ADDING OR AMENDING CONTRIBUTIONS ON YOUR INITIAL PRICE PERSONAL PENSION (PP5)

Financial adviser stamp ADDING OR AMENDING CONTRIBUTIONS ON YOUR INITIAL PRICE PERSONAL PENSION (PP5) Financial adviser agency number Please enter your business postcode Are you enclosing a cheque with this application? Yes No This application contains technical and legal terms with which you may not be familiar. You should therefore complete it with the help of your financial adviser. This form is used to make a single payment, or to start/amend the amount of regular contributions to an Initial Price Personal Pension (PP5). There is a separate form for making transfers in from other pension arrangements. The guidance overleaf will help you understand which sections of this application form you need to complete. Please use BLOCK CAPITALS only and blue or black ink. Please ensure any amendments or corrections are initialled by the applicant. All references to Old Mutual Wealth in this application mean Old Mutual Wealth Life Assurance Limited. Please answer the following question. Failure to do so will delay your application. Have you been given advice about this application by your financial adviser? Yes No Please enter the number of the plan you wish to make/amend contributions to: Plan Number P P 5 0

Is your existing plan on an Adviser Charging basis? No Yes Your account will remain on an Adviser Charging basis. Please complete section F (Part 2) to confirm any ongoing fees and ignore section F (Part 1). Have you received advice from your financial adviser for this transaction? No Yes No Do you wish for Old Mutual Wealth to continue the payment of commission to your financial adviser from your plan? Yes Your plan will not be affected and any commission will continue at the rate previously requested. If you wish, you can select a rate of initial commission to apply to your additional single contribution or increase to regular contributions. This top-up application will convert your plan to Adviser Charging. This means that you can select to add an Adviser s fund-based fee to your plan, and any existing commission being paid to your financial adviser will cease. Your plan will not be affected and any existing commission will be paid as previously specified. If you have previously requested an Adviser s fundbased fee, this will be removed from your plan. Please note that no commission will be payable to your financial adviser in respect of this contribution. Please complete section F (Part 1) to select a different rate of commission and ignore section F (Part 2). Please complete this form ignoring section F (Part 1)*. Please complete this form ignoring section F (Part 1) and confirm this decision within section F (Part 2). * Once your plan converts to Adviser Charging, this cannot be reversed. 2

A YOUR PERSONAL DETAILS If you are under 16 or between 16 and 18 and not in employment, this application must be completed by your legal guardian. Member s Name Contact number E-mail address Legal guardian s name Permanent residential address (only complete this if your address has changed) Postcode B MAKING A SINGLE CONTRIBUTION Complete this section if you are making a single contribution to your plan Single contribution Gross Net* Employer** Personal including third-party payments other than those from your employer* (payable net of basic rate income tax) Total Minimum single contribution contributions 500 gross. Please note: If this is the first contribution to the policy (other than transfer payments or contracting-out rebates), the first pension input period will automatically end on the first 5 April which follows payment of the first contribution. Payments must be made by BACS or Cheque. All cheques must be made payable to Old Mutual Wealth Life Assurance. If payments are being paid by a third party by cheque, please complete the third party payer details in section E. * The net contribution must be based on current basic rate income tax applicable to the year in which the contribution is received. This net amount may vary in future, if basic rate income tax is altered. ** All employer s contributions are payable gross. Where employer s contributions are being made, or where your employer is acting as a co-ordinator for the payment of contributions, your employer must complete section H. 3

C STARTING OR AMENDING REGULAR CONTRIBUTIONS Total regular contribution Gross Net* Employer** Personal including third-party payments other than those from your employer* (payable net of basic rate income tax) Total Minimum 100 gross each month, 1,000 gross each year. If you wish to amend the amount of your regular contribution please enter the total amount you wish to pay each month/year. Frequency of regular contributions Monthly Yearly The regular contribution start date or the start date for the amended regular contribution will be the first of the month following receipt of the application for direct debit payments. If you require contributions to commence in a later month, please specify the date you require. Please note that the date cannot be backdated. I require regular contributions to commence or be amended from (dd/mm/yyyy) 0 1 2 0 If you are paying regular contributions for the first time, do you wish any regular contributions you have chosen to be increased automatically at each annual review? Please note, the increase in contributions will normally be the greater of 10% or the rate of inflation. Yes No How will the first regular contribution be paid? Cheque = Direct debit == We will collect all regular contributions using one direct debit instruction. If you are an employee and your employer is paying any part of the contributions, the direct debit must be drawn on your employer s bank account. Your employer will be responsible for collecting your personal contributions. Please note you could be liable for tax if contributions are funded from a tax-free cash sum received from a registered pension scheme. Old Mutual Wealth will allocate the gross personal contribution and reclaim the basic rate income tax from HM Revenue & Customs. Please note: If this is the first contribution to the policy (other than transfer payments or contracting-out rebates), the first pension input period will automatically end on the first 5 April which follows payment of the first contribution. * The net contribution must be based on current basic rate income tax applicable to the year in which the contribution is received. This net amount may vary in future, if basic rate income tax is altered. ** All employer s contributions are payable gross. Where employer s contributions are being made, or where your employer is acting as a co-ordinator for the payment of contributions, your employer must complete section H and the following Direct Debit Mandate. = All cheques must be made payable to Old Mutual Wealth Life Assurance. If yearly payments are being paid by a third party by cheque, please complete the third party payer details in section E. == Payments will normally be collected on the first working day of each month. 4

Instruction to your bank or building society to pay by Direct Debit. Please complete the form and send to: Old Mutual Wealth Life Assurance Limited, Old Mutual House, Portland Terrace, Southampton SO14 7AY. Name and full postal address of bank/building society Service user number 9 9 5 3 0 1 Reference To: The Manager B Address bank/building society Postcode Instruction to your bank or building society Please pay Old Mutual Wealth Life Assurance Limited Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Old Mutual Wealth Life Assurance Limited and, if so, details will be passed electronically to my bank/building society. Name(s) of accountholder(s) Signature(s) Date / / / / Bank/building society account number Branch sort code - - Banks and building societies may not accept Direct Debit Instructions for some types of account. If your regular contributions are not paid by you or your employer, please complete the payer details below. FOR OFFICIAL USE ONLY This is not part of the instruction to your bank or building society and must be detached by Old Mutual Wealth Life Assurance Limited before submission to the paying bank Where the payer is not the policyholder or their employer, please provide the full name, date of birth, address and telephone number of the payer. The payer s personal information may be made available to a third party by electronic or other means for the purpose of verifying identity in accordance with Money Laundering Regulations. In some circumstances the policyholder may be the only person permitted to pay contributions. Please contact Old Mutual Wealth if you have any queries with this. Full forename(s) Address Surname Date of birth Telephone number Postcode This Guarantee should be detached and retained by the payer. The Direct Debit Guarantee. This Guarantee is offered by all banks and building societies that accept Instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit Old Mutual Wealth Life Assurance Limited will notify you five working days in advance of your account being debited or as otherwise agreed. If you request Old Mutual Wealth Life Assurance Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit, by Old Mutual Wealth Life Assurance Limited or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when Old Mutual Wealth Life Assurance Limited asks you to. You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. 5

Old Mutual Wealth Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number 1363932. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number 110462. VAT number 386 1301 59. When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF8819/218-0058/January 2018 Old Mutual Wealth Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number 1363932. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number 110462. VAT number 386 1301 59. When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF8819/218-0058/January 2018 Old Mutual Wealth Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number 1363932. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number 110462. VAT number 386 1301 59. When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF8819/218-0058/January 2018 6

D FUND CHOICE Please state your fund choice below. Amended regular contributions If your fund choice for the amended contribution is the same as your current regular contribution fund choice, tick here* OR Complete the table below to select different fund(s) for your amended contributions Now go to section E Single/New regular contributions Complete the table below to select fund(s) for your single/regular contributions NOTE If your fund choice is incomplete or otherwise invalid, we will allocate part or all of the investment as appropriate to the OMW Deposit Fund. We are not authorised to provide advice; your financial adviser will be able to help you choose the funds most suitable for you. You can choose up to 99 funds if there is insufficient space for you to list all of your chosen funds below, continue on a separate sheet and attach it to this application. Any Portfolio Rebalancing currently in place will be cancelled as a result of this application; we will need a new Portfolio Rebalancing instruction if you want this service to continue. Fund manager Full fund name Whole % Total 100% If you require more space for your fund choice, please use the investment instruction continuation sheet and attach it to this application. Old Mutual Wealth offers a Phased Investment and Portfolio Rebalancing Service. Full details of these are available from your financial adviser. Please note that any Portfolio Rebalancing currently in place will be cancelled as a result of this application. If you want this service to continue you must complete a new portfolio rebalancing instruction. E THIRD-PARTY PAYER DETAILS Please complete this section where a third party other than your employer is making payments by cheque on your behalf. If you or your employer are not the payer, please provide the full name, date of birth, address and telephone number of the payer. The payer s personal information may be made available to a third party by electronic or other means for the purpose of verifying identity in accordance with Money Laundering Regulations. In some circumstances the policyholder may be the only person permitted to pay contributions. Please contact Old Mutual Wealth if you have any queries with this. Title (3) Full forename(s) Mr Mrs Miss Other Surname Address Date of birth (dd/mm/yyyy) Telephone number Postcode 7

F ADVISER CHARGING/COMMISSION Complete this section to confirm the fees payable to your financial adviser. If you are unsure which parts of this section apply to you, please refer to the guidance on page 2 to help you understand which sections of this application form you need to complete. Please note that Old Mutual Wealth does not pay remuneration to financial advisers for plans opened in their own names. Financial advisers should refer to our Terms of Business with them for further information. PART 1: COMMISSION PAYABLE FOR TRANSACTIONS WITHOUT FINANCIAL ADVICE If your plan has converted to Adviser Charging, please do not complete this section and instead complete Part 2. If you are unsure whether your plan is on an Adviser Charging basis, please contact your financial adviser or call our Customer Contact Centre on 0808 171 2600. If you do not complete this section, any existing ongoing commission will continue at the rate previously requested. If you wish to apply a different rate of initial commission to an additional single contribution or increase to regular contributions, please enter it below. OPTION 1: COMMISSION ON REGULAR CONTRIBUTIONS Where regular contributions are being added for the first time you can select FROM ANY one of the options below. Where regular contributions are being increased and you selected the level initial commission option (option A or B) at outset, you cannot select a different option. Where regular contributions are being increased and the plan was set up on either an indemnified or non-indemnified initial commission basis you can select FROM OPTIONS C AND D along with the level of commission required on the increase if this is different to that selected at outset. The rate selected below will only apply to the increase. Commission on any existing contribution will continue to be paid on the basis previously selected. Please complete ONE option only. 3 Option A Maximum level initial commission of 3.80% (no fund based commission) If you do not require maximum initial commission, please enter the rate or amount you require. If you would like no commission to be paid to your financial adviser for this transaction, please enter 0% or 0 below.. % or Option B Maximum level initial commission of 2.25% plus 0.50% a year fund based commission. % or Option C Maximum indemnified initial commission of 8.00% of each monthly contribution paid during the initial period. % or Option D Maximum non-indemnified initial commission of 8.00% of each monthly contribution paid during the initial period. % or OPTION 2: COMMISSION ON SINGLE CONTRIBUTIONS Please complete ONE option only. 3 Option 1 Maximum initial commission of 4.00% (no fund based commission) If you do not require maximum initial commission, please enter the rate or amount you require. If you would like no commission to be paid to your financial adviser for this transaction, please enter 0% or 0 below.. % or Option 2 Maximum initial commission of 3.10% plus 0.25% a year fund based commission. % or Option 3 Maximum initial commission of 2.25% plus 0.50% a year fund based commission. % or OPTION 3: FUND-BASED FEE Please complete the below to reduce the rate of the fund-based fee. The percentage you enter here will override any existing rate on your plan. It is not possible to add or increase the rate of fund-based fee unless the plan converts to Adviser Charging. Fund-based fee. % of the plan value each year 8

F ADVISER CHARGING/COMMISSION (CONTINUED) PART 2: FEES PAYABLE FOR TRANSACTIONS WITH FINANCIAL ADVICE Please choose one of the following options: Option 1 (tick if required) Your plan is not currently on an Adviser Charging basis and Old Mutual Wealth should continue to facilitate the payment of commission to your financial adviser from your plan as per any existing instructions, but no commission will be paid in respect of this transaction. Please note that any existing fund-based fee will be removed from your plan. If you tick this option, you do not need to complete the section below and you should continue to section G. Option 2 Your plan is on or you would like to convert your plan to an Adviser Charging basis. (tick if required) Please complete this section to give authorisation for Old Mutual Wealth to pay a fund-based fee that you have agreed with your financial adviser from your pension. Please note that this will stop any current commission payments to your financial adviser from your plan. If you do not complete this section, Old Mutual Wealth will not make any payments of fees to your financial adviser and any existing fees will be removed from your plan. Please complete and sign below to confirm the rate of the fund-based fee. Fund-based fee This fee applies to the plan as a whole and is levied by the ongoing deduction of units from the plan.. % of the plan value each year I authorise Old Mutual Wealth to deduct any the fund-based fee detailed above from my plan and pay it to my financial adviser. (a) I understand that: (i) the fee agreed will be met by deduction of units from the investments in my pension (ii) the amount of the agreed fee is assumed to include VAT (at the rate prevailing when the fee is due), if applicable. (b) I confirm that: (i) I have completed and agreed this section with my financial adviser (ii) my financial adviser has explained the effect that selling units from my pension will have on its future value (iii) any fees agreed under Adviser Charging on this application are solely in relation to advice and/or services I have received or will be receiving on this plan only and do not relate to any other advice or services provided. (c) I understand that: (i) I can amend the Fund-based fee by giving at least 10 working days notice before it is deducted (ii) I cannot cancel a fee once it has been deducted from my plan, instead I would need to contact my financial adviser to discuss whether a refund is payable in full or in part. Name Signature Date 2 0 9

G DECLARATION, APPLICATION AND PERSONAL DATA STATEMENT You must complete this section. Any omission or misstatement of a material fact in this application form could affect the payment of benefits under the arrangements comprising the Personal Pension. A material fact is one which is likely to influence the assessment and acceptance of this application. If you are uncertain whether a fact is material, you should give full details so that we can assess its possible significance. If you become aware of such a fact while we are considering your application, you should notify us immediately. Declaration I request that the changes detailed in this application are made to my existing plan. a) I declare that to the best of my knowledge and belief the statements made in this application and declaration and any related documents are correct and complete and that I have not concealed any material fact. b) I declare that the total contributions paid by me or on my behalf to any registered pension scheme on which I am entitled to tax relief do not exceed the higher of the basic amount ( 3,600) or my relevant UK earnings for the tax year. c) I agree to supply information relevant to the Personal Pension as shall be required by Old Mutual Wealth from time to time. d) I undertake to notify the Scheme Administrator immediately if the total contributions paid by me or on my behalf to any UK-registered pension scheme on which I am entitled to tax relief do exceed the higher of the basic amount ( 3,600) or my relevant UK earnings for the tax year or if I cease to be entitled to relief at source on my contributions. I will give notice of this by the later of: i) 5 April in the year of assessment in which the event occurs; and ii) the date which is 30 days after the occurrence of that event. e) I declare that contributions made to the Plan have not been and will not be funded from a tax-free cash sum from a registered pension scheme to the extent that neither myself nor Old Mutual Wealth will suffer a tax liability. f) I declare that any person paying contributions as a third party has been made aware and accepts that they have no claim to benefits arising from my membership of this pension scheme. g) If Portfolio Rebalancing applies to my plan, I understand that: i) my instructions will automatically be cancelled as a result of this application. ii) a new set of Portfolio Rebalancing instructions will be required should I wish to reinstate the instructions. Legal guardian declaration a) I understand the contributions paid to the plan may only be returned to the member in the form of benefits payable under the rules of the personal pension scheme (after age 55 except in the case of earlier incapacity). b) I declare that I am responsible for the plan until the member reaches 18. c) I declare that I will be responsible for ensuring that contribution limits in respect of the minor are not exceeded. d) I agree to advise Old Mutual Wealth of the national insurance number of the minor when they reach age 16. continued 10

G DECLARATION, APPLICATION AND PERSONAL DATA STATEMENT (CONTINUED) Personal Data Statement consent by Applicant I agree that you may keep and use my personal data to process my application and to service my plan. I confirm that the beneficiary/each beneficiary and/or my spouse or civil partner or dependant referred to in this application (or parent where parental consent is required if a beneficiary is a dependant) consents and agrees to my acting as their agent for the purposes of the personal data provided within the application being returned to you for the administration of my plan. I understand that you may provide my personal data, by electronic or other means, to: other companies within the Old Mutual plc group of companies if you regard this as necessary to service my plan my financial adviser including via a secure restricted access internet service my employer/trustee/administrators of the scheme (where applicable) a third party to verify my identity in line with money laundering or other requirements re-insurers and other third parties who perform tasks for you to help you to service my plan. These third parties may be based in countries outside the EEA. These countries may not have laws to protect data equivalent to those in the UK. However, you will ensure that any such third parties agree to treat my data with the same level of protection as if you were dealing with it. investigate or prevent fraud. I understand that to prevent and detect fraud you may: share my personal data with other organisations including the police check and/or file my personal data with fraud prevention agencies and databases and if I give you false or inaccurate information and you suspect fraud you will record this. I understand that the Old Mutual plc group of companies may use my data for assessment and statistical analysis purposes and without identifying me make results available to third parties. I understand that my personal data may be made available to third parties where required by law, court order or regulation. I understand that on payment of a small fee I am entitled to receive a copy of the personal data that you hold on me and that I have the right to require you to correct any inaccuracies. THIS FORM ACTS AS AN APPLICATION FOR TAX RELIEF AT SOURCE ON YOUR CONTRIBUTIONS. IT IS THEREFORE A SERIOUS OFFENCE TO MAKE A FALSE STATEMENT. THE PENALTIES ARE SEVERE AND COULD LEAD TO PROSECUTION. I confirm that I have received a Key Features Document and my financial adviser has explained the basis of their remuneration, where relevant. Signature of applicant (if 16 or over) Signature of Legal Guardian (if applicant under 18. This will be in addition to the applicant s signature where the Applicant is 16 or over, but under 18) Date (dd/mm/yyyy) 2 0 PLEASE ATTACH YOUR CHEQUE FOR THE AMENDED REGULAR CONTRIBUTION (IF APPLICABLE) AND/OR ANY SINGLE CONTRIBUTION. The Scheme Administrator undertakes on behalf of Old Mutual Wealth Life Assurance Limited to administer the Scheme in accordance with the Rules. A copy of this completed application form and the Member s Guide are available on request. 11

H EMPLOYER S SECTION This section should be completed by the employer where the employer is making contributions (employer and/or personal) to Old Mutual Wealth for the applicant s Personal Pension. The applicant s Personal Pension is a contract between Old Mutual Wealth and the employee, although either the employer, the employee, or both can contribute. All employer contributions must be paid gross. Employee personal contributions are based on a gross contribution which is payable net of basic rate income tax. The employer deducts these contributions from the employee s salary after tax. The net contribution will change if the basic rate of income tax changes. Please note that we require only one direct debit instruction for payments (not one for the employer and one for the employee). Please complete the direct debit instruction included within this application. Employer and personal contributions will be collected from the same bank account using this instruction. It is imperative that the Group Co-ordinator named below advises Old Mutual Wealth within 30 days if the member wishes to amend or discontinue payments or leaves the employer s service. If you fail to complete this section we are unable to monitor payments in accordance with the Pensions Act 2004, and you may be reported to The Pensions Regulator (TPR). Group Co-ordinator Person dealing with correspondence Correspondence address Postcode E-mail address Telephone number Please provide the information below. Pay day (dd/mm/yyyy) Contributions due: Employer 2 0 The pay day is the date of your payroll. Regular contribution Gross Net* Employee Total REGULAR contribution** Due date for regular contributions (dd/mm/yyyy) each month each year 1 9 2 0 The due date will always be the 19th of the month following the month in which the deductions were made from payroll. Please note, this is the final due date under The Pensions Regulator (TPR) requirements. The date by which Old Mutual Wealth must receive the payment is the 1st of each month. Contributions due: Employer Single contribution Gross Net* Employee * Net equivalent based on current basic rate income tax. Total SINGLE contribution** ** The total contribution should equal the total of any GROSS employer contribution and any NET employee contribution. For regular contributions this will be the amount of subsequent payment requests. If the amount of basic rate income tax is changed in the future we will vary the amount requested. continued 12

H EMPLOYER S SECTION (CONTINUED) Full name of employer Type of entity (Corporate, trust, etc) Registered office Postcode Registered number (If appropriate) Relevant company registry or regulated market listing authority ( Relevant company registry includes other registers, such as those maintained by charity commissions (or equivalent) or chambers of commerce) Names of directors (Or equivalent for private companies only) Names of principal beneficial owners (Over 25% for private companies only) Employer s declaration 1. We declare that to the best of our knowledge and belief the statements made in this section and any related documents are correct and complete and that we have not concealed any material fact. 2. We agree to pay to Old Mutual Wealth all regular contributions by or for the Member. 3. We confirm that the Member s personal net contributions shall be deducted from their net pay. 4. We understand that, although we can contribute to the Member s benefits, the contracts exist between the Member and Old Mutual Wealth and that, with the exception of 5. and 6. below, correspondence will take place between the Member and Old Mutual Wealth direct. 5. We understand that we will be responsible for dealing and corresponding with Old Mutual Wealth regarding the payment or non-payment of contributions by or on behalf of the Member. 6. We undertake to advise Old Mutual Wealth within 30 days of the Member ceasing to be employed by us or where contributions are reduced or terminated. 7. We undertake to operate the Personal Pension in accordance with Old Mutual Wealth s published requirements and we agree to supply relevant information in respect of the Member which Old Mutual Wealth may require from time to time. 8. We understand that if any payment due is not received by Old Mutual Wealth within 90 days of the due date or where Old Mutual Wealth feels that non-payment is of material significance, you may be required to advise The Pensions Regulator (TPR) and the Member. 9. We understand that it is our responsibility to ensure Old Mutual Wealth is provided with relevant information to monitor payments and that should we fail to provide it we will be reported to The Pensions Regulator. 10.We confirm that all Members have provided consent for us to include their personal information within the Schedules to be provided to Old Mutual Wealth from time to time. 11.We understand you may make our personal information available to a third party by electronic or other means for the purpose of verifying identity in accordance with the Money Laundering Regulations. Signed for and on behalf of the Employer Name Capacity (Authorised Official) Date (dd/mm/yyyy) 2 0 13

I CONFIRMATION OF VERIFICATION OF IDENTITY - TO BE COMPLETED BY YOUR FINANCIAL ADVISER Please complete this section to verify the identity of all relevant parties referred to in this application. I/We confirm that: (a) the information in this form was obtained by me/us in relation to the relevant parties (b) the evidence I/we have obtained to verify the identity of the relevant parties meets the standard of evidence set out within the guidance for the UK Financial Sector issued by the Joint Money Laundering Steering Group (c) I have not verified the identity of the following parties because they are exempt from verification under Money Laundering Regulations (d) The following parties were existing client(s) of mine/ours prior to the introduction of the requirement for identity verification Signed* Name Date (dd/mm/yyyy) 2 0 Position Full name of regulated firm (or sole trader) FS registered number * This must be signed by the person who has seen the original documentary evidence, which may include an electronic identity check. www.oldmutualwealth.co.uk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number 1363932. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number 110462. VAT number 386 1301 59. When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF8819/218-0058/January 2018 14