12W9HB D01
HSBC Holdings plc
8 Canada Square, London E14 5HQ, United Kingdom. Web: www.hsbc.com
Registered in England: number 617987. Registered Office: 8 Canada Square, London E14 5HQ. Incorporated in England with limited liability
A B C 1 2 3
Please use a black pen.
Print in BLOCK CAPITALS
inside the boxes.
1
HSB J
HSBC Dividend Election Form
The default currency on the Bermuda Overseas Branch Register is United States dollars and can also be paid in Hong Kong dollars or
pounds sterling, or a combination of these currencies. You can change your dividend election by completing this form.
You may register or change your banking instructions by using the form overleaf. All instructions must be received before the dividend election
deadline date. Please refer to www.hsbc.com for more information on the dividend deadline dates.
If you wish to change the currency of your whole dividend, please complete the “one currency election” section overleaf.
In the case of joint holders ALL must sign. In the case of a corporation, this form should be executed under its common seal or by a duly authorised representative.
If the form is not signed correctly, you will be paid the dividend as if you had not returned it.
All enquiries regarding this form should be addressed to the Investor Relations Team, HSBC Bank Bermuda Limited, 37 Front Street,
Hamilton, HM 11, Bermuda (telephone +1 441 299 6737 or email: hbbm.shareholder[email protected]).
Registered address
Daytime telephone number (if any)4th Joint Holder
THIS DOCUMENT IS IMPORTANT AND REQUIRES YOUR IMMEDIATE ATTENTION. If you are in any doubt about this document or as to the action you should take, you should
consult a stockbroker, solicitor, accountant or other appropriate independent professional adviser. This advice is personal to the registered holder(s) named below and is not
transferable. A general outline of the tax consequences in the UK and overseas is provided in the Shareholder Information section of the current HSBC Holdings plc’s Annual
Report and Accounts. Shareholders should consult their own tax advisers with regard to their liability to taxation. No tax is currently withheld from dividends paid by HSBC
Holdings plc.
This currency election form is only applicable for Bermuda registered shareholder(s) of HSBC Holdings plc, who own paper share certifi cate(s) issued in his/her own name(s).
Shareholder Name Shareholder Reference Number (SRN)
Date
Signature (Please sign in box below) 2nd Joint Holder 3rd Joint Holder
GBP
USD
HKD
Total
*#
* If the aggregate of the numbers of existing ordinary shares is not equal to the number
of ordinary shares registered in your name on the record date, the Registrar will
automatically adjust the numbers (except where no number has been indicated) up
or down as appropriate to eliminate the di erence, in the following order: (i) United
States dollars (ii) sterling (iii) Hong Kong dollars
#
Shareholders are advised to check their shareholdings as at record date with the
Registrar or through the Registrar’s Investor Centre at www.investorcentre.co.uk/bm
12W9HB D01
Completed forms must be returned to the Investor Relations Team at the address shown below. Any instructions received after the election deadline date will not apply
for the current dividend but only to subsequent dividends. No acknowledgement of receipt of a form of election will be issued. All enquiries regarding this form should
be addressed to the Investor Relations Team, HSBC Bank Bermuda Limited, 37 Front Street, Hamilton, HM 11, Bermuda (telephone +1 441 299 6737 or email:
hbbm.shareholder[email protected]).
2
Dividends payable in sterling
This section need only be completed if you wish any dividends payable to you in cash to be sent direct to your bank account, or if you wish to
change bank account details you have previously given. The bank account must be denominated in the selected currency.
Please send any dividend cheques, payable in sterling and/or United States dollars, to the credit of my/our bank account(s) specified below; and/or
Please credit any cash dividend, payable in Hong Kong dollars, directly to my/our bank account specified below.
ONE CURRENCY ELECTION
sterling
Until further notice to the contrary, I/we hereby elect to receive any dividends that may be payable to me/us in cash in the following currency (please insert
a ‘X’ in one box only)
DIVIDEND PAYMENT INSTRUCTION
Bank Sort Code:
Bank Account Number:
Reference or Roll Number: (if applicable)
Branch:
Address:
Dividends payable in Hong Kong dollars
Bank Number:
Branch Number:
Bank Account Number:
Dividends payable in United States dollars
ABA/ACH Number:*
Please insert a
‘X’ if this is a
Savings Account
Savings
Account
* It is advisable to check with your bank regarding the routing
number to be used for a payment to be sent direct to your bank
account.
Signature (Please sign in box below) 2nd Joint Holder 3rd Joint Holder
4th Joint Holder Date
In the case of joint holders ALL must sign. In the case of a corporation, the One Currency Election and/or Dividend Payment Instruction should be executed under its common
seal or by a duly authorised representative.
Daytime telephone number (if any)
Bank Account Number:
If no instructions are given here for dividends payable in cash to be sent to a bank, they will be sent in accordance with instructions you have previously given for the payment
of your dividends in that currency or, if none have been given, they will be sent to your registered address.
Compliance by HSBC Holdings plc with this authorisation will discharge it from all liability in respect of dividends so paid.
Hong Kong dollars
United States dollars
Bank:
Bank:
Branch:
Address:
Bank:
Branch:
Address:
