Application for a collective

*APIPC0700F* Application for a collective investment BOND (CIB) Individual or joint applicants With this form you can: invest in a new CIB top up an existing CIB. Did you know? Your financial adviser can apply for you online in which case we do not require a paper application as well because we will only use the information submitted online. This form cannot be used for: our Managed Portfolio Service (MPS) this service is only available online through financial advisers to investors on Charge Basis 3. For new or top-up investments into the MPS, please speak to your financial adviser. corporate, trust or pension scheme applicants, for which there is a separate form, available from your financial adviser.! IMPORTANT DOCUMENTS YOU NEED TO HAVE RECEIVED BEFORE PROCEDING You need to have received several important documents about this product and the funds you choose, before you send us your application to invest in, or top up, a CIB. More information about these documents is in section 1. This application contains 11 pages. The supplementary sections included at the back only need to be completed where relevant, they are: Section 13 Third party payer details Section 14 Power of Attorney TAX INFORMATION Under Exchange of Information regulations we are required to obtain various details of our investors, including where they were born, their nationalities, countries of tax residence* and related tax identification numbers** - section 2 of this form is where you can provide this information. We also need to obtain `a self-certification that the information provided is true and complete - this is contained in the declaration in section 11. We may have to provide this information to HMRC who may share it with overseas tax authorities. We may contact you for further information if required. *Country of tax residence Normally you are resident for taxation in the country in which you spend the majority of your time each year. However, some countries (eg the United States) may also treat an individual as resident for taxation based on their nationality or citizenship. As tax residence is determined by the country in which tax is paid, it is possible to be tax resident in more than one country. **Tax identification number (TIN) If your country of tax residence is the UK or the Isle of Man your TIN is your National Insurance number. If it is Guernsey, Jersey or Gibraltar it is your Social Security Number. If you are a US national/tax resident it is your US Tax Identification Number. For help to work out where you are tax resident, or if you are unsure about your TIN, please consult a financial adviser or the information at www.oecd.org/tax/automatic-exchange. If you are unsure what information to include, please consult a financial adviser. Page 1 of 11

Charge Basis Information New bonds - will be on Charge Basis 3. Top-ups - you need to know which Charge Basis applies to your bond because this will determine the sections you need to complete, the investment range available and what happens if you top up. If you are unsure of your current Charge Basis, please contact your financial adviser or call our Customer Contact Centre on 0808 171 2626. Charge Basis 1 Charge Basis 2 Charge Basis 3 This applies to bonds that are subject to the Investor Charge and on which financial advisers are entitled to receive commission. On Charge Basis 1 you can only invest in our SelfSelect investment range. This applies to bonds that are subject to the Investor Charge and Adviser Charging, where financial advisers are paid by fees rather than commission. On Charge Basis 2 you can only invest in our SelfSelect investment range. This applies to bonds that are subject to the Old Mutual Wealth Product Charge and Adviser Charging, where financial advisers are paid by fees rather than commission. On Charge Basis 3 you can invest: in our SelfSelect investment range in our WealthSelect investment range using our Managed Portfolio Service (MPS). Bonds opened before 18 December 2012, which have not been converted to Charge Basis 2 either by request or automatically.* These are bonds that have been converted from Charge Basis 1, either by request or automatically.* These are bonds opened from 18 December 2012. * The Terms and Conditions outline which transactions automatically convert bonds to Charge Basis 2; your financial adviser will be able to advise you if your bond has been converted. Is your application for a new bond? Yes NO Your new bond will be opened on Charge Basis 3. Please ignore section 8. Which Charge Basis is your BOND currently on? Charge Basis 1 Charge Basis 2 Your bond will remain on Charge Basis 2. Please ignore section 8. Charge Basis 3 Your bond will remain on Charge Basis 3. Please ignore section 8. Have you received advice from your financial adviser for this application? Yes NO Do you wish to remain on Charge Basis 1 or convert to Charge Basis 2? This top-up application will convert your bond to Charge Basis 2.** Charge Basis 1 To remain on Charge Basis 1, please ignore section 8. Charge Basis 2 To convert to Charge Basis 2, please complete section 8.** ** Once you convert to Charge Basis 2, you cannot revert to Charge Basis 1. Page 2 of 11

Please tick/complete this form, as applicable, using BLOCK CAPITALS and blue or black ink. ucomplete the form carefully; errors or omissions by you or your financial adviser will not be corrected retrospectively 1 FINANCIAL ADVICE We only accept business for investors who have received financial advice. This is because financial advisers can recommend investments that are most suitable for investors financial circumstances. Old Mutual Wealth cannot provide such advice. However, in exceptional circumstances we can accept top-up applications on an execution only (without advice) basis, provided we ensure you have been given appropriate information and you complete some additional paperwork, see 1.2. Tick 1.1 or 1.2 as applicable 1.1 I have received financial advice in respect of this application On what basis was the advice given? (your financial adviser will help you answer this) Restricted Independent IMPORTANT DOCUMENTS YOU NEED TO HAVE RECEIVED BEFORE APPLYING Your financial adviser will have provided you with the following: A Key Features Document and Terms & Conditions for the Collective Investment Bond A Key Information Document (KID) about the Collective Investment Bond Information, including rebates, about the funds chosen for your investment In section 11, the declaration you sign will include your confirmation that you have received and read these documents. Key Investor Information Documents (KIIDs) or Key Information Documents (KIDs) are also produced by fund managers and provide important information about their funds. We strongly recommend reading these documents to assist you in making an informed investment decision. 1.2 I have NOT received financial advice in respect of this application this section applies to top-ups only; if you are opening a new Collective Investment Bond you must do so through a financial adviser. Please contact us on 0808 171 2626 or by email at ask@omwealth.com. We can then: assess whether we can accept your top-up application on an execution only basis explain the restrictions when investing without financial advice tell you which documents you need to have read before you send us your top-up application provide you with the additional Execution Only Form you will need to sign and attach to your application. tick here, if you have already contacted us, and your signed Execution Only Form is attached to this application. Page 3 of 11

2 YOUR Details Type of investment New bond Top up into this bond number First applicant s details Client reference number, if known Title Mr Mrs Miss Other (please specify) Surname (dd/mm/yyyy) Permanent UK residential address Town/City of birth Gender Male Female Country of birth Postcode Correspondence address (if different from residential address) Telephone number (in case of query) E-mail address Postcode Nationality(ies) Country(ies) of tax residence Tax identification number(s) (TIN) Reason for no TIN (if applicable) Joint applicant details (if applicable) Client reference number, if known Title Mr Mrs Miss Other (please specify) Surname (dd/mm/yyyy) Permanent UK residential address Town/City of birth Gender Male Female Country of birth Postcode Correspondence address (if different from residential address) Contact telephone number (in case of query) E-mail address Postcode Nationality(ies) Country(ies) of tax residence Tax identification number(s) (TIN) Reason for no TIN (if applicable) Page 4 of 11

3 LIFE/LIVES ASSURED NOTE Once the bond is live, if it to be assigned into a Discounted Gift Trust or Lifestyle Trust at a later date, neither the Settlor nor the Settlor s spouse/civil partner (as defined under the Civil Partnership Act 2004) should be included as lives assured. This is because under the Finance Act 1986, Paragraph 7, Schedule 20, a Gift with Reservation may arise where the Settlor and/or Settlor s spouse/civil partner are included as lives assured. Where the applicants detailed within section 2 are the lives assured on this bond please tick here: First applicant Joint applicant Both applicants For any other lives assured please complete the details below. u please provide the same information for any additional lives assured by using a copy(ies) of this page. First life assured Title Mr Mrs Miss Other (please specify) Surname (dd mm yyyy) Relationship to the applicant Gender Male Female Second life assured (if applicable) Title Mr Mrs Miss Other (please specify) Surname (dd mm yyyy) Relationship to the applicant Gender Male Female Third life assured (if applicable) Title Mr Mrs Miss Other (please specify) Surname (dd mm yyyy) Relationship to the applicant Gender Male Female 4 INVESTMENT DETAILS CIB investment amount Select payment method Cheque number please enclose cheque payable to Old Mutual Wealth Life & Pensions Limited Electronic bank transfer (in favour of Old Mutual Wealth Life & Pensions Limited) To: Natwest. Sort code 56-00-68. Account number 37632116. In the reference field on your bank transfer please enter your postcode and surname to help us process your application. Page 5 of 11

5 FUND CHOICE Complete part A, then B or C if required A Tick one of the following to indicate which investment range* your fund choice is from, then list the funds below: WealthSelect u only available for bonds on Charge Basis 3 SelfSelect u available for bonds on Charge Basis 1, 2 or 3 Bundled funds u SelfSelect only Where both bundled funds (full Annual Management Charge (AMC) with rebates) and unbundled funds (lower AMC with reduced rebates) are available, we will automatically default to unbundled funds even if you currently hold the bundled version in your bond. Tick here if you wish us to use the bundled version of the funds selected (where available) *If you are topping up a CIB on Charge Basis 3, and have chosen a different investment range from that which you currently hold, we will automatically swap all of the funds in your bond and replace them with the funds listed below before carrying out your top-up application. However, we will not automatically apply a switch fee as part of the swap process. Full name of fund or portfolio u the funds must all be from the same investment range, not a mixture from both Unit/Share type ie Inc/Acc Investment % An investment choice continuation sheet is available on request. If no unit/share type (ie Inc/Acc) is stated, accumulation units (where available) will automatically be applied. Where accumulation units have been selected and they are not available, income units will be automatically applied or vice versa. For more information on income and accumulation units/shares, refer to our Funds List. TOTAL 1 0 0 % NOTE If the fund choice you give is: missing, illegible or otherwise invalid, or from an investment range that is not available for your Charge Basis, we will place the investment into the BlackRock Cash Fund, after which you or your adviser can switch* into a revised fund choice. * Remember: if you have automatic rebalancing on your bond, switches will cause it to be cancelled and you will need to provide us with a new rebalancing instruction for it to continue. B Phased investment u not available in conjunction with automatic rebalancing We can place your investment into the BlackRock Cash Fund then phase it into your selected fund choice on the first working day of each month over 3, 6 or 12 months. To request phased investment, complete the required frequency and start date below: Phase every month for: 3 months 6 months 12 months Starting on: 0 1 2 0 Phased investment instructions will apply to all BlackRock Cash Fund holdings within your CIB, not just the investment in this application. You cannot phase back into the BlackRock Cash Fund. If you do not specify a start date, phasing will begin in the next available month following your application. C AUTOMATIC REBALANCING u not available in conjunction with Phased Investment We can automatically rebalance your CIB back to your selected fund choice and proportions on the 15th of the month every 3, 6 or 12 months. To request automatic rebalancing complete the required frequency and start date below: Automatically rebalance every: 3 months 6 months 12 months Starting on: 1 5 2 0 If you do not specify a start date, rebalancing will begin on the next available date for the frequency selected. If automatic rebalancing applies to your bond, and you top up with a different fund choice, or you switch funds, you will need to complete a new rebalancing instruction to continue with it. You can obtain the necessary form from your financial adviser or by calling our Customer Contact Centre on 0808 171 2626. Page 6 of 11

6 Capital Protected Death Benefit Please tick to indicate which of these options you require If neither option is ticked, Capital Protected Death Benefit will NOT apply. The Capital Protected Death Benefit CANNOT be added at a later date. With Capital Protected Death Benefit* This benefit is independently calculated on each policy within your bond. The benefit payable on each policy within the bond will be: a cash sum equal to the greater of the total premiums paid on each policy less any previous encashments, including adviser fees where appropriate, or 101% of the policy encashment value. *Death Benefit Charge - This monthly charge may apply depending on the value of your bond. More information is in the CIB Terms and Conditions. OR Without Capital Protected Death Benefit This benefit is independently calculated on each policy within your bond. The benefit payable on each policy within the bond will be: a cash sum equal to 101% of the policy encashment value. 7 AUTOMATIC WITHDRAWAL INSTRUCTION u if required NOTE Any instructions you give in this section will apply to your entire bond, and will override any existing instructions. Automatic withdrawals paid from your bond will count towards your 5% annual withdrawal allowance and may therefore have tax implications. We recommend that you consult your financial before requesting automatic withdrawals. A Amount State how much you wish to be withdrawn for each payment: (minimum payment 25) B FUNDS TO SELL You can choose the funds to be used to pay your withdrawals by selecting one of the following options: Largest fund OR: All funds OR: The following fund(s) If you do not specify a preference, we will deduct withdrawals from all funds in your bond proportionally by their bid values. C FREQUENCY Do you want to receive payments every month? Yes No tick below the months in which you would like to receive payments: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec When would you like payments to start? 2 8 2 0 u if left blank the start date will be the next available of the months selected D BANK DETAILS FOR YOUR PAYMENTS This must be your personal bank account; we CANNOT make withdrawal payments to third parties. We may need to see proof of bank account ownership. We will let you know if this is the case as soon as we can. Some banks or building societies cannot accept direct credits. Name and address of bank/ building society (must be in the UK) Postcode Sort code Bank account number Building society reference number (if applicable) Name of bank account holder(s) 8 Converting to a new Charge Basis (only applicable if you are topping up an existing bond on Charge Basis 1) Tick here to convert from Charge Basis 1 to Charge Basis 2. This will mean that: all commission payments to your financial adviser will stop part of any fund manager rebates will be reinvested into your bond you can authorise us to pay fees from your bond to your financial adviser by completing section 9b once you have converted to Charge Basis 2, you cannot go back to Charge Basis 1. Please note that existing bonds on Charge Basis 1 or 2 cannot be converted to Charge Basis 3. Charge Basis 3 is available for new bonds only. Page 7 of 11

9 Payments to your financial adviser (to be completed with your financial adviser) a) Commission (Charge Basis 1) This section is only relevant to you if you are topping up an existing bond which is on Charge Basis 1, is to remain on Charge Basis 1, and you have received no advice for this investment. NOTE If you do not complete this section, we will pay the maximum commission amount to your financial adviser. If our records show that you do not have a financial adviser then Old Mutual Wealth will make an initial charge of 4.5% of your investment amount, which we will deduct before we invest the balance into your bond. We will also retain any rebates we receive from the fund managers in respect of the funds in your bond. Initial commission (If the reduction box is left blank, your adviser will receive the maximum commission amount under their agreed terms with us) The standard initial commission rate is 4.5 % Reduction of initial commission % Use multiples of 0.05% Please enter the % by which the standard amount of commission is to be reduced. For example, if no commission is payable, this should be completed as 4.5%. Trail commission option (Select one only; if neither option is selected, fund-based trail will apply.) Fund-based trail (tick) Up to 0.5% depending on the funds selected Payments will be met from rebates we receive from fund managers; they are not deducted from your bond. OR: Nominated trail of Minimum 0% maximum 1.5% Enter the rate in multiples of 0.1% and 0.25%.This is an annual rate, which we will divide by 12 to make monthly payments to your adviser. Payments will be met by fund-based trail commission, but if this is not enough to meet the required amount, we will deduct any shortfall from your bond, as an additional charge, by selling units. % b) Adviser charging (Charge Basis 2 or 3) Complete this section if you wish us to deduct fees for your financial adviser from your bond. NOTE Percentage fees must be entered in multiples of 0.05%. If you wish to cancel an existing fee instruction using this form, enter 0 or 0% in the boxes for the fee in question. It will be cancelled for the whole bond, not just the investment in this application. Initial fees are deducted prior to investment. The 5% tax deferred allowance on the bond should therefore be calculated using the net investment amount. Any switch or servicing fees paid from your bond will count towards your 5% annual withdrawal allowance and may therefore have tax implications. Any Switch Fee or Servicing Fee you authorise here will apply to the entire bond and will therefore override any existing Switch or Servicing Fee instructions. Initial fee OR % from your lump sum payment Switch Fee up to: OR % from each switch The amount you authorise using this form is the maximum fund Switch Fee payable to your financial adviser. The actual fee payable for each switch must be stipulated up to this limit, at the time the switch instruction is given. Servicing Fee OR % each year Add VAT on top of the Servicing Fee? Yes Tick the frequency required Monthly Quarterly Half-yearly Yearly If you leave the frequency blank, we will assume monthly. The fee is an annual amount which will be divided by the payment frequency selected and paid to your adviser accordingly. If VAT applies to this fee, your financial adviser can either include VAT within this fee or add it on top. If you tick yes VAT will be added to the amount shown above. Where a percentage fee amount is agreed, the fee paid to your financial adviser may go up or down depending on the value of your bond on the date the fee is deducted. We will only pay an ongoing adviser fee to your authorised financial adviser. If you are receiving discretionary fund management services from a third party, your adviser may pay all or a proportion of the fee to the third party as payment for these services, and where relevant, to cover any associated VAT. Page 8 of 11

10 Old Mutual Wealth Product Charge and adviser servicing fee deductions (where applicable) Only complete this section if: you are setting up a new bond; or your existing bond is on Charge Basis 3; or you have agreed a servicing fee for your adviser in section 9b. You can choose which funds are sold to meet the Product Charge and Adviser Servicing Fee, as applicable; the option selected will apply to both of these payments. Select one of the following options: Largest fund OR All funds OR The following fund(s) NOTE For each of these choices, deductions will be made proportionally across all life policies within your bond. If you do not specify a preference, we will deduct the payments from the largest fund in your bond. More information about charges and fees is in the document Making the cost of investment clear. 11 Declaration and signature(s) (all applicants must sign) Please read this section carefully it is important that you read and understand the Terms & Conditions as well as this declaration. You should ask questions if there is anything you do not understand before you sign and date below. This declaration is made by each applicant. 1. a) I apply to invest in 1,000 unit-linked, whole of life assurance policies referred to collectively as the Collective Investment Bond. Alternatively I apply to invest an additional amount into my existing Collective Investment Bond with that additional amount invested equally in each policy. b) I declare that: I am 18 years of age or over; I am resident in the United Kingdom and will inform Old Mutual Wealth Life & Pensions Limited if this changes in the future. c) I understand that Old Mutual Wealth Life & Pensions Limited will administer the Collective Investment Bond in accordance with UK tax legislation. d) I understand that incorrect information regarding lives assured may result in a reduced death benefit being paid. 2. I authorise Old Mutual Wealth Life & Pensions Limited a) to hold interest distributions, dividends, rebates and any other rights or proceeds in respect of my investments in the Collective Investment Bond; and b) to sell units or shares in investments within my bond 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 confirmation 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: phased investments automatic rebalances automatic withdrawals dividend and rebate reinvestments, and sales of units to meet Old Mutual Wealth Life & Pensions 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) Key Information Document about the Collective Investment Bond d) information including 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 this application has been completed correctly and to the best of my knowledge and belief. 7. I confirm that I have obtained the consent of each life assured to use of their personal data in accordance with the Personal Data Statement contained within the Terms and Conditions and am signing the application as his/her agent(s) as well as applicant(s)/trustee(s). 8. If I have completed section 9b of this form: a) I authorise Old Mutual Wealth to deduct any fees detailed in section 9b from my investment and pay them to my financial adviser. b) I understand that: i) the fees agreed will be met as follows (as applicable): Initial fee by deduction from my payment before the balance is invested into my choice of funds Fund switch fee by deduction from the sale proceeds of the switch, before they are invested into my new choice of funds Servicing fee by selling units as instructed in section 10 ii) if I have ticked Yes in section 9b to add VAT to any servicing fees, the amount of the agreed fee will be increased to include VAT at the rate prevailing when the fee is deducted continued Page 9 of 11

11 Declaration and signature(s) (continued) iii) if I select a percentage amount servicing or switch fee, the fee paid to my financial adviser may go up or down depending on the value of my bond on the date the fee is calculated iv) I will need to reauthorise any increases to fees that have been previously agreed. v) switch or servicing fees will count towards my 5% annual withdrawal allowance and could therefore have tax implications. c) I confirm that: i) I have completed and agreed section 9b with my financial adviser ii) my financial adviser has explained the effect that selling units to pay Adviser Charges from my investment will have on its future value. iii) I confirm that Old Mutual Wealth has brought to my attention the importance of reading and discussing section 9b of this form with my financial adviser before signing this application. d) I understand that: i) I can cancel an adviser servicing fee at least 10 working days before it is deducted, by contacting Old Mutual Wealth ii) I cannot cancel a fee once it has been deducted, instead I would need to contact my financial adviser to discuss whether a refund is payable. 9. If I am converting to Charge Basis 2 I instruct Old Mutual Wealth to stop any commission payments currently being paid to my adviser in respect of this investment under Charge Basis 1 with immediate effect 10. 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 section 2 of this application and I am not resident for taxation elsewhere. ii) I am a national of the country(ies) shown in section 2 of this application and I am not a national or a citizen of any other country. iii) I will inform Old Mutual Wealth if this changes in the future. iv) the information in section 2 and the statements made in this declaration are correct and complete, to the best of my knowledge and belief. 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, and/or a US citizen, Old Mutual Wealth may need to share my information with the relevant tax authorities. Signature(s) Applicant 1 Applicant 2 Date (dd mm yyyy) 2 0 Date (dd mm yyyy) 2 0 If the application was NOT signed in the UK, please specify the country in which it was signed *APIPC0700X* 12 FINANCIAL ADVISER S DECLARATION u to be completed by your financial adviser 1. I understand that adviser fees will be paid subject to the limits outlined in Old Mutual Wealth s Remuneration Guide. 2. I confirm that: (a) I have verified the identity of all relevant parties referred to in this application (b) the information in this form was obtained by me in respect of the relevant parties (c) the evidence I have obtained to verify the identity of the relevant parties can be produced on demand and meets the standard of evidence set out within the guidance for the UK Financial Sector issued by the Joint Money Laundering Steering Group (JMLSG) (d) if any individual referred to in this application has changed address within the last three months, I can provide evidence on demand (e) I have not verified the identity of the following parties referred to in this application because they are exempt from verification under Money Laundering Regulations (f) this section is signed below by the person who has seen the documentary evidence (which may include an electronic identity check). 3. Tax information Based on the knowledge I have gained of the relevant parties, I have no reason to believe that the tax residency self-certification in section 11 of this form (point 10) requires any follow-up action. Financial adviser s signature Date (dd/mm/yyyy) 2 0 Print name Financial Services number Full name of regulated firm (or sole trader) Position Contact number Page 10 of 11

Send the completed form to: Old Mutual Wealth Old Mutual House Portland Terrace Southampton SO14 7AY Tel: Customer Contact Centre 0808 171 2626 CHECKLIST Once you have signed the application, please check that you have completed all applicable sections and enclosed the following: (as applicable) Execution Only form (see section 1.2) Signed cheque for the amount shown in section 4 Third Party Payer details in section 13 (if someone else is paying for the investment) Power of Attorney details in section 14 (if an attorney is acting for the applicant) 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 is the trading name of Old Mutual Wealth Limited which provides an Individual Savings Account (ISA) and Collective Investment Account (CIA) and Old Mutual Wealth Life & Pensions Limited which provides a Collective Retirement Account (CRA) and Collective Investment Bond (CIB). Old Mutual Wealth Limited and Old Mutual Wealth Life & Pensions Limited are registered in England and Wales under numbers 1680071 and 4163431 respectively. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority. Old Mutual Wealth Life & Pensions Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Their Financial Services register numbers are 165359 and 207977 respectively. VAT number 386 1301 59. Page 11 of 11

Please complete THE FOLLOWING sections where relevant If these sections are relevant to your application but not completed, your investment will be delayed *APIPC0700F* CIB Application Supplement 13 THIRD-PARTY PAYER DETAILS This section must be completed with details of any third party paying for your lump sum investment. If there is more than one third-party payer please attach the same information for each one by using a copy of this page. Surname/ Company name (if applicable) Permanent UK residential/ registered office Postcode address (dd/mm/yyyy) u the payer must be at least 18 years of age Company registration number (UK companies only) 14 POWER OF ATTORNEY Where there is more than one attorney, please attach the same information for each one by using a copy of this page. Where an attorney is signing the Declaration in section 11 on behalf of the applicant we will need: the attorney s details below the original power of attorney, or a copy certified as a true copy of the original in ink on each page by a solicitor or the donor (the person giving the power) the attorney s identity verified. Surname Full postal address (if correspondence for this CIB is to be sent to this address, please enter it in section 2) (dd/mm/yyyy) I have read the Personal Data Statement in the Terms and Conditions and consent to my personal data being used in accordance with that statement. Attorney s signature (You must sign both here and in section 11 writing the words as attorney after your signature) Date (dd/mm/yyyy) 2 0 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 is the trading name of Old Mutual Wealth Limited which provides an Individual Savings Account (ISA) and Collective Investment Account (CIA) and Old Mutual Wealth Life & Pensions Limited which provides a Collective Retirement Account (CRA) and Collective Investment Bond (CIB). Old Mutual Wealth Limited and Old Mutual Wealth Life & Pensions Limited are registered in England and Wales under numbers 1680071 and 4163431 respectively. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority. Old Mutual Wealth Life & Pensions Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Their Financial Services register numbers are 165359 and 207977 respectively. VAT number 386 1301 59. PDF5184/218-0246/March 2018 Supplement 1 of 1 *APTRF0600F*