DATA CAPTURE FORM COLLECTIVE INVESTMENT ACCOUNT INDIVIDUAL AND JOINT

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1 DATA CAPTURE FORM COLLECTIVE INVESTMENT ACCOUNT INDIVIDUAL AND JOINT For financial adviser use only. 3 Editable fields to allow you to input information electronically. 3 Space to embed your company logo and footer. 3 Data fields follow the same sequence as the online application process. 3 You can delete this page if you wish. HOW TO CUSTOMISE THIS FORM Firstly, save the form to your desktop. To add a logo: Open the form from your desktop in Acrobat Standard 7* or above. In the toolbar, click on Document. Select Add a Watermark & Background. Under Source, select From file, where you can browse pdf, jpg or bmp files for your logo. Use the Position and Appearance options to alter the size and location. Use the Page Range option to select the page(s) for your logo. To add a footer: Open the form from your desktop in Acrobat Standard 7* or above. In the toolbar, click on Document. Select Add Headers & Footers. Select the footer tab and type the text required in the fields required. Use the options underneath the footer tab to adjust the style and location. To delete this page: Open the form from your desktop in Acrobat Standard 7* or above. In the toolbar, click on Document. Select Delete Pages. * For Acrobat 10 users, this can be found under Tools then pages. IMPORTANT NOTES This form is updated on a regular basis. It is your responsibility to ensure you are using the most up-to-date version which can be found on the Old Mutual Wealth Literature Library at Please ensure that all applicable sections are completed, as you may not be able to submit the application online if information is missing. Ensure that your client has checked the data that is captured on this form. To reset the editable data fields simply click on the reset button at the end of this form. For new investments by non-private applicants (eg trusts/companies), the form entitled Tax Information for Trustees and Corporates MUST also be completed and returned to us, otherwise the investment could be delayed. SUPPLEMENTARY FORMS WHICH MAY BE REQUIRED (These can be found on the Old Mutual Wealth Literature Library). Adviser fee authorisation form this needs to be completed and signed by your clients if they agree to pay fees. Transfer authority form - this needs to be completed and signed by your clients if they are transferring to us. Direct Debit Instruction this should be completed and signed by: the client if he/she wishes to complete a paper instruction rather than submitting the information online any third party wishing to make regular payments into the client s CIA. Confirmation of verification of identity (COVI) the online application process will capture all money laundering requirements for individuals. However, the identity of any third parties paying for private investments will need to be verified using this form. Power of Attorney Form - if an attorney is acting on the client s behalf. This form should not be used for corporate or trustee applications. Please complete a paper application available from the Old Mutual Wealth Literature Library. Where you see an symbol, more information is provided. If you have further queries please refer to the online help options, or call This is to enable us to comply with regulations concerning taxation. Personalised versions of these forms can be printed during the online application process.

2 DATA CAPTURE FORM COLLECTIVE INVESTMENT ACCOUNT INDIVIDUAL AND JOINT FORM PURPOSE This form is for financial advisers to gather the necessary information and declarations from a client to input new business online for a Collective Investment Account on Old Mutual Wealth s platform. If Old Mutual Wealth does not already hold a signature for your client then the last page can be detached and sent to Old Mutual Wealth for this purpose. Please be aware that this form is not an application and will not be accepted as such if sent to us. You must submit this information online. APPLICANT DETAILS For existing clients, please enter the client reference : *Title (3) *First name *Surname For new clients: * Date of birth (dd/mm/yyyy) *UK residence status (3) *National Insurance (NI) *Address *Town/City County Mr Mrs Miss Other * Relevant UK individual (3) Middle name(s) Home phone Work phone *Gender (3) *Individual status (3) Employed Pensioner Self-employed Caring for person aged 16 or over Permanent UK residential address Full-time education Other (please state) Mobile phone Male n-resident Female Resident Your client has never had an NI (3) Unemployed Caring for children under 16 You may not need to capture all of the detailed information if the client s details are already held. To identify existing clients online, you can use all or part of the client name or client reference. Select Resident if the investor resides in the UK; select n-resident for Guernsey, Jersey and Isle of Man residents. Investors residing elsewhere cannot invest in a CIA. *Postcode *Country address Occupation *Country of birth Industry *Nationality(ies) *Country(ies) of Tax Residence *Tax Reference Number(s) * This is a mandatory field when creating a client online. Investment range WealthSelect or SelfSelect Your choice here will determine the funds available to choose from during the online process.

3 JOINT APPLICANT DETAILS (IF APPLICABLE) For existing clients, please enter the client reference : *Title (3) Mr Mrs Miss Other *First name *Surname Middle name(s) Joint applicants need to have a client record created online. To identify existing clients online, you can use all or part of the client name or client reference. For new clients: * Date of birth (dd/mm/yyyy) *UK residence status (3) *National Insurance (NI) * Relevant UK individual (3) *Gender (3) Male Female n-resident Resident Your client has never had an NI (3) Select Resident if the investor resides in the UK; select n-resident for Guernsey, Jersey and Isle of Man residents. Investors residing elsewhere cannot invest in a CIA. *Individual status (3) Employed Pensioner Self-employed Permanent UK residential address *Address *Town/City County Caring for person aged 16 or over Full-time education Other (please state) Home phone Work phone Mobile phone Unemployed Caring for children under 16 *Postcode *Country address Occupation *Country of birth Industry *Nationality(ies) *Country(ies) of Tax Residence *Tax Reference Number(s) * This is a mandatory field when creating a client online. YOUR ADVICE Registered individual/account to receive remuneration Have you given advice to the client in respect of this transaction? (3) Are you appropriately authorised to conduct this business? (3) On which basis are you acting for this transaction? (3) Independent Restricted CONTRIBUTION DETAILS Lump sum contribution Lump sum amount Adviser Initial Fee (minimum 2,500) When topping up an existing account, the 2,500 minimum does not apply. % OR

4 Transfer Ceding provider s details: Complete for each ceding provider. Name Address Type of transfer required: Total estimated transfer value Cash transfer This must be the current address for the provider to avoid any delays or the need to complete a replacement authority. Account (s) being transferred Designation (if applicable) Adviser Initial Fee for cash transfers Transfer Ceding provider s details: Name Address % cannot be used in conjunction with WealthSelect or the Managed Portfolio Service. If a fee is required for re-registration, you will need to request an ad hoc fee using the Ongoing Adviser Fee Authorisation form available from our Literature Library. Type of transfer required: Cash transfer Total estimated transfer value Account (s) being transferred cannot be used in conjunction with WealthSelect or the Managed Portfolio Service. Designation (if applicable) Adviser Initial Fee for cash transfers % Transfer Ceding provider s details: Name Address Type of transfer required: Total estimated transfer value Cash transfer cannot be used in conjunction with WealthSelect or the Managed Portfolio Service. Account (s) being transferred Designation (if applicable) Adviser Initial Fee for cash transfers % Regular contribution Regular contribution amount per month (minimum 99.00) Adviser Initial Fee % OR from each direct debit

5 FUNDS Portfolio name (if applicable) Please make your clients aware that VAT will be added to the Service Charge for CIAs investing in a WealthSelect Managed Portfolio. Select funds Is phased investment required? (3) Phased investment over (3) Phased investment start date Automatic rebalancing option (3) Rebalancing frequency (3) Funds PHASING AND AUTOMATIC REBALANCING OPTIONS (NOT AVAILABLE WITH THE WEALTHSELECT MANAGED PORTFOLIO SERVICE) OR Inc/Acc 3 months 6 months 12 months (mm/yyyy) Quarterly Half-yearly Yearly % The funds chosen here will also apply to any cash transfers or proceeds of funds that cannot be re-registered. The funds selected will not be used as a switch instruction for any funds that can be re-registered. You must make sure your clients have seen the latest Key Investor Information Document (KIID) or Key Information Document (KID) in respect of their chosen funds, where applicable. More information about this can be found on our website www. oldmutualwealth. co.uk/fund-info You will also need to declare online that you have informed your client of the rebate information for the funds selected, where applicable, and that the client has seen the Costs and Charge Statement (which is part of the illustration/projection) Please continue on a separate sheet if more funds are required. Rebalancing start date (mm/yyyy) This will rebalance back to the fund allocation selected in the application. Rebalancing cannot be selected where an application includes re-registration. continued

6 APPLICATION OPTIONS Income payment/automatic withdrawal option (3) Income payment option OR Automatic withdrawal option Withdrawal option (complete as appropriate) Frequency for income/ withdrawal payments (3) or Monthly % of the account value, annually amount for each payment (minimum payment 25) This is the distribution of income generated by funds. One or more income funds must be chosen as your fund selection. This option is not available where a WealthSelect managed portfolio has been chosen. OR Please select months required (3) Jan Feb Mar Apr May Jun Jul Aug Sep Oct v Dec Payment start date Annual escalation basis (3) (for monetary amount only) Deduction preference for automatic withdrawals (3) (mm/yyyy) Nil Retail Prices Index 5% Largest fund Proportionally from all funds Proportionally from the following funds (3) Please list below: This is the only option available in conjunction with the Wealth Select Managed Portfolio Service. Bank details for income/withdrawal options Name of bank account holder Branch Branch sort code I confirm that the bank account holder is the client (3) ADVISER FEES Adviser Servicing Fee % each year OR Add VAT to the servicing fee? (3) Frequency (3) Charge/fee deduction preference Bank/building society Account Building society reference each year Monthly Quarterly Half-yearly Yearly A personalised Adviser Fee Authorisation form will be generated during the online process for you to print for your client to sign and return to us. Alternatively, you can download the form from our website www. oldmutualwealth. co.uk/adviser/ literaturelibrary/ We will be unable to process the application before we receive the Adviser Fee Authorisation form. If the form is not received within 10 working days we will refund any payments to the client. Same deduction preference as automatic withdrawals? (3) This applies to the Old Mutual Wealth Service Charge and Adviser Servicing Fee.

7 ADVISER FEES (CONTINUED) If select one of the following options for selling units to meet the Old Mutual Wealth Service Charge and any servicing fees. Largest fund Proportionally from all funds Proportionally from the following funds (3) This is the only option available in conjunction with the Wealth Select Managed Portfolio Service. Please list below: Adviser Fund Switch Fee This is the maximum switch fee you agree with your client. You will be able to stipulate the actual fee payable for each switch at the time the switch instruction is given. % OR from each switch Illustration options Consider additional accounts held on our platform by your client in this illustration? Additional holdings amount We calculate the Old Mutual Wealth Service Charge on the projected value of all the client s accounts and bonds on the platform. The illustration will assume that this value of additional holdings will be retained on the platform for the full duration of the illustration. PAYMENT DETAILS Lump sum payment method (3) Cheque Debit card CHAPS Internet banking transfer For cheques: Make cheques payable to Old Mutual Wealth Limited For debit cards: Follow the instructions online. Your client must be with you when the debit card details are recorded online. You will need to enter the cheque, account and sort code online. Then use the Print Cheque Confirmation option on the application summary screen once submitted, and attach the cheque to this when sending it to us. For CHAPS and internet banking transfer: Bank must be provided with Old Mutual Wealth Limited s bank details: Bank name: NatWest Bank plc Account name: Old Mutual Wealth Limited Sort code: Account : Reference: The reference is the application reference. It will be generated online during submission and can be input here for your records. Regular payments: (3) A signed paper Direct Debit Instruction might be required. Direct debit collection day (3) 10th 20th A paper direct debit instruction must be completed if the direct debit payments will be paid by a third party, or if your client is not the only one required to authorise payments from the bank account. ANTI-MONEY LAUNDERING As part of the online submission you will need to have verified the identity of the client under Money Laundering Regulations.

8 CLIENT SIGNATURE Please make sure that all of the information in this form is correct, before signing and dating below. Client signature APPLICATION NUMBER Date (dd/mm/yyyy) 2 0 This signature is for your own records. If Old Mutual Wealth does not already hold a signature for your client then the last page can be detached and sent to Old Mutual Wealth for this purpose. This form is not an application. It is solely for financial adviser records and will not be accepted if sent to us as an application. This will be generated online during submission and can be input here for your records. CLIENT DECLARATION As your financial adviser will be submitting the application electronically on your behalf, please see the Collective Investment Account (CIA) declaration below which they will be agreeing to on your behalf: This declaration is made by each investor associated with the application. 1. On the basis of the details supplied in my application: a) I declare that: I am 18 years of age or over. I am a UK resident or I am resident in the Isle of Man, Guernsey, Jersey, Gibraltar (this does not apply to top-ups). I will inform Old Mutual Wealth Limited if my residency changes in the future. b) I understand that Old Mutual Wealth Limited will administer the CIA in accordance with UK tax legislation. c) I confirm that if withdrawals are to be paid to a beneficiary, the beneficiary is aged 18 or over. 2. I authorise Old Mutual Wealth Limited: a) to hold my investments, interest distributions, dividends and any other rights or proceeds in respect of those investments and any other cash; and b) to sell units or shares in investments within my account to meet any charges or fees for my financial adviser, in accordance with the Terms and Conditions; and c) to give effect to my instructions in accordance with the Terms and Conditions. 3. I understand that I will not receive contract notes relating to transactions involving the purchase or sale of investments which are carried out on a periodic basis in the manner agreed to in this application. Details of these transactions will be shown in the periodic statement which will be sent to me. In particular, such transactions include: regular investments payable by direct debit phased investments automatic rebalances automatic withdrawals dividend and rebate reinvestments; and sales of units to meet Old Mutual Wealth Limited charges and fees for my financial adviser (if applicable). 4. I have been given the opportunity to read and keep the following, and to have any questions concerning them answered to my satisfaction: a) Terms and Conditions, to which I agree b) Key Features Document c) Costs and Charges Statement, included in an illustration or projection regarding my investment d) all available Key Investor Information Documents, Key Information Documents and information about rebates, in respect of my chosen funds. 5. I consent to my personal data being used in accordance with the Personal Data Statement in the Terms and Conditions. 6. I declare that my application has been completed correctly and to the best of my knowledge and belief. 7. I understand that if I want adviser fees to be deducted from my investment, I will need to sign and submit an Adviser Fee Authorisation form. 8. Tax information I understand that for regulatory purposes Old Mutual Wealth is required to obtain information concerning my taxation status. a) I declare that: i. I am resident for taxation in the country(ies) shown in this application and I am not resident for taxation elsewhere. ii. I am a national of the country(ies) shown in this application and I am not a national or citizen of any other country. iii. I will inform Old Mutual Wealth if this changes in the future. b) I understand that: i. Old Mutual Wealth may need to contact me for further information regarding tax information. ii. if I am resident for taxation outside of the UK, Old Mutual Wealth may need to share my information with the relevant tax authorities.

9 WEALTHSELECT MANAGED PORTFOLIO SERVICE DECLARATION Where you are using the WealthSelect Managed Portfolio Service in conjunction with a CIA, your financial adviser will be acting on your behalf. Old Mutual Wealth Limited will therefore treat your financial adviser as the client in relation to this service. Your financial adviser will therefore be required to make the following declaration during the online application process. I have read and agreed to the following WealthSelect Managed Portfolio Service declaration. I confirm that I have explained the Managed Portfolio Service to my client(s); I have their authority to use the WealthSelect Managed Portfolio Service in respect of their account and I request that you invest their account into the Managed Portfolio I have selected. I confirm for each client: I have given advice in relation to the suitability of using the Managed Portfolio Service and to the Managed Portfolio to be selected here which meets my client s needs. I have provided the client with the factsheet for the relevant Managed Portfolio and I have given the client an opportunity to read it and they understand the investment risks relating to the Managed Portfolio Service in general and specifically to the relevant Managed Portfolio. I am responsible for ensuring that the Managed Portfolio selected is suitable currently and on an on-going basis in accordance with my duties under the FCA rules and the Managed Portfolio Service terms with Old Mutual Wealth Limited. My client is aware that you, as the portfolio manager, will have complete discretion over the assets in each Managed Portfolio to buy, sell, retain, exchange or otherwise deal in assets, take all routine and day-to-day decisions about the asset allocation of the Managed Portfolios, and that neither I, nor the client is permitted to provide such dealing instructions or modifications to the Managed Portfolio. My client accepts that the agreement to provide the Managed Portfolio Service is between you and me, and I am offering this service to them as part of my agreement with them. I have informed my client that while the Managed Portfolio Service is in use for their account, the Service Charge (formerly known as Platform Charge) will be subject to VAT and the standard charge will therefore be increased by the VAT amount. I understand and have informed my client that switches made by you, as the portfolio manager, take no account of a client s tax affairs and can incur a chargeable event for capital gains tax purposes. I understand that you, as the portfolio manager, are not liable for any capital gains tax incurred by the client as a result of any switches made to their account to review and adjust the asset allocation for the selected Managed Portfolio. My client understands that where they have existing instructions to pay withdrawals or deduct the Service Charge or adviser servicing fees from specific funds, these will automatically be changed to withdrawals or deductions taken proportionally across all funds. I have explained the potential tax implications of this change to my client and they accept these. My client has a copy of the Supplementary Terms and Conditions for Collective Investment Accounts on Charge Basis 3 to reflect the two investment ranges and the WealthSelect Managed Portfolio Service and they have had an opportunity to read and understand the conditions and restrictions relating to their account while the Managed Portfolio Service is in use before agreeing to the use of the Managed Portfolio Service.

10 CLIENT SIGNATURE SPECIMEN If Old Mutual Wealth does not already hold a specimen signature for your client, this page can be detached and sent to Old Mutual Wealth for this purpose. Old Mutual Wealth must hold a valid signature for all clients to ensure any future instructions are not delayed whilst security checks are made. Application Client reference Once completed please send this page to: Freepost RSJX-XAJZ-BKKT Old Mutual Wealth Old Mutual House Portland Terrace Southampton SO14 7AY The application will be generated when the application is entered online The client reference will be generated when the client is created online. This freepost address is for specimen signatures only. Please do not use it for other correspondence as it will not be delivered to the correct area. First applicant Joint applicant (if applicable) Print name Signature* Date (dd/mm/yyyy) Date (dd/mm/yyyy) * If you are an attorney signing this on behalf of the investor please add as attorney after your signature and ensure our completed Power of Attorney form and documentary evidence accompany this specimen signature page. Please be aware that this form is not an application and will not be accepted if sent to us. SK6679/ /December 2017 **investor**