*PPPPEN01* Applying for your

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1 Financial adviser stamp Financial adviser agency number Please enter your business postcode Are you enclosing a cheque with this application? Applying for your Group Personal Pension *PPPPEN01* Please use BLOCK CAPITALS only and blue or black ink Please complete all relevant sections If any are incomplete, we will write to you and ask for the missing information, which may delay your application If you have two sources of earnings, for example one employed and the other self-employed, you must complete a separate application for each source All references to Old Mutual Wealth in this application mean Old Mutual Wealth Life Assurance Limited This must be completed by your financial adviser Please confirm if you have given advice to the client in relation to this transaction Employer s details Employer s name Employer s address Postcode Group Scheme number (if known) Expected date of first payment D D M M Y Y Y Y

2 A Personal details of the applicant and eligibility Are you already a member of the Old Mutual Heritage Personal Pension Scheme? If, go to Part 2 If, please complete Part 1 Part 1 Existing details Please enter your Membership number Do you wish to add payments to your existing Personal Pension? If, we will set up a new plan, please complete Part 2 Part 2 Applicant s details Title (3) Mr Mrs Miss Other Full forename(s) Surname Permanent residential address (Please note that c/o addresses are not acceptable) Postcode Contact number address Date of birth Spouse s/civil partner s* date D D M M Y Y Y Y of birth D D M M Y Y Y Y (if applicable) Sex (3) Male Female Marital status (3) Single Married Widowed Divorced Separated Civil partnership* National Insurance number (without the full National Insurance number, Old Mutual Wealth will not be able to accept your application) * As defined by the Civil Partnership Act 2004 Applicant s status Tick the statement which applies to you (3) Eemployed Chargeable to tax on earned income for the income tax year of assessment concerned in respect of an office or employment held by you Pensioner Chargeable to tax on earned income for the income tax year of assessment concerned in respect of a pension Self-employed Chargeable to tax under Schedule D for the income tax year of assessment concerned in respect of annual profits or gains arising or accruing from any trade, profession or vocation carried on by you This section applies to employees only and must be answered Failure to do so may result in your application being delayed 1 Are you setting up this plan as a result of opting-out of your employer s occupational pension scheme, or are you planning to do so? 2 Have you chosen not to join your employer s occupational pension scheme which you are eligible to join, or which you will be able to join at the end of a waiting period? 2

3 B Confirmation of earnings My UK earnings chargeable to income tax for the current tax year are C Pension age and contributions Selected Pension Age (Any birthday between 55 and 75 inclusive Other ages may be permitted in some circumstances) Frequency of regular contributions (3) Monthly Yearly Please state the gross regular contribution as a percentage of your pensionable salary* AND/OR as a gross or net monetary amount The net amount will be deducted from your monthly salary Personal regular contributions (gross) Personal regular contributions (net)** Employer s regular contributions Pensionable salary the regular contribution is based on* % Personal single contributions (gross) Personal single contributions (net)** Employer s single contributions Minimum total single contribution 500 gross Please note you could suffer a tax liability if contributions are funded from a tax-free cash sum received from a registered pension scheme * Pensionable salary may be defined as basic salary, total salary or a proportion of salary You should consult your employer for the definition which applies to you Where contributions are expressed as a percentage of your pensionable salary, the contribution levels will increase in line with changes to your pensionable salary as notified to us by your employer Please note that this figure may not match the earnings declared in the confirmation of earnings section ** The net contributions must be based on current basic rate income tax This net amount may vary in future, ie if basic rate income tax relief is altered ALL PERSONAL CONTRIBUTIONS ARE PAYABLE NET OF BASIC RATE INCOME TAX Old Mutual Wealth will allocate the gross contribution and reclaim the basic rate income tax from HM Revenue & Customs All employers contributions are payable gross 3

4 D Investment instructions Please complete question 1 and 2 as appropriate 1 (a) If your employer and financial adviser have specified a fund choice, do you wish contributions to be allocated in accordance with this selection? (b) If your employer and financial adviser have specified a LifeStyle option, do you wish contributions to be allocated in accordance with this selection? If you have answered to question 1(a) and 1(b), go to section E If you have answered to question 1(a), or your employer and financial adviser have not specified a fund choice and/or LifeStyle option selection, please enter investment instructions in 2 below 2 Please enter your choice of fund(s) Maximum of 10 funds, minimum of 1% in any one fund and whole numbers only Fund manager Full Fund name Whole % 100% If you want to choose different funds for lump sum contributions, please fill in your fund choice on a separate sheet If no investment choice has been specified by your employer or the financial adviser and you do not provide complete investment instructions, Old Mutual Wealth reserves the right to allocate part or all of the investment as appropriate to the Sterling Deposit Fund 3 Do you want the LifeStyle option to apply to your fund choice? (Only available for schemes of 50 or more members) If, which LifeStyle option term do you wish to select? 5-year option 10-year option 4

5 E Benefits payable on death You must complete this section If you die before drawing pension benefits, the value of the fund may provide benefits as described below, in line with regulations Discretionary death benefits If you wish your beneficiaries to choose one of the following benefits, enter details in the box below If you wish to suggest more than one beneficiary, please enter the proportion payable to each Where a beneficiary is a trust, please include the full name of the trust and trustees Your instructions will be carried out at the discretion of the Scheme Administrator The benefits your beneficiaries could choose are: payment of a lump sum to receive income withdrawals to buy a lifetime annuity Income withdrawals and lifetime annuity are only available to a beneficiary who is a spouse, civil partner* or a dependant** ** As defined by the Civil Partnership Act 2004 ** Dependant means one of your children who is under 23 or dependent on you due to physical or mental incapacity, or an individual who is financially dependent on you Beneficiary I understand that the Scheme Administrator has absolute discretion, but in the event of my death I should like the Scheme Administrator to consider making any payments to: Name Address % 100% 5

6 F Declaration AND Application You must complete this section Any omission or misstatement of a material fact in this application form could affect the payment of benefits under the arrangements comprising the Group Personal Pension A material fact is one which is likely to influence the assessment and acceptance of this application If you are uncertain whether a fact is material, you should give full details so that we can assess its possible significance If you become aware of such a fact while we are considering your application, you should notify us immediately declaration a) I declare that, to the best of my knowledge and belief, the statements made in this application and declaration and any related documents are correct and complete and that I have not concealed any material fact b) I undertake to notify the Scheme Administrator immediately if the total contributions paid by me or on my behalf to any UK registered pension scheme on which I am entitled to tax relief do exceed the higher of the basic amount ( 3,600) or my relevant UK earnings for the tax year or if I cease to be entitled to relief at source on my contributions or if I am no longer a UK resident I will give this notice by the later of: i) 5 April in the year of assessment in which the event occurs; and ii) the date which is 30 days after the occurance of that event c) I agree to supply information relevant to the Group Personal Pension as shall be required by the Scheme Administrator from time to time d) I declare that the total contributions paid by me or on my behalf to any UK registered pension scheme on which I am entitled to tax relief do not exceed the higher of the basic amount ( 3,600) or my relevant UK earnings for that tax year e) I declare that contributions made to the Plan have not or will not be funded from a tax-free cash sum from a registered pension scheme to the extent that myself or Old Mutual Wealth will suffer a tax liability f) I confirm that I have seen and read the privacy notice at wwwoldmutualwealthcouk/privacy APPLICATION a) I apply to become a Member of the Old Mutual Wealth Group Personal Pension Scheme ( the Scheme ) in accordance with this application and agree to be bound by the Rules of the Scheme ( the Rules ) b) I understand that the Group Personal Pension will comprise one separate arrangement in respect of regular or single contributions paid by me or on my behalf by my employer THIS FORM ACTS AS AN APPLICATION FOR TAX RELIEF AT SOURCE ON YOUR CONTRIBUTIONS IT IS THEREFORE A SERIOUS OFFENCE TO MAKE A FALSE STATEMENT THE PENALTIES ARE SEVERE AND COULD LEAD TO PROSECUTION Signature of Applicant Date D D M M Y Y Y Y The Scheme Administrator undertakes on behalf of Old Mutual Wealth Life Assurance Limited to administer the Scheme in accordance with the Rules A copy of this completed application form and the Member s Guide/Scheme Booklet are available on request *SIGGPP01* 6

7 Checklist all applicants 3 Have you completed all relevant sections and signed section F? Have you initialled any amendments or corrections? Checklist financial adviser 3 Please ensure full remuneration instructions are enclosed with each application Have you answered the question regarding advice at the start of this form? For Office Use Only Basis Signed 7

8 Old Mutual Wealth Old Mutual House Portland Terrace Southampton SO14 7AY United Kingdom T +44 (0) F +44 (0) wwwoldmutualwealthcouk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority Financial Services register number VAT number SK0698/ /July