4971329106 No. 16.0 June 2013 Pension Provident Preservation Fund application Please complete this fm if you wish to become a member of the Allan Gray Pension Preservation Fund the Allan Gray Provident Preservation Fund. Allan Gray Investment Services Proprietary Limited, an approved Fund administrat and authised administrative financial services provider, is the Administrat. 1. Imptant infmation 1. You will need an investment overview to complete this fm. This is available from your financial adviser the Client Service Centre at 0860 000 654. 2. Based on Exchange Control egulations and the Pension Funds Act, certain unit trusts are subject to availability. Availability can be confirmed with the Client Service Centre. 3. Please complete all relevant sections of this application in der to process this investment. 4. We will require additional documentation from the transferring fund in der to finalise the investment. 5. Please read the Conditions of Membership that apply to this investment. This is available from your financial adviser, the Client Service Centre at www.allangray.co.za 6. Please fax the required documents in the checklist below to the Client Service Centre at 0860 000 655 +27 (0)21 415 2492 email instructions@allangray.co.za 7. The Administrat will only process this application once all required documents have been received and once the money reflects in the relevant Allan Gray Preservation Fund bank account. 8. If you are requesting a unit transfer please ensure that the: - rules of the transferring fund allow this - unit trusts you select and its class are available from Allan Gray at the time of the transfer. If not, you may switch to a unit trust class that is available befe the transfer is completed. Please arrange this with your current fund. Document checklist Completed Pension Provident Preservation Fund application (pages 1-5 of this fm) Where a unit transfer is required, please provide a recent statement of your investment If a representative is acting on behalf of the invest, we need the following: Proof of authity (e.g. power of attney) Copy of South African bar-coded ID valid passpt (if feign national) 2. Invest details Copy of your South African bar-coded ID valid passpt (if feign national) First name(s) Date of birth d d / m m c c y y ID number (Passpt number if feign national) Income tax number / / / esidential address / Country of birth Postal address If the same as above, please tick this box. Business address Page 1 of 7
Telephone (h) Fax Email 0810329104 Secure online access I want secure online access to my investments Yes No If yes, the online account will be activated within two business days after processing this application. If a legal guardian is acting on behalf of the invest, he/she will be given online access to this investment. Communication choice Allan Gray sends two types of communications: 1. Transaction confirmations: Every time we receive an instruction on your account we will send a transaction confirmation containing details of the completed instruction. 2. Quarterly statements and other communications relating to your account. Please indicate how you would like to receive these: Email Post If you have a financial adviser, you may choose to have your communication sent to you, your financial adviser to both. 1. Send transaction confirmations to: Me My financial adviser Both If no selection is made we will send transaction confirmations to both you and your financial adviser. 2. Send my statements and other communications to: Me My financial adviser Both If no selection is made we will send these communications to you only. Please note that your annual benefit statement will be sent to you only. Telephone (w) Please provide your email address if you require online access, if you prefer email communication. Person acting on behalf of the invest Please insert name of legal guardians persons with a power of attney to act on behalf of this invest. First name(s) Date of birth esidential address d d / m m / c c y y elationship ID number (Passpt number if feign national) Cell Telephone (h) Cell Email Please provide your email address if you require online access, if you prefer email communication. Secure online access I want secure online access to this investment Yes No If yes, the online account will be activated within two business days after processing of this application. 3. Contribution details Will this be a unit transfer? Yes No This is subject to the rules of the transferring fund. The minimum lump sum contribution is 50 000 per account. 1. A transfer from another pension / provident preservation fund 2. A transfer from an employer fund Please complete last date of employment (if transfer is due to termination of employment, merger takeover) d d / m m / c c y y 3. A transfer due to pension interest in a divce der Estimated transfer contribution Transferring fund details egistered name egistration number Telephone (w) Policy number Page 2 of 7
7591329107 Investment allocation The selected combination of unit trusts must be egulation 28 compliant. Many of the unit trusts that members can select already comply with this requirement. Please see the latest Allan Gray Investment Platfm fund list to confirm your selection of unit trusts and which class and fee structure applies. What is egulation 28? These are the guidelines that set, amongst other things, the maximum exposures that retirement fund savings may have to various asset classes, f example: 75 in equities, 25 in property and 25 in feign assets. How to check if your investment is egulation 28 compliant After submitting this instruction an administrat will contact you if your investment is not compliant. Alternatively, please find the egulation 28 calculat on www.allangray.co.za contact your financial adviser, our Client Service Centre on 0860 000 654 email us at info@allangray.co.za to confirm whether your selection is compliant. Unit trust name Unit trust class Lump sum contribution 1 0 0 You may phase-in your lump sum contribution. The amount to be phased in must be 50 000 me. Do you require a phase-in? Yes No If yes, please attach a completed 'Phase-in instruction' to this application. If you select a unit trust with a fixed financial adviser fee, please complete the 'Fixed financial adviser fee' fm. These fms are available from your financial adviser, the Client Service Centre at www.allangray.co.za Preferred fee unit trust You may choose to have your annual administration and annual financial adviser fees deducted from your Allan Gray Money Market Fund. This will be known as your preferred fee unit trust. Do you require a preferred fee unit trust? Yes No If the preferred fee unit trust does not have sufficient funds to pay fees, the Administrat will: 1. Deduct fees from the unit trust(s) where the fees have accrued, 2. If there is an insufficient balance in that unit trust the Administrat will deduct fees proptionately from the remaining unit trusts with balances. 4. Details of dependants If there are me dependants, please attach a signed copy of this section to the application fm. Please refer to the 'Nominate Beneficiaries' section in the Conditions of Membership f me infmation. and amount spent on dependant per month elationship Page 3 of 7
4418329102 and amount spent on dependant per month elationship and amount spent on dependant per month elationship and amount spent on dependant per month elationship 5. Beneficiary nominations You may nominate beneficiaries to receive the benefit on your death. Legislation requires the Trustees to use their discretion when allocating a death benefit. Please refer to the Conditions of Membership f me detail. You need to change this as necessary when your circumstances change. If you are already a Member of the Pension Provident Preservation Fund, this nomination will apply to all your investment accounts related to that Fund. Please attach a letter of explanation to this application fm if there are any special facts that you would like the Trustees of the Fund to take into account. If there are me beneficiaries, please attach a signed copy of this section to the application fm. Total number of beneficiaries elationship Benefit ID number (Passpt number if feign national) elationship Benefit ID number (Passpt number if feign national) elationship Benefit ID number (Passpt number if feign national) Page 4 of 7
4783329107 If you wish to nominate a trust other legal entity please complete the details below: Name egistration Master's reference number Benefit Name egistration Master's reference number Benefit Name egistration Master's reference number Benefit 6. The Funds' details Allan Gray Pension Preservation Fund Allan Gray Provident Preservation Fund FSB registration number 12/8/37184/ 12/8/37185/ SAS number 18/20/4/41344 18/20/4/41565 Bank account details Cheque deposits, electronic transfers and internet transfers should be made in favour of 'Allan Gray Pension Preservation Fund' 'Allan Gray Provident Preservation Fund', whichever is applicable. Please use the invest name as a reference to make it easy f the Administrat to identify your money. Account name: Allan Gray Pension Preservation Fund Allan Gray Provident Preservation Fund Bank: First National Bank First National Bank Branch: Global Transactional Services Cape Town Global Transactional Services Cape Town Branch code: 20-41-09 20-41-09 Account type: Current Current Account number: 620 463 424 08 620 463 428 96 7. Financial adviser details Full name and surname Practice name (FSP) Allan Gray adviser code Adviser assistant dealing with this transaction I confirm that this financial adviser, as authised representative of the FSP above, is my appointed financial adviser. Negotiable financial adviser fees I agree to the following negotiated fees on this and all future transactions unless otherwise specified: Please specify the percentage (excluding VAT). Initial. Maximum 3.0 (excluding VAT) deducted pri to the investment being made. If it is agreed that no initial fee is payable, please insert 0. Where the annual fees are me than 0.5, initial fees are capped at 1.5. Annual. Maximum 1.0 (excluding VAT) of the investment account. Where the initial fee is me than 1.5, the maximum annual fee is 0.5. If no annual fee is payable, please insert 0. Discretionary mandate declaration This section is only applicable if the FSP above holds a 'Categy II' license with the FSB and is therefe an approved discretionary FSP. I confirm that I have entered into a mandate with the above approved discretionary FSP. Yes No I agree and understand that in terms of the mandate the FSP may give Allan Gray investment instructions directly and I authise Allan Gray to accept all instructions submitted by the FSP on my behalf. Signature of invest Date d d / m m / c c y y Financial adviser FAIS declaration 1. I have made the disclosures required, in terms of the Financial Advisy and Intermediary Services Act 37 of 2002, to the invest. 2. I have explained all fees that relate to this investment to the invest. I understand and accept that the invest may instruct the Administrat to cancel my fees at any time. Signature of financial adviser Date d d / m m / c c y y Page 5 of 7
1213329102 8. Invest declaration 1. I confirm that all infmation provided in this fm and all other documents signed by me in connection with this application, whether in my handwriting not, is crect. 2. I am responsible f the accuracy and completeness of all answers, statements other infmation provided by me on my behalf. 3. I have not received advice from the Administrat in respect of this application. 4. I confirm that the Administrat may accept instructions from my financial adviser any authised third party who has been appointed and authised by me in writing. 5. I confirm that the Administrat may accept instructions in the prescribed fmat by facsimile via other electronic means. 6. I confirm that my appointed financial adviser will have access to my investment details via the secure section of the Allan Gray website via a secure electronic channel at my adviser's request. 7. I have read and understood the investment overview. The version number is compulsy f the application to be processed. Investment overview version number 8. I have read, understood and agree to the Conditions of Membership. Signature of invest Date d d / m m / c c y y Page 6 of 7 Allan Gray Proprietary Limited is an authised financial services provider.
0475329101 Pension Provident Preservation Fund - Employee and Fund details A representative of the Employer the Administrat of the transferring fund must complete this section of the fm. 1. Employee details First 2. Transferring fund details egistered name of transferring fund FSB registration number Date of withdrawal from transferring fund d d / m m / c c y y Date of the merger take-over, if applicable d d / m m / c c y y Start of pensionable service date d d / m m / c c y y If any service was perfmed outside the SA, please state periods and territy of such service From To d d / m m / c c y y d d / m m / c c y y d d / m m / c c y y d d / m m / c c y y Territy Amount to be transferred Member's contributions to the fund which were not previously tax deductable Transferring fund restrictions (if applicable) 3. Withdrawal benefit Has the member's benefit been decreased at transfer by any of the following: Divce der Section 37D of Pension Funds Act Transfer to etirement Annuity Fund Signature Who warrants that he / she is authised to act on behalf of the fund. Full name and surname epresentative capacity Date d d / m m / c c y y Page 7 of 7