Application and income payment form B.

Annuities Application and income payment form A Below Standard Lifetime Allowance Please use black ink and write in CAPITAL LETTERS or tick 4 as appropriate. Any corrections must be initialled. Please do not use correction fluid as this will invalidate your application. About this form Please read the Key Features Document as this will provide you with important information regarding the key risks and benefits of the product to help you make a decision. Please fully complete the information on this form and send it to us at the following address: Prudential Lancing BN15 8GB This form must be signed in Part 6 and in all instances all pages must be returned. Your annuity will be set up once we receive all our requirements. If there is a fall of 10% or more in the amount we receive to buy your annuity and/or your starting income, we'll contact you with a new quote. For example, your starting income could change because your postcode is different to the one shown in your quote. Important note This form is only to be used where: > You are below the standard Lifetime Allowance and are not relying on protection of any kind > Plans involved are UK registered Pension Schemes Please visit www.hmrc.gov.uk for more information on the Lifetime Allowance. If your plans are NOT subject to either of the above please contact us on the telephone number shown on your quote. You will then need to complete Application and income payment form B. Please complete in all instances: Your full annuity quote reference A Q If you have a quote with more than one option, please select the one which best suits your needs and tell us here Page 1 of 10

Part <X> 1 Personal Sub heading details Title Mr Mrs Miss Ms Other Surname Forenames N. I. Number Daytime telephone number Your date of birth D D M M Y Y Y Y Your home address Postcode E-mail address Title Mr Mrs Miss Ms Other Full name of your spouse/civil partner/dependant (only complete if applying for a Joint-life annuity) Their date of birth D D M M Y Y Y Y Male Female What is their relationship to you? For example, spouse, civil partner or unmarried partner. Part 2 Your payment details Your income and any tax-free cash will automatically be paid to the bank or building society shown below. If you require your tax-free cash to be paid to a different account please let us know in writing. UK Bank Account details Please note that we will not make annuity payments by cheque and that we only make payments into a UK personal bank account in your name. It cannot be a business account. Name of Bank or Building Society Name of Account Holder Bank Account Number Building Society Roll Number (if applicable) This is the six digit number shown on your cheque book or bank card. Sort Code Page 2 of 10

Part <X> 3 Current Sub heading scheme details Please provide separate details for each pension plan that you're using to buy your annuity. Please complete the scheme name(s) or types(s) of pension plan you are using to buy this annuity. Any money paid in respect of this application will be applied as soon as practical after acceptance. No interest or growth is payable on funds held before your annuity goes into payment. Existing pension plan details Name of the current provider Full name of the pension scheme It helps us to have the full name of your existing pension scheme, but if you don't know it, the full name of your existing pension provider and your existing plan/policy/ membership number will be enough. Existing plan number Approximate fund value to be paid to us Is the full fund value of the existing plan being used to provide tax-free cash and income payments? Yes No If no, please provide details If you have an: Open Market Option: > This will speed up the payment of the tax-free cash. > You will remain a member of your existing scheme. > You will not be able to combine all your pensions into one annuity contract. Each Open Market Option must have its own individual annuity. > current provider will pay any tax-free cash. Or Transfer: > You will no longer be a member of your existing scheme and you become a member of the Prudential Pension scheme. > You may be able to combine all of your pensions into one annuity and so receive your pension income at the same time. > Prudential will pay any tax-free cash. If you have more than 2 existing pension plans you can either; photocopy this page or write the details on an additional sheet of paper Is a tax-free cash sum to be paid? Yes No If yes to above: a) who will be paying this sum? b) is the maximum to be paid (normally 25% of the fund value)? If not 25%, what percentage or value should be paid? % Name of the current provider Full name of the pension scheme Existing plan number Approximate fund value to be paid to us Current provider Is the full fund value of the existing plan being used to provide tax-free cash and income payments? If no, please provide details Is a tax-free cash sum to be paid? Yes No If yes to above: a) who will be paying this sum? b) is the maximum to be paid (normally 25% of the fund value)? If not 25%, what percentage or value should be paid? % Not applicable already taken via a drawdown policy Current provider Yes Yes Prudential No No Not applicable already taken via a drawdown policy If you don't have any other pension plans, please read part 5 and then complete part 6. Yes Prudential No Page 3 of 10

Part 4 Advice notification This section should only be completed by a financial adviser, if appropriate. This section is for your financial adviser to complete, so if you have an Adviser please ask them to complete it. If you are not using a financial adviser then this section does not need to be completed. Complete this part of the form if you are the Adviser in this transaction, and return it to Prudential. Has advice been given and a recommendation made (advised sale)? Yes No For an Advised Sale what date was the advice given? D D M M Y Y Y Y I/we confirm that the benefits and commencement date in respect of the accepted annuity are in accordance with the rules of the scheme. Adviser s Signature 7 Date D D M M Y Y Y Y Your firm s telephone number Firm Reference Number (FRN) R.I. Number e.g. 1 2 3 4 5 6 7 8 Your office email address Page 4 of 10

Understanding the Lifetime Allowance rules is important because if you provide incorrect or incomplete information you may be liable to a Lifetime Allowance tax charge. If you are unsure how to calculate the value of your benefits, please refer to your financial adviser or your existing provider. * A significant increase is where: The total tax-free cash you receive in the 12 month period ending on the day the tax-free cash from this plan is paid, exceeds 7,500, and more than 30% of those tax-free cash sums is used to make contributions to one or more registered pension schemes which exceed the expected level of contributions. This includes any contributions you pay directly or indirectly, paid by someone on your behalf such as your employer, or which you may have paid in anticipation of receiving the taxfree cash. Part 5 Declaration Declaration to Existing Pension Provider 1. I would like to take the benefits from the plan(s) listed in Part 3. 2. I authorise Prudential, the current provider and any financial intermediary named in this application to obtain from each other, and release to each other, any information that may be required to enable the transfer of sums and assets to Prudential. 3. I authorise and instruct you to transfer the sums and assets from the plan(s) as listed in Part 3 of this application directly to Prudential, and to provide any instructions and/or discharge required by any relevant third party to do so. 4. I authorise and instruct you to pay me any taxfree cash as indicated, to pay the balance of sums and assets to Prudential to provide me with an annuity on the basis set out in the illustration indicated in Part 3 of this application, and to provide any instructions and/or discharge required by any relevant third party to do so. 5. Where you have asked me to give you the original policy document(s) in return for the transfer of sums and assets and I am unable to do so, I accept responsibility in respect of any claims, losses, expenses, additional tax charges or any penalties that Prudential and the current provider may incur. 6. Until this application is accepted and complete, Prudential s responsibility is limited to the return of the total payment(s) to the current provider(s). 7. When payment is made to Prudential as instructed, this means that I shall no longer be entitled to receive pension benefits from the whole of the plan(s) listed in Part 3 where the whole of the plan(s) is transferring, or that part of the plan(s) represented by the payment(s) if only part of the plan(s) is transferring. 8. I confirm that any Adviser Charge paid on my behalf by Prudential on the initial set up of this annuity: Is wholly connected to the purchase of this annuity; and is appropriate to the advice and service my financial intermediary provided me in relation to this annuity purchase. If this is not the case then some or all of the Adviser Charge and any tax-free cash may become liable to a tax charge, which I may be responsible for. 9. I accept responsibility in respect of any claims, losses, expenses, additional tax charges or any penalties that Prudential and the current provider may incur as a result of any incorrect, untrue, or misleading information in this application or given by me, or on my behalf, or of any failure on my part to comply with any aspect of this application. Declaration to Prudential and Existing Pension Provider I confirm that: > The total value of: the pension income and tax-free cash I have already taken (including drawdown income and any income taken before 6 April 2006); any pension funds transferred overseas, and; the benefits I am taking now. are below the current standard Lifetime Allowance threshold. > If I have a pension which was in payment as at 5 April 2006 and I have not already taken benefits from another scheme I will provide the current and receiving provider with details of the level of income currently in payment; or > I will notify the current and receiving providers if I am, or I believe I am, above the standard Lifetime Allowance threshold; and > I will advise them if I have a protection in place against the Lifetime Allowance tax charge. I will provide a copy of my HMRC protection certificate if asked to do so. > I'll be solely responsible for any additional tax charges or any penalties which arise if the information provided in this application is incorrect or if I have failed to comply with any aspect of this application. > Where I have chosen to take tax-free cash, I have not made, and do not intend to make, either directly, indirectly or by someone making contributions on my behalf, a significant* increase in my total contributions to any registered pension scheme. Declaration to Prudential > I accept the annuity quote shown on page 1 provided that the total pension fund or annuity is within 10% of the figure shown in this quote. > Where appropriate, I apply for membership of The Prudential (Corporate) Personal Pension Scheme and for one arrangement to be established under it and I agree to be bound by the rules of the scheme. Page 5 of 10

Part 5 Declaration continued > I confirm that at the time of making this application I am a UK resident. > I confirm that the terms of this application, any other statement by me or on my behalf to Prudential, together with Prudential s acceptance shall form part of any relevant contract and to the best of my knowledge and belief are true and complete. Prudential may change the terms of the contract if I have given incomplete or inaccurate information. > I've read the Key Features Document and quote and I'm aware of my cancellation rights. > I confirm that I m not the subject of a bankruptcy order which affects my rights to get this income. > I confirm that, where I am transferring in Guaranteed Minimum Pension or Salary Related contracted out benefits for pensionable service after 5 April 1997, I acknowledge that benefits provided will be in a different form to those payable from the transferring scheme. > I authorise the financial adviser acting as my agent to submit information contained in my application form online to Prudential where appropriate. > I authorise Prudential to obtain from and release to any information that may be required in relation to the purchase of my annuity to the Adviser named in this application. > By completing this form, I understand that I am applying for the removal of any restrictions in my existing policy/contract terms relating to my benefits where such restrictions are no longer necessary because of the 6th April 2006 legislation changes. Prudential agrees to the removal of these restrictions and confirms that this constitutes an endorsement to the policy/contract terms to allow for the legislation effective from 6th April 2006. Adviser Charging > I authorise Prudential to act upon my instructions regarding the facilitation of Adviser Charges (the Adviser Charge Instruction ) whether specified in my annuity quote or elsewhere at any time in future. I also understand that Prudential shall not be required to carry out such instructions (including any permitted by my adviser firm) where they conflict with any applicable law or regulation and/or where they are inconsistent with Prudential's Adviser Charge administration capability. > I understand that where there is a difference between the Adviser Charge Instruction and the Adviser Charges agreed with my adviser firm, Prudential will only facilitate payment in accordance with my Adviser Charge Instruction. > I confirm that the Adviser Charge specified in my Adviser Charge Instruction is inclusive of any VAT at the prevailing rate from time to time. > I understand that if the level of VAT applicable within the Adviser Charge changes (including where previously VAT free Adviser Charges become subject to VAT) Prudential will only alter my Adviser Charge following a new Adviser Charge Instruction or instruction from my adviser firm which sets out the new level of charges to be deducted. > I understand that, with the exception of changes in the level of VAT, the Adviser Charge may not be increased without my explicit authority. > I agree that the Adviser Charge may be reduced or stopped by Prudential or my adviser firm without my explicit authority. > I agree that where my adviser firm arranges for the services I have agreed with them to be provided by another adviser firm, I authorise Prudential to amend my Adviser Charge Instructions to pay the Adviser Charges at the existing agreed level to the new adviser firm, except where they conflict with any applicable law, regulation and/or HMRC practice and/or where they are inconsistent with Prudential s Adviser Charge administration capability. > I confirm that I have discussed with my financial adviser the tax implications of having my Adviser Charge deducted from the Annuity; and > I confirm that any Adviser Charge deducted on the initial set up of this annuity: is wholly connected to the purchase of this annuity; and is part of genuinely commercial remuneration arrangements between myself and my adviser which are appropriate to the advice and service my adviser provided me in relation to this annuity purchase. > I am aware that if this is not the case then some or all of the Adviser Charge and any pension commencement lump sum may become liable to a tax charge, which I will be responsible for. Page 6 of 10

*The Prudential Assurance Company Limited is part of the Prudential group of companies which at the time of printing includes Prudential UK & Europe, the M&G Investments Group, Prudential Corporation Asia, Jackson National Life, and PPM America Inc (indirect wholly owned subsidiary). Part 6 Policy conditions How we use your personal data The Prudential Assurance Company Limited, its group companies* and its business partners will use your information together with other information for administration, credit decisions, customer services, marketing and profiling your purchasing preferences. We will pass your information to them (including our service providers and agents) for these purposes. If you are a joint applicant, we will also pass your information to the other joint applicant/s. For certain products, we may search the files of credit reference agencies that will record any credit searches on your file. This is to help us make credit decisions about you, to prevent fraud, to check your identity and to prevent money laundering. We may disclose details of how you conduct your account to such agencies. The information will be used by other credit grantors for making credit decisions about you and the people with whom you are financially associated, for fraud prevention, money-laundering prevention and occasionally for tracing debtors. This information may be used to recheck these purposes. We will pass your information to any legal or regulatory body if required to do so. For certain products, we will need to process sensitive personal data such as health data. It may also be necessary, for the above purposes, to transfer your information to countries that provide a different level of data protection from the UK. In such circumstances, we will put a contract in place to ensure your information is protected. By completing and submitting this form, you consent to us processing your sensitive data and to the processing mentioned above. You have a right to obtain a copy of your personal information (for which we may charge a fee) and to have any inaccuracies corrected by writing to: The Information Risk & Security Team, Prudential, Lancing BN15 8GB. To make sure we follow your instructions correctly and to improve our service to you through training of our staff, we may monitor or record telephone calls. Acting on someone s behalf? When giving us information about another person, you confirm that they have appointed you to act on their behalf. This includes providing consent to: > the processing of their personal and sensitive data > receive any data protection notices on their behalf > receive marketing information as indicated. Marketing choice We would like to keep you updated with information on our products and services. To do this we would like to contact you by telephone, e-mail or text. If you would not like to be contacted, please tick this box. Please confirm if you have received free, impartial guidance from Pension Wise the Government guidance service Yes, I have used Pension Wise, the Government guidance service. No, I have not used Pension Wise, the Government guidance service. Page 7 of 10

Part <X> 6 Policy Sub conditions heading continued WARNING: Please remember it is a serious offence to make false statements, the penalties are severe and could lead to prosecution. For your own benefit and protection you need to read carefully the documentation provided before signing this form. You also need to read carefully any further documentation provided to you in the future. If there is anything you do not understand please ask us for further information. By signing, you are confirming that you have read parts 5 and authorise Prudential to pay any adviser charge as detailed in your quotation (if applicable). Signature of applicant 7 Date signed D D M M Y Y Y Y A copy of this application and the terms and conditions of the contract are available on request. Part <X> 7 Checklist Sub heading Please use this checklist to double check you have completed all the information we need in this form, in order to set up your annuity. Tick as appropriate. The full annuity quote reference and if applicable, the quote option number (Page 1) Personal details (Part 1) Phone number (Part 1) Dependant's details (if applicable) (Part 1) Bank details (Part 2) All plan/policy/membership numbers (Part 3) Signature and date (Part 6) Page 8 of 10

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www.pru.co.uk The Prudential Assurance Company Limited (PACL) is registered in England and Wales. This name is also used by other companies within the Prudential Group. Registered Office at Laurence Pountney Hill, London, EC4R 0HH. Registered number 15454. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. ANNF10353 03/2018 Page 10 of 10