instructions:
Account number:
Name:
Other Details:











Details of the account into which any future payment (in cash) in relation to this claim should be made. Include full details, including name, account number, sort code and IBAN number, if appropriate. Icelandic law states that the payment must be made to an Account that the Claimant is the beneficial owner of, unless various formalities are complied with, as specified in the FAQs on http://www.glitnirbank.com. You will have the option of updating this information should you wish to do so at a later date. Your account number will not be publicly disclosed by the Winding-Up Board.







This section is NOT needed for claims related to ISINS beginning in “XS” or “US”
Payment instructions for any future payment (in kind)


Insert your Accountholder’s Depository:

    Depository: _________________________________________________________________


Participant number of the Accountholder to RECEIVE the future payment (in kind): _____________________________


Contact person at your Accountholder:
Name: ________________________________________________
Telephone Number: ____________________________________
Email Address: ________________________________________
YOUR Account number to receive any future payment (in kind): ____________________________________________










Details of the account into which any future payment (in kind) consisting of securities will be deposited. Include the name of the depository, the depository participant account number into which any future payment (in kind) consisting of securities in relation to this claim should be made. You must acquire the relevant participant account number from your Accountholder (i.e. the bank, broker or other entity that holds such securities on your behalf). Icelandic law states that the payment must be made to an account that the Claimant is the beneficial owner of, unless various formalities are complied with, as specified in the FAQs on http://www.glitnirbank.com. You will have the option of updating this information should you wish to do so at a later date. Your account number will not be publicly disclosed by the Winding-Up Board.







Other claims submitted in this process













Detail any other claims that have been submitted to the Winding-Up Board as part of the formal claims filing process. Include date submitted, amount claimed and, if available, any reference number.







Signed













The signature of the person submitting this claim form who warrants that he or she agrees to the declaration and gives the consents noted at the bottom of this form.







Position













The position of the person submitting the claim form.







Date










DECLARATION

I/we declare that, to the best of my/our knowledge and belief, the information in this form (and any attachments thereto) is complete, accurate and not false or misleading. I/we am/are duly authorised to make this claim on behalf of the Claimant.

I/we consent to the information provided herein and any other information relating to this claim being made available to any part of Glitnir and its Winding-Up Board, their staff and advisors.

I/we acknowledge that details of creditors’ claims are made available to all creditors under Icelandic law. Accordingly, I/we consent to the extent reasonably necessary to waive rights under banking secrecy or other confidentiality or data protection rules or laws whether in Iceland or elsewhere. Without prejudice to the generality of this waiver, I/we consent to the details of my claim being verified with my agent/nominee/custodian.


DISCLAIMER

The information appearing in this claims form is for general informational purposes only and is NOT intended to provide any accounting, legal or tax advice to any individual or entity and does not create a fiduciary or attorney-client relationship. We urge you to consult with your own accounting, legal, and tax advisors before taking any action based on information appearing in this claims form.

Information in this claims form is provided “as is” without warranty of any kind, either express or implied, including, but not limited to, the implied warranties of merchantability, fitness for a particular purpose, or non-infringement.

Information in this claims form may contain technical inaccuracies or typographical errors. The claims form may be changed or updated without notice. The Winding-Up Board may also make improvements and/or changes in the products and/or the programs described in this claims form at any time without notice. This claims form may contain other proprietary notices and copyright information, the terms of which must be observed and followed.

In no event will the Winding-Up Board be liable to any party for any direct, indirect, special or other consequential damages for any use of this claims form, even if we are expressly advised of the possibility of such damages.



TRANSFER OF CLAIM

Under Icelandic law a Claimant is permitted to sell its claim. However, the Winding-Up Board will only recognize such a transfer and accordingly make any future payment to the transferee if the Winding-Up Board is notified of the transfer and the transfer is perfected in accordance with the procedures set out in the FAQs on http://www.glitnirbank.com. The Winding-Up Board reserves the right to make any payment to the original Claimant, notwithstanding any purported transfer of a claim, if the Winding-Up Board is not satisfied that the procedures set forth in the FAQs have been complied with and / or the submitted documentation does not provide satisfactory evidence of the transfer or new ownership.




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