FOR FUNDSERV TRANSACTIONS ONLY DEALER CODE: REP CODE: Client Services Dealer Support (FUNDSERV) Tel: 506-853-6040/1-888-577-7337 Tel: 506-853-6040/1-855-577-3863 Fax: 506-853-9369/1-855-577-3864 Fax: 506-853-9369/1-855-577-3864 Email: investments.retirement@assumption.ca Email: fundserv.support@assumption.ca Financial Transaction Request Policy Number: Client Number: Type of contract: Individual Group Non-registered RSP Spousal RSP Fed. locked in RSP Locked-in RSP (prov.) TFSA LIRA (prov.) RIF Spousal RIF LIF (prov.) Annuitant Name Last Name Date of Birth (Day/Month/Year) Address Telephone No. E-mail Owner and/or Contributor Name Last Name Date of Birth (Day/Month/Year) Address Telephone No. E-mail NOTE FOR NON REGISTERED ACCOUNTS ONLY : If your residence for tax purposes has changed, please complete the Canada Revenue Agency form RC518-Declaration of Tax Residence for Individuals, or form RC519-Declaration of Tax Residence for Entities, available on our website at www.producerscorner.ca. Each account holder of a joint account has to fill out a Declaration of Tax Residence form. INVESTMENT FUNDS Segregated Segregated Series B Series C Series B Series C Assumption Life s Emerging Markets s 429 529 Growth Portfolio 414 514 NorthStar Balanced 430 530 Balanced Growth Portfolio 415 515 CI s Balanced Portfolio 420 520 Signature Corporate Bond 426 526 Conservative Portfolio 421 521 Signature Canadian Bond 179 277 Louisbourg s Harbour Growth & Income 182 280 Balanced 140 202 Signature High Income 412 512 Canadian Dividend 107 207 American Value 403 503 Money Market 109 209 Cambridge Canadian Dividend 425 525 U.S. Equity 166 205 Global Small Companies 411 511 Preferred Share 431 531 Cambridge Canadian Asset Allocation Corporate 422 522 Fixed Income 152 204 Signature Global Resource Corporate Class 427 527 Canadian Small Capitalization Equity 144 206 Signature Global Dividend 428 528 Momentum 129 229 Interest Accounts GIC Fidelity s Guaranteed Interest Account, 1-year non-redeemable GICN1 Canadian Opportunities 146 230 Guaranteed Interest Account, 2-year non-redeemable GICN2 True North 174 231 Guaranteed Interest Account, 3 year non-redeemable GICN3 International Growth 194 292 Guaranteed Interest Account, 4-year non-redeemable GICN4 Europe 185 283 Guaranteed Interest Account, 5-year non-redeemable GICN5 American Disciplined Equity 404 504 Guaranteed Interest Account, 1-year redeemable GICR1 North Star 409 509 Daily Interest Account DIA Monthly Income 408 508 Canadian Asset Allocation 413 513 Far East 419 519 4920-00A-NOV17 Page 1 of 5
1. Transfer between funds (Select from the list of investment funds on page 1) Transfer from Transfer to 2. Deposit Allocation Select from the above list of investment funds for additional deposits and preauthorized debit (PAD) deposits. Lump Sum Deposit External transfer You must submit the original T2033 or T2151 form directly to the transferring financial institution for external transfers and attach a copy to this request form. Additional Deposit PAD Deposit 4920-00A-NOV17 Page 2 of 5
3. Account withdrawal(s) Cheque Direct Deposit (include void cheque) Reason for withdrawal (please specify) : a) Partial withdrawal b) Full withdrawal c) Automatic partial withdrawal for non-registered and TFSA accounts d) Specific withdrawal $ Gross (Before tax) or PAD deposits to continue, if applicable PAD deposits to stop immediately Net (After tax) Monthly Quaterly Semi-annually Annually Montant $ Gross (Before tax) or Net (After tax) Start date (between the 1 st and the 28 th of the month) (Day/Month/Year) Prorated withdrawal Withdrawal per instructions below Direct deposit only (Attach VOID cheque) Withdrawal from (Name) : % or $ 4. Request to change guaranteed interest account term upon reinvestment GIA number. Upon maturity of the GIA on / /, change investment term according to the following instructions and guarantee today`s interest rate: Daily interest account 1-yr redeemable 1-yr non-redeemable 2-yr non-redeemable 3-yr non-redeemable 4-yr non-redeemable 5-yr non-redeemable The interest rate to be applied will be the greater of the interest rate in effect on the date this form is signed or the interest rate in effect on the reinvestment date for the term specified above. If this form is signed more than forty-five (45) days prior to the reinvestment date, the interest rate to be guaranteed will be the rate in effect on the forty-fifth day prior to reinvestment for the term specified above. This form must be received at Assumption Life s head office within two (2) working days of the date it is signed. Interest income option is requested (Attach void cheque) Monthly Annually 5. Start, change or stop preauthorized debit (PAD) deposits Begin PAD deposits (attach void cheque) Single deposit (attach void cheque) $ $ Frequency of withdrawals: monthly weekly every two weeks quarterly semi-annually annually twice monthly and PAD start date / / (between 1st and 28th) Date of single Deposit / / (between 1st and 28th) 4920-00A-NOV17 Page 3 of 5
Increase current PAD deposits Increase amount to $ PAD to increase on / / Decrease current PAD deposits Decrease amount to $ PAD to decrease on / / Stop PAD deposits PAD arrangements may be terminated on 5-days written notice Stop PAD payment on / / Banking information Account shown on the attached Void Cheque or Bank Confirmation Savings account only: Bank Confirmation Required Please note that we require 5 business days notice to modify or cancel a PAD. AUTHORIZATION (PAD): If this request is to remit a new «VOID» sample cheque, Assumption Life is hereby authorized to make withdrawals from the new account. If two signatures are required on the account, obtain the signatures of the authorized persons. Signature of Bank Account Owner(s) (1) (2) 6. Modification to payments from a retirement income fund (RIF), life income fund (LIF), subject to the minimum and maximum amount prescribed by the applicable provincial pension benefit legislation, and automatic withdrawals from non-registered accounts. Increase current payment RIF LIF Non-registered Increase the deposit to $ Date of increase Decrease current payment RIF LIF Non-registered Decrease the deposit to$ Date of decrease Suspend the current payment RIF LIF Non-registered (The minimum amount of a RIF or LIF must be paid no later than the December 31 of the current year) Date of suspension Modify the frequency of the payment RIF LIF Non-registered to : monthly quarterly semi-annually annually Modify the method of payment RIF LIF Non-registered, to : direct deposit* * Include a void cheque Additional income tax to be withheld from the payment RIF LIF Federal income tax : amount $ or percentage % (all provinces including Quebec) Provincial income tax : amount $ or percentage % (Quebec only) Decrease the income tax withheld from the payment RIF LIF Federal income tax : amount $ or percentage % (all provinces including Quebec) Provincial income tax: amount $ or percentage % (Quebec only) Date of modification Date of modification Date of increase Date of decrease / / / / Decreasing or increasing the amount of income tax is subject to the minimum amount of income tax required by the Income Tax Act (Canada). We require 5 working days written notice for all modifications to a payment that is deposited directly to your bank account and 12 working days written notice for a payment received by cheque. 4920-00A-NOV17 Page 4 of 5
7. Special instructions: I, the undersigned, hereby declare that all the information provided herein is truthfully given to the best of my knowledge and request that Assumption Life make the changes requested. Signature of contributor (for spousal RRSP) Signature of Annuitant Signature of Irrevocable Beneficiary (Required for withdrawals and external transfers) If the owner is a Body Corporate, the authorized persons signature as well as their title and the company name (or seal) is required. Signature of Owner(s) Signature of Witness or Agent Signed at this day of 20 4920-00A-NOV17 Page 5 of 5