EX-99.4 5 tv521101_ex99-4.htm EXHIBIT 99.4

Exhibit 99.4

FINANCIAL STATEMENT REQUEST FORM

May 2019

Pursuant to National Instrument 51-102, Continuous Disclosure Obligations, of the Canadian Securities Administrators, we shall deliver our annual and interim financial statements and the management discussion & analysis (“MD&A”) related to such financial statements to our shareholders when they request that copies be sent to them. If you wish to receive either our annual financial statements and related MD&A or our interim financial statements and related MD&A, please complete the information below and mail, fax or email this form, or the information on this form, to us at:

FORTUNA SILVER MINES INC.

200 Burrard Street, Suite 650

Vancouver, BC V6C 3L6

Attention: Corporate Secretary

Fax: 604-484-4029

Email: info@fortunasilver.com

I wish to receive your:

(Check one or both as applicable)

¨ Annual financial statements and MD&A

¨ Interim financial statements and MD&A

which should be sent to me as follows:

¨ | By regular mail to: |
|  | NAME (please print)
|  | Mailing Address
|  | Postal or Zip Code
OR: |  |
¨ | By email to: |
|  | Email Address