a. A certified copy of current (i.e. in date) and valid passport b. A certified copy of current, full and valid driving license

Transcription

1 Internal Use Only: ARF/AMRF Application Form It is a prerequisite for providing LEAP services to you that you supply us with accurate, comprehensive and current details about you and your retirement benefits. Please complete all sections of this form diligently. This form relates to LEAP services in relation to your ITC ARF. If you wish for LEAP services to be provided in relation to assets of a (pre-retirement) pension scheme, please complete the (additional) relevant form(s). The information sought below are also utilised for anti-money laundering purposes, for your advisor to assess the suitability of investments, for Independent Trustee Company Limited ( ITC ) to ensure proper governance of your ARF and for Conexim Advisors Limited ( Conexim ) to assess the suitability and/or appropriateness (where relevant) of investments or services that may be provided to you. Checklist - what to do next: Before returning this application please ensure that you have all the relevant documentation: Copies of the photo ID, proof of address and proof of PPS must be certified by an accountant, solicitor, garda or regulated entity based in Ireland. 1. Proof of ID (one of the following) Check a. A certified copy of current (i.e. in date) and valid passport b. A certified copy of current, full and valid driving license 2. Proof of address (One of the following and less than 3 months of the issue date) Check a. A recent utility bill for the applicant s home address (and application address) (landline phone, gas, electricity, water) b. Bank / Building Society financial statement 3. Confirmation of PPS Check Most recent P60 or one of the below Revenue documents: i. Tax Credit Statement ii. Revenue Balancing statement iii. Revenue C2 Tax Certificate 4. Completed and signed Application form Check Pension/Property Adjustment Order (if applicable) Completed Eligibility for ARF/AMRF Signed Unit Trust Subscription This application form, fully completed and signed 5. Asset Transfer Form Check Completed Asset Transfer Form/details (if applicable) Conexim Advisors Ltd are regulated by the Central Bank of Ireland. Pershing Securities International Ltd are regulated by the Central Bank of Ireland. Independent Trustee Company Limited, part of the ITC Group, is regulated by the Central Bank of Ireland. LEAP ARF/AMRF LEAP ARF/AMRF Application Form - Page 1 of 13

2 Financial Advisor Details Advisor Advisor Firm Address Telephone Investment Type Approved Retirement Fund Investment amount Approved Minimum Retirement Fund* Investment amount *Subject to the calculation of allowable limits Personal Details Title Surname First name Date of Birth Marital status Married Single Separated Divorced Widowed Civil Partnership Gender PPS Number Spouse s : Spouse s Date of Birth Dependents /s Are your benefits subject to a pension/property adjustment order? Yes* No *If your benefits are subject to a Pension/Property Adjustment Order please provide a copy of the order Contact Details Address Resident in Ireland for tax purposes? Yes No Country of residence Are you a US citizen or resident in the US for tax purposes? Yes* No Address Work Tel. Home Tel. Mobile We will issue correspondence to the address provided. If you would like to receive correspondence in a format other than , please confirm here: * Please note that we may require additional information and may be unable to supply you with certain services due to custodian restrictions and FATCA requirements. Additional Tax Identification Details Please indicate your country of tax residence and associated taxpayer identification number ( TIN ). If you have been issued with an additional TIN from other jurisdictions please also indicate these below. Country Of Tax Residency Tax ID Number (e.g. PPS) Page 2 of 13 - LEAP ARF/AMRF Application Form

3 Under the Taxes Consolidation Act 1997 Conexim is required to collect certain information about each investors tax arrangements. This is to comply with the Common Reporting Standard developed by the Organisation for Economic Co-operation and Development ( OECD) and approved on 15 July For further information on FATCA or CRS please refer to Irish Revenue website at international-tax/aeoi/index.aspx You can also check for a short FAQ which outlines the reasoning behind collection of this additional information. If any of the information above changes, regarding the beneficiaries tax residency or FATCA/CRS classification, please notify us of these changes immediately. Existing Pension Benefits (include all Pension Types e.g. Personal, Occupational, PRSA, ARF etc.) 1. Life Assurance Company or Trustee 2. Life Assurance Company or Trustee NRA on Scheme NRA on Scheme Full Scheme Full Scheme Policy or Ref No Transfer Value (approx) Policy or Ref No Transfer Value (approx) Personal, Occupational, PRSA or ARF/AMRF? Personal, Occupational, PRSA or ARF/AMRF? In respect of previous or current employment To be transferred in* Y N In respect of previous or current employment To be transferred in* Y N 3. Life Assurance Company or Trustee 4. Life Assurance Company or Trustee NRA on Scheme NRA on Scheme Full Scheme Full Scheme Policy or Ref No Transfer Value (approx) Policy or Ref No Transfer Value (approx) Personal, Occupational, PRSA or ARF/AMRF? Personal, Occupational, PRSA or ARF/AMRF? In respect of previous or current employment To be transferred in* Y N In respect of previous or current employment To be transferred in* Y N * We will use all reasonable endeavours to facilitate a transfer, however this may not always be possible and we may require the cooperation of your existing provider. LEAP ARF/AMRF Application Form - Page 3 of 13

4 National Identifier Numbers ( NIN ) INSTRUCTIONS FOR COMPLETION 1. Under the MiFIR regulations we are obliged to capture certain information on investors in specific formats for our records and for compliance with the Central Bank s transaction reporting requirements. 2. As part of this process we need to record your National Identifier reference. If you hold dual or multiple nationalities we are required to capture this information to facilitate the European Regulations on transaction reporting, which requires us to record National IDs from other member states when transaction reporting. 3. As an example, if you are a British national we require your National Insurance number. If you have both British and German nationality, we require both your UK National Insurance number and your German Personal Identity Card number. 4. For clients who are Irish nationals and who do not have dual or multiple nationalities we do not require any information on this form. FIRST APPLICANT JOINT APPLICANT (if applicable) Country National Identifier Country National Identifier NATIONAL IDENTIFIER LIST Country Ireland, Austria, France, Germany, Hungary, Luxembourg Cyprus, Iceland, Liechtenstein, Netherlands Belgium Bulgaria Croatia Czech Republic Denmark Estonia Finland Greece Italy Latvia Lithuania Malta Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden UK All Other Countries National ID No National ID required (information used is gained from name and date of birth) National Passport Number Belgian National Number (Numéro de registre national Rijksregisternummer) Bulgarian Personal Number Personal Identification Number (OIB Osobni identifikacijski broj) National Identification number (Rodné èíslo) Personal identity code 10 digits alphanumerical: DDMMYYXXXX Estonian Personal Identification Code (Isikukood) Personal identity code 10 DSS digit investor share Fiscal code (Codice fiscale) Personal code (Personas kods) Personal Code (Asmens kodas) National Identification Number 11 digit personal ID (Foedselsnummer) National Identification Number (PESEL) Tax number (Número de Identificação Fiscal) National Identification Number (Cod Numeric Personal) Personal number (Rodné číslo) Personal Identification Number (EMŠO: Enotna Matična Številka Občana) Tax identification number (Código de identificación fiscal) Personal Identity Number UK National Insurance Number National Passport Number Page 4 of 13 - LEAP ARF/AMRF Application Form

5 Eligibility for ARF/AMRF If you cannot answer Yes to at least one of the following three questions you must invest 63,500 in an Approved Minimum Retirement Fund until age 75 or purchase an annuity with 63, Are you currently receiving a guaranteed pension income for life of at least 12,700 per annum (this may include the single person s State pension entitlement)? Yes No If yes, please provide details: State pension entitlement (single person entitlement only) Other pension entitlements Pension Provider Address Policy / Annuity Ref Number 2. Have you used at least 63,500 from any pension fund to buy an annuity? Yes No If yes, please provide details: Purchase of Qualifying Fund Manager Pension Provider Annuity Account Number Please enclose a copy of your annuity policy 3. Do you have 63,500 invested in an Approved Minimum Retirement Fund already? Yes No If yes, please provide details: Purchase of Qualifying Fund Manager Date of Investment (DD/MM/YYYY) AMRF Ref Number / / Signed Date Print LEAP ARF/AMRF Application Form - Page 5 of 13

6 Please indicate the gross level of annual income to be drawn from your ARF and how you would like it to be paid: 1. I require the statutory minimum drawdown (currently 4% / 5% / 6%) or 2. I require the following gross income per annum Payable: Half Yearly Payable: Quarterly Payable: Monthly Bank Account Details Note: these details are required so we can transfer monies to you electronically from your accounts for distributions from your ARF. Please note we cannot transfer monies to 3rd party accounts. Account name of Bank / Building Society Address of Bank / Building Society IBAN No Swift/BIC Declaration I hereby declare that, to the best of my knowledge, I am entitled, under the Taxes Consolidation Act 1997 (as amended), to invest in an ARF and/or an AMRF and that the investment made is from an approved source. I authorise any insurance company, QFM, pension scheme trustee or PRSA provider to give Independent Trustee Company Limited details of any pension arrangements, annuities and/ or ARF/AMRF investments applying to me. I undertake to notify ITC if I at any stage become entitled to receive an annual pension payment of 12,700 or more. / / Signature in capitals Date Page 6 of 13 - LEAP ARF/AMRF Application Form

7 Investment Instruction I confirm that I wish to make this investment on an execution-only basis with Conexim. I understand that this means that Conexim will provide its services following my request and without having ascertained whether the service is suitable or appropriate for me. I confirm that I do not wish to provide any financial or other personal information to Conexim to enable it to determine whether the service is appropriate for me. Please only ONE. For additional investment instructions please detail choices overleaf. Allianz Multi Asset Opps A H2 EUR LU Allianz Multi Asset Long/Short A H2 EUR LU BSF Managed Index Portfolio Defensive D2 EUR LU BSF Managed Index Portfolio Conservative D2 EUR LU BSF Managed Index Portfolio Moderate D2 EUR LU BSF Managed Index Portfolio Growth D2 EUR LU Dimensional Ultra Defensive * Dimensional Defensive * Dimensional Moderate * Dimensional Balanced * Dimensional Growth * Dimensional Equity Focused * Dimensional Targeted Equity * GAM STAR FUND Cautious Z EUR Acc IE00BWXBYN46 GAM STAR FUND Balanced Z EUR Acc IE00BWXBYL22 GAM STAR FUND Growth Z EUR Acc IE00BWXBYP69 Ivy+ Balanced Growth C Institutional Eur IE00BYQ86C95 global allocation Global Allocation Cautious see Global Allocation Morningstar KFD Global Allocation Moderately Cautious see Global Allocation Morningstar KFD Global Allocation Morningstar Moderate see Global Allocation Morningstar KFD fund strategies Global Allocation Moderately Adventurous see Global Allocation Morningstar KFD Global Allocation MorningstarAdventurous see Global Allocation Morningstar KFD Schroder ISF Mlt-Asst Ttl Rt C Acc EUR H LU Please refer to PortfolioMetrix s Consent and Declaration, Mandate & Deal sheet for consent to services and dealing instruction * Minimum investment in a Dimensional Model Portfolio is 50,000 LEAP ARF/AMRF Application Form - Page 7 of 13

8 Additional Instructions If you have any direct investment instructions, please indicate these below. Any comments detailed below will form part of the instruction on the account. of fund, share, product / Sedol / Ticker of money to invest Rebalancing Instructions within Model Portfolios I confirm that I wish to make this investment on an execution-only basis with Conexim, having received advice from my financial advisor. I understand that this means that Conexim will provide its services following my request and without having ascertained whether the service is suitable or appropriate for me. I confirm that I have provided all the information required to enable my financial advisor to confirm that this investment is suitable for me and I confirm that I am instructing Conexim to follow this recommendation, or I am making this instruction on an execution-only basis. I confirm that I have requested Conexim to provide its services to me on an execution-only basis and that I do not wish to provide any financial or other personal information to Conexim to enable it to determine whether the service is appropriate for me, as my financial advisor has provided investment advice and assessed the suitability of this investment for me, or I am making this instruction on an execution-only basis. I note that in some of the model portfolios available through LEAP, in order to maintain the asset allocation discipline of my chosen portfolio after I have invested Conexim will, from time to time, need to rebalance the holdings in my portfolio to the percentage allocations at the date of my original investment ( Original Asset Allocation ). I note that a rebalance will need to be effected on my behalf where the asset allocations in my portfolio drift by the amount specified in the Key Features Document ( Asset Allocation Drift ) relative to that model portfolio. This pre-authorised rebalance to the Original Asset Allocation will normally be effected by Conexim at 10am (Irish time) on the first business day following the occurrence of the Asset Allocation Drift (the Rebalance Date ) provided the Asset Allocation Drift has still occurred at that time. Where Asset Allocation Drift has occurred in my portfolio, I HEREBY INSTRUCT Conexim to effect, on the Rebalance Date, the number of sale and buy instructions of units in each of the funds in the portfolio, based on the published net asset value of the funds on the Rebalance Date, as are required to restore each of the holdings in the portfolio to my Original Asset Allocation. I understand and acknowledge that I retain absolute discretion over all investment decisions and that I may by notice in writing to my financial advisor and/or Conexim rescind this/these standing rebalancing instruction(s). I understand that the above pre-authorised rebalancing instruction(s) is/are designed to maintain the asset allocation discipline of my chosen portfolio after I have invested. I understand that the Original Asset Allocation may change due to market movements and the above pre-authorised rebalancing instruction is intended to restore my investment to the Original Asset Allocation in order to keep my portfolio consistent with my risk appetite as I have described it to my financial advisor. Should I wish to change into a different portfolio with different asset class allocations, this can be facilitated but will require a new instruction from me accepting the changes in the risk/return characteristics of the chosen portfolio. Page 8 of 13 - LEAP ARF/AMRF Application Form

9 Unit Trust Subscription The assets of your ARF are held under the Terms of the Custody Trust (the Custody Trust ), an Exempt Unit Trust, established by deed of 25th April 2014 pursuant to Section 731(5) TCA 97. If you wish to invest in non-exchange traded assets, typically bonds, bank deposits or direct property, or where funds need pre-clearing, we will open a separate bank account under the terms of the Custody Trust dated 25th April 2014, an Exempt Unit Trust, established pursuant to Section 731 (5) TCA97 (the Custody Trust ). The terms of the Custody Trust are available to view on the ITC website at This application form relates to all initial and subsequent subscriptions for Units in the Custody Trust made on behalf of your ITC ARF, as evidenced by the transfer of subscription monies into the appropriate Sub-fund account. To be completed by ITC Trust Reference The Pension Investor Representations and Warranties The capitalised words and expressions used in this application form shall have the meaning ascribed to them in the Custody Trust. 1. I confirm that having considered the Declaration of Trust and a specimen Supplemental Declaration of Trust in relation to the Sub-fund, this application is based solely on the Declaration of Trust and the Supplemental Declaration of Trust and I am not relying on any other information or representation. 2. I agree that all representations, warranties and declarations which I make or give here will apply with respect to future acquisitions of Units in the Custody Trust as if repeated in full at the time of the future acquisition. 3. I hereby acknowledge and agree that the Trustee reserves the right at its sole discretion to accept or reject in whole or in part my application. 4. I acknowledge the right of the Trustee in its capacity as trustee of the Custody Trust to issue such number of Units upon the transfer of initial or subsequent subscription monies into the account of the Sub-fund as the Trustee may in its sole discretion determine in accordance with the provision of the Declaration of Trust. 5. I further acknowledge and agree that the transfer of monies by me into the account of the Sub-fund will be deemed to be an irrevocable subscription for Units in the Custody Trust. 6. I acknowledge the right of the Trustee in its capacity as trustee of the Custody Trust, to redeem the Units in the event that the representations or warranties set out herein above are no longer accurate. 7. I acknowledge the right of the Trustee in its capacity as trustee of the Custody Trust to compulsorily redeem Units in the event that such units are (i) held in breach of any law or requirement of any country or governmental authority; (ii) held in circumstances which in the opinion of the Trustee might result in the Trust incurring any liability for taxation or suffering any legal, pecuniary, regulatory or material administrative disadvantage which the Trust might not otherwise have incurred or suffered; or (iii) are held by a Unit holder who is not or cease to be a Pension Investor (as defined in the Declaration of Trust); or (iv) held in circumstances in the opinion of the Trustee which might result in the Series Trust or Trust being deemed to be a unit trust scheme as defined in Section 1(1) of the Unit Trusts Act, 1990; (v) held in the circumstances in the opinion of the Trustee might result in the Sub-fund or Trust being deemed to be an Alternative Investment Fund (as defined in the European Union (Alternative Investment Fund Managers) Regulations 2013). 8. I understand that during the Term of the Sub-fund, the redemption of Units shall be subject to restrictions which may adversely affect the ability to redeem Units. 9. I shall provide the Trustee with any additional information which it may require in connection with my tax status and authorise them to disclose such information relating to this application to such persons as it may be required for taxation, legal or regulatory purposes. LEAP ARF/AMRF Application Form - Page 9 of 13

10 10. I acknowledge that it is envisaged that additional subscriptions for Units in the Custody Trust shall be made in such an amount as shall be determined by me. Where additional subscriptions are not made and where, as a result, there may not be sufficient assets within the Series Trust to discharge its liabilities from time to time I acknowledge that this may result in the Trustee being obliged to sell or otherwise dispose of some or all of the assets of the relevant Series Trust. Acknowledged and agreed by Investor Signature Print Date Page 10 of 13 - LEAP ARF/AMRF Application Form

11 Consent and Declaration 1. Declaration I declare that the information provided by me on this form is correct and I undertake to immediately inform my financial advisor should any of the information change. 2. Receipt and understanding of Terms of Business This is my application to ITC to act as the Qualifying Fund Manager of my ITC ARF, and for my financial advisor, ITC and Conexim to provide LEAP services, as set out in the Terms of Business. I have received the Terms of Business both in relation to the LEAP services and the ITC ARF (jointly, the Terms ) and have read them carefully. In particular, I confirm that I understand and agree to the following terms, policies and statements, i.e. the Risk Disclosure Statement, Summary Order Execution Policy, Summary Conflicts of Interest Policy and The Pershing Agreement. 3. Receipt of Clients Assets Key Information Document ( CAKID ) I confirm I have received a CAKID relating solely to the client assets which Conexim instructs PSIL to provide safe custody and nominee services on my behalf and outlines the Client Asset Regulations as they pertain to Pershing Securities International Limited only. 4. Invitation to treat I understand that my completing and submitting this form and associated documents (if any) is an invitation to treat and that ITC, Conexim, Pershing Securities International Ltd ( PSIL ) and Pershing Securities Ltd ( PSL ) are not bound by the Terms until such times as a welcome letter is communicated to me and my advisor, an account opened in respect of my investments and funds contributed or in specie transfer of existing funds, shares, or product effected. I further note that the Terms may subsequently change as provided for in the Terms. 5. Investor Declaration 5.1. I confirm that I have taken such professional advice as appropriate in connection with the quality, suitability and appropriateness of the investments provided for inclusion in my portfolio. I understand that this means that Conexim will provide their services following my request and without having ascertained whether the service is suitable or appropriate for me and that their services may be provided on an execution-only basis. Where Conexim rebalance investments within a model portfolio I confirm that such rebalancing is based on the pre-authorised rebalancing instruction as detailed in the model portfolio guides, which I have received a copy of, and that such rebalancing does not imply that Conexim is making an assessment of suitability or appropriateness for the purposes of providing LEAP services to me and if any discretion is employed it is only to rebalance the portfolio to remain consistent with the characteristics for each model portfolio as specified in the model portfolio guides I understand that the transmission of any order by me will by ITC be treated as a request to trustees and is subject to the discretion of ITC as trustee and pension provider I authorise and direct ITC to accept further requests regarding the transfer of funds to the custody of PSIL, PSL or any other custodian or credit institution from me or my financial advisor when relayed via post or I understand that ITC act in the capacity of Qualifying Fund Manager of my fund and that my financial advisor acts as my investment manager. Pension/Property Adjustment Order I confirm that no Pension Adjustment Order or Property Adjustment Order exists in relation to the assets the subject of the LEAP services. Yes No* (Copy Order attached) 5.5. I undertake to immediately notify ITC if I receive annual guaranteed pension payments of 63,500 or more and understand that, should I fail to do so, this may give rise to a tax liability. I agree to indemnify ITC against any such liability I understand that the provision of services as a Qualifying Fund Manager by ITC does not require licensing, authorisation or registration with the Central Bank and, as a result, it is not covered by the Central Bank s requirements designed to protect consumers by way of a statutory compensation scheme. 6. Express consent to execute order outside of regulated market or multilateral trading facility Where I have requested that an order be executed in an instrument admitted to trading on a Regulated Market ( RM ) or Multilateral Trading Facility ( MTF ), then I acknowledge that PSL may execute such order outside an RM or MTF in accordance with PSL s execution policy and I hereby give my consent for such execution. LEAP ARF/AMRF Application Form - Page 11 of 13

12 7. Fees, commissions, charges I have received details of the fees, commissions and charges in relation to the LEAP services and I agree to these. In doing so, I confirm that Conexim has explicit permission to deduct such amounts from my account to satisfy any indebtedness to ITC, Conexim, PSIL, any nominated financial advisor or any 3rd party nominated by you and notified to us by you. 8. Taxation I confirm that no representations have been made to me and I rely on no confirmations or actions by ITC, or Conexim regarding the tax treatment or any tax advantage understood by me as applicable. To this end I will have to take my own, separate tax advice. 9. W-8BEN I understand that I will be unable to trade in US securities until a correctly completed W-8BEN form has been submitted and lodged with the appropriate withholding agent. I understand that while W-8BEN form may confer certain reliefs and exemptions with regards to withholding tax under the terms of the Double Taxation Agreement between Ireland and the United States, it is not the responsibility of my advisor, ITC or Conexim to claim or secure any such reliefs or exemptions or notify me should such reliefs or exemptions not be available. To that end, I will take my own tax advice. 10. Contract notes I understand that I will be able to access valuations and contract note(s) online via the client portal. Should you wish to receive hard copy contract notes please contact us. 11. ITC Client Portal Access to the ITC Client Portal can be gained from the website, or by downloading the app to phone or tablet from the App Store. I confim that I wish to gain access to the ITC Client Portal and consent to receiving relevant scheme documentation, reports, statements and projections via my ITC Client Portal. Should you wish to receive hard copy of any of these documents please contact us. 12. FATCA / CRS Self-Certification Declaration By opening this account and signing below, the beneficial owner(s) represents and warrants that he/she/it is not a US person for the purposes of US Federal income tax and that he/she/it is not acting for, or on behalf of, a US person. A false statement or misrepresentation of tax status by a US person could lead to penalties under US law. If your tax status changes or you become a US citizen or resident, you must notify us immediately. I declare that the information provided in this form is, to the best of my knowledge and belief, accurate and complete. I acknowledge that the information contained in this form and information regarding the beneficial owner(s) may be reported to the tax authorities of the country in which this account(s) is/are maintained and exchanged with tax authorities of another country or countries in which the beneficial owner(s) may be tax resident where those countries (or tax authorities in those countries) have entered into Agreements to exchange financial account information. I undertake to advise the recipient promptly and provide an updated Self-Certification form where any change in circumstances occurs which causes any of the information contained in this form to be incorrect. 13. Advisor Fees The charges payable to my financial advisor which will be levied and deducted from my LEAP account are: Implementation Charge ( or %): Annual Charge ( or %): I hereby consent to the deduction of these charges from my account(s). The implementation charge will be deducted once cleared funds are received into my account, and the annual charge will be deducted monthly in arrears consistent with the charging schedule issued to you. I acknowledge receipt of a charging schedule which details the charges levied by Conexim in relation to their services. I acknowledge receipt of a charging schedule which details the charges levied by ITC and Conexim in relation to the LEAP services. Consent and Declaration to items 1 to 13 above Investor Signature Print Date Page 12 of 13 - LEAP ARF/AMRF Application Form

13 Advisor Declaration I declare that I have met the above named applicant and have explained the relevant investments provided within the services and am satisfied that the investments chosen on this application form and any subsequent instructions are suitable and appropriate in relation to the clients knowledge and experience, risk tolerance, capacity for loss and the client s investment needs and objectives. I can also confirm that I/we have fully complied with all Anti-Money Laundering and Terrorist Financing Legislation and other relevant legislative requirements in relation to this client. Advisor Signature Print Date LEAP ARF/AMRF Application Form - Page 13 of 13