APPLICATION FORM SELF INVESTED PERSONAL PENSION (SIPP)

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1 FOR PROVIDERS WITH EXISTING AGREEMENTS WITH QUILTER CHEVIOT Please help us by providing as much information as you can. The more information you are able to share, the more we will be able to match our investment service to your requirements. SIPP PROVIDER MEMBER S PERSONAL DETAILS Title: MEMBER S NAME Title: Surname: Surname: Forename(s): Forename(s): Number of dependants PROVIDER REFERENCE Date of birth: SERVICE CATEGORY Please tick the category of service required Discretionary Portfolio Service (DPS) Our principal bespoke investment management service where your manager is directly responsible for every aspect of your portfolio and can undertake transactions without prior reference to you. Taking into account your investment objective, attitude to risk and any other relevant information, your investments are individually tailored to best match your requirements. Advisory Portfolio Service (APS) Our investment management service for accounts where it is not possible to delegate the day to day decisionmaking process. When appropriate, we will contact you with recommendations and comments on the portfolio but we will not undertake transactions without your prior agreement. Nationality: Country of birth: National Insurance number: l / l l l l l / Or Local tax number for overseas residents Are you, or have you ever been, a US citizen, the holder of a US passport, Green Card or US bank account: or have you ever resided in or owned property in the US? *Yes No *If you have ticked yes, please provide details: 01

2 CONTACT DETAILS Permanent residential address (we are unable to accept a care of or post box): * If inheritance, please state the full name of the deceased or donor (as applicable), their relationship to you and their primary source of wealth. If this source of wealth derives from any activities abroad, please state which country(ies). Postcode: Preferred correspondence address (if this is not the permanent residential address we are unable to accept a care of or post box): *If other, please specify. Postcode: EMPLOYMENT/OUTSIDE BUSINESS INTERESTS Are you a director or significant senior manager of a Plc? * *If yes, which company(ies)? Preferred telephone numbers: Fax number Do you have a shareholding of 5% or more in any Plc? * SOURCE OF OVERALL WEALTH Please tick all applicable sources of wealth. Please note that we may ask for evidence of source(s) of wealth in some cases; Employment* Investment or Savings Inheritance* Family trust Business ownership or sale Property Other* * If employment, please state the nature of the business or occupation from which your wealth derives: *If yes, which company(ies)? Are you or have you ever been employed in the financial services industry? Are you a politically exposed person or associated with one now or at any time in the past? * *If yes, please state your position and/or association 02

3 What is your current occupation or your previous job if you have retired in the last 5 years? Address: Postcode: Does your employer need to receive contract notes? If yes, please provide details; Telephone: Can we take investment instructions from your pension adviser? INVESTMENT EXPERIENCE Your answers to these questions will enable us to determine your familiarity with particular types of services and investment. We would draw your attention to the risk warnings outlined in Annex 1 of our Terms and Conditions booklet in respect of some of these types of investment. Have you been an investor in financial markets for more than 5 years? Do you have experience of managing your own investments and directing deals? Do you have experience of using derivatives (including options), warrants, leveraged or unregulated products? SOURCE OF FUNDS Please tick the applicable sources of how you fund your pensions; Surplus earned income Employee share or share option sales or sale of business Transfer from/consolidation of existing schemes Savings previously held outside of pension scheme Inherited capital Existing fund Additional contributions Other sources YOUR PENSION ADVISER Contact name: If other, please provide details; Name of company: FCA reference number (if applicable): Existing fund: Additional contributions: 03

4 YOUR FINANCIAL DETAILS ASSETS Beneficial ownership Applicant 1 Joint Total value of assets Main residence Y / N Other property Y / N Pension funds Investments Stocks & shares ISAs Cash ISAs Cash/term deposits Other* Total LIABILITIES Total Amount Mortgage(s) Method of repayment Repayment date YYYY Other loans* Method of repayment Repayment date YYYY GROSS INCOME PER ANNUM Applicant 1 Employment Pensions Savings Other* Total *If other, please give details: 04

5 DETAILS OF YOUR PENSION FUND(S) This section can be answered by your pension adviser Please indicate the amount being invested into this SIPP If in pension withdrawal, when is the next formal review of pension? Are you making or do you plan to make additional contributions into this fund? If yes, how much each year What is the approximate value of your invested pension funds? What is the approximate asset allocation of your pension funds not managed by Quilter Cheviot? Cash and bonds UK equities % % Overseas equities Alternatives % % What percentage of your Quilter Cheviot fund is available as a tax-free lump sum? % What percentage of your overall retirement income do you expect this SIPP to provide? % Do you or will you have a secured annual pension income of over 20,000 and qualify for the Minimum Income Requirement? If known, what is the anticipated annual pension withdrawal from this SIPP? or % Are there any other considerations we should be aware of in respect of managing this SIPP? Does Quilter Cheviot manage any of your other investments? Yes No No other investments INVESTMENT STRATEGY A good starting point for any investment portfolio is a clear definition of the aims, objectives, constraints and risk tolerance as well as the anticipated time horizon. The following questions will help us recommend and implement a suitable long-term investment strategy. It is important that you keep us informed of any changes to your circumstances or objectives so we can review the strategy. YOUR INVESTMENT OBJECTIVE Please select one of the following as your main objective: Capital Growth the principal objective is to grow the capital value of the portfolio. Capital Growth and Income the objective is to grow the capital value of the portfolio, as well as generating some degree of income from the portfolio. Income the principal objective is to generate income from the portfolio. UNDERSTANDING RISK Obtaining an investment return higher than cash deposits will involve taking risk. To meet your longer-term objectives, you may have to be prepared to take on a higher level of risk than you have historically. Risk associated with investments can take many different forms, including: The sensitivity of your investments to various market events or economic factors, including changes to interest rates and inflation The possibility that your investments do not meet your objective, such as a targeted future expenditure The chance of irregular or unusual investment returns, particularly in times of financial crisis The likelihood of temporary or permanent loss of capital or income The possible lack of liquidity, meaning that in certain market circumstances, it might not be possible to sell a particular investment. Completing the information and questions in this section will help us assess your risk profile. We have divided the questions into two parts: Your ability to bear loss this is sometimes referred to as your Risk Capacity and is a function of your broader financial circumstances. Willingness to accept risk in the portfolio this is sometimes called your Risk Tolerance 05

6 YOUR ABILITY TO BEAR LOSS Here, we are trying to ascertain your ability to bear investment losses, in the broader context of your overall current financial situation and standard of living. Please select one of the following which most closely matches your circumstances: I/we have NO ability to bear investment losses. Any losses to the value of the portfolio would have an unacceptable impact on my/our overall financial position and standard of living. I/we have a LOW ability to bear investment losses. In extreme circumstances, falls in the value of the portfolio of up to 20% would not have a material impact on my/our overall financial position and standard of living. I/we have a MODERATE ability to bear investment losses. In extreme circumstances, falls in the value of the portfolio of up to 35% would not have a material impact on my/our overall financial position and standard of living. I/we have a SIGNIFICANT ability to bear investment losses. In extreme circumstances, falls in the value of the portfolio in excess of 35% would not have a material impact on my/our overall financial position and standard of living. INVESTMENT RESTRICTIONS Do you wish to exclude certain investments and/or asset classes for ethical reasons from your portfolio? If yes, please contact us for our Investment Restrictions supplement. 06

7 YOUR WILLINGNESS TO ACCEPT RISK The Quilter Cheviot Understanding Your Investment Portfolio document must be read for further guidance. Please select the risk category that most closely matches your tolerance to risk and minimum time period for the investment portfolio we will be managing for you. Please tick one box only. The tables below provide guidance on the level of equities that would be involved and the range of returns that can be experienced in each of the risk categories. Lower I/we have a low tolerance for risk and regardless of market circumstances, I/we would only be comfortable with minimal variation or disruption to capital value or current income weighting up to 25% 1 year or more Estimated range of annualised return* +8% across * -2% -15% Lower to Medium I/we have a lower to medium tolerance for risk, I/we would only be comfortable with moderate variation or disruption to capital value or current income weighting up to 50% 3 years or more Estimated range of annualised return* +15% -3% across * -20% Medium I/we have a medium tolerance for risk and can accept moderate variation or disruption to capital value or current income in order to meet my/our longer-term objectives weighting up to 75% 5 years or more Estimated range of annualised return* +20% -6% across * -35% Medium to Higher I/we have a medium to high tolerance for risk and can accept significant variation or disruption to capital value or current income in order to meet my/our longer-term objectives weighting up to 100% 5 years or more Estimated range of annualised return* +25% -10% across * -45% Higher I/we have a high tolerance for risk and can accept significant variation or disruption to capital value or current income in order to meet my/our longer-term objectives weighting up to 100% 7 years or more Special situations apply to specialist mandates where the types and concentration of riskier assets could be significant across * >-45% * Source: Quilter Cheviot. These figures are for illustrative purposes and represent estimated pattern of return for each risk profile. Past performance is not indicative of future performance and actual performance may vary. 07

8 INTERNET ACCESS Do you want to access and download valuations and transactions from our website? Yes No If yes and you already have an internet account with us, please enter your user ID. Member: Either Passport number (this is at the very bottom of the photo page): l l l l l l l l l / l l / l l l l l l / / l l l l l l / l Date of expiry: Adviser: Or Driving licence number: ANTI-MONEY LAUNDERING VERIFICATION REQUIREMENTS We are required to verify the identity of all potential clients and their beneficial owners (where applicable). We cannot conduct business with you until this process is complete. For UK and Jersey resident individuals, we will use the following information to perform electronic identification checks. For overseas residents, or where the electronic identification check fails, we will ask you for certified copies of identity documentation. Previous surname if changed in the last 5 years: Previous residential address, if less than 1 year at current address (we are unable to accept a care of or post box): Postcode: l l l l / l l l l l / l l / l Date of expiry photocard: ADDITIONAL REPORTING Our half yearly summaries, the annual tax summary and valuations as requested will be sent to the SIPP administrator. Please enter what you and/or your adviser would like to receive. Correspondence Copy contract notes Comprehensive half yearly summary Member Adviser 08

9 MEMBER S DECLARATION The below confirmations are, what we call in legal terminology, representations and warranties. This means that we are entitled to rely on these confirmations without the need to check whether they are correct, and will have legal rights against you if the confirmation is not correct. I confirm that all the information in this form is accurate, complete, can be relied upon, and that my investment objectives are as set out in this application form. I confirm my acceptance of the Quilter Cheviot fee arrangement. If the Quilter Cheviot fee cannot be paid from the SIPP, I will be personally liable for such fees. I acknowledge receipt of a copy of the Quilter Cheviot Terms and Conditions and risk disclosures. I agree to the terms for online access as detailed in the Quilter Cheviot Terms and Conditions I authorise Quilter Cheviot to obtain relevant financial details from my pension adviser. Signed: Date: Print name: QUILTER CHEVIOT One Kingsway London WC2B 6AN t: +44 (0) w: quiltercheviot.com Quilter Cheviot Limited is registered in England with number , registered office at One Kingsway, London WC2B 6AN. Quilter Cheviot is a member of the London Stock Exchange and authorised and regulated by the UK Financial Conduct Authority. 09 QW538 (08/2015)