TRUSTEE BUYOUT PLAN APPLICATION FORM

TRUSTEE BUYOUT PLAN APPLICATION FORM

Important Note Before completing this application, please note that we cannot accept transfers from the following; Any transfer from Defined Benefits schemes Any transfer from proposed planholders where there is Section 9 (2B) rights or they have a Guaranteed Minimum Pension Policies where benefits have already come into payment If any proposed planholders are non participating spouses To be completed by the trustees or administrator of the transferring scheme or arrangement. Please also ensure you complete all relevant sections of the Member Schedule. A. SCHEME AND TRANSFER DETAILS Full name of the scheme ( the Scheme ) Full name of the administrator Scheme address Postcode Note 1) This can be provided by the ceding scheme. Failure to provide this will delay the process. Contact telephone number HMRC Pension Scheme tax reference number (see note 1) Full name of the principal employer Principal employer address Postcode Contact telephone number 1. Is the Member Schedule, which forms part of this application, a complete list of all the individuals for whom a Buyout Plan is to be issued by Scottish Widows? These individuals are referred to in this application as the proposed planholder(s). Yes No 2. Is the transfer from: A Registered Pension Scheme (as defined in Part 4 of the Finance Act 2004) A Recognised Overseas Pension Scheme (as defined in Part 4 of the Finance Act 2004) An Overseas Pension Scheme (as defined in Part 4 of the Finance Act 2004) An Employer-Financed Retirement Benefits Scheme (as defined in Income Tax (Earnings and Pensions) Act 2003) 1

A. SCHEME AND TRANSFER DETAILS (CONT D) 3. Scheme Normal Retirement Age a) Please provide a Scheme Normal Retirement Age b) If you wish to select, for a proposed planholder, an intended retirement age which is different from the Scheme Normal Retirement Age, please do so by completing the Selected Pension Age column in the Member Schedule as appropriate. If no selection is made in the Member Schedule, the intended retirement age will be the Scheme Normal Retirement Age. In this application we use the term selected pension age to refer to the intended date on which pension benefits for a proposed planholder are to be taken. If a selected pension age is below the normal minimum pension age (as defined in Part 4 of the Finance Act 2004), please tick the box to confirm that all such selected pension ages are each a protected pension age. Notes 2) If not completed, we will select our default option and all outputs will be sent to the client. No copies will be sent to the adviser. These options will be explained to you by the scheme adviser. 3) The review date is the first and subsequent date that annual statements will be issued. (Annual statements will be issued in accordance with the output package option selected in question 4.) 4. Scheme Output Package (see note 2) please select option 1 2 3 4 5 5. Will Scottish Widows be required to sign the discharge forms from the Yes No ceding provider? 6. What review date would you like to apply to the Buyout Plan(s) (see note 3) (DD MM YYYY) Please note: if no date is selected the review date for the Buyout Plan(s) will normally be on the anniversary of the outset of the Buyout Plan(s). 7. Estimated Transfer Payment (the estimated total of the transfer values of all proposed planholders). If the transfer payment includes Protected Tax-Free Cash amounts, please complete the appropriate sections in the Member Schedule. 2

B. INVESTMENT OF TRANSFER VALUES Notes 1) Each investment approach is mainly invested in our Pension Portfolio funds*. These funds use a varying mix of higher and lower risk investments. The fund the proposed policyholder will initially be invested in will depend on their chosen investment approach and the time until retirement. Over time, the proposed policyholder s pension fund will be progressively moved to lower risk investment funds. *Please note that our Pension Investment Approaches invest in our Pension Portfolio funds, our Premier Pension Investment Approaches invest in our Premier Pension Portfolio funds. You, the Trustee, must record in this part how the transfer values to be applied to the Buyout Plans are to be invested. The available options are set out in this section. Your choice will apply to all those members where there is no specific selection on the member transfer spreadsheet. You can choose either a; Pension Investment Approach or indicate your investment choice of investment funds(s) or select a Bespoke Lifestyle Approach (by completing the bespoke application form available on request ) YOU CANNOT SELECT MORE THAN ONE OPTION. We may change the selection of funds that we make available and restrict how much can be invested. 1. Pension Investment Approaches This part should only be completed if you wish to select a Pension Investment Approach for all proposed planholders. Before considering one of these you should read our Pension Investment Approaches Guide and our Premier Lifestyling Options Guide (see note 1). Adventurous (Targeting Annuity) Adventurous (Targeting Encashment) Adventurous (Targeting Flexible Access) Balanced (Targeting Annuity) Balanced (Targeting Encashment) Balanced (Targeting Flexible Access) Cautious (Targeting Annuity) Cautious (Targeting Encashment) Cautious (Targeting Flexible Access) Premier Adventurous (Targeting Annuity) Premier Adventurous (Targeting Encashment) Premier Adventurous (Targeting Flexible Access) Premier Balanced (Targeting Annuity) Premier Balanced (Targeting Encashment) Premier Balanced (Targeting Flexible Access) Premier Cautious (Targeting Annuity) Premier Cautious (Targeting Encashment) Premier Cautious (Targeting Flexible Access) As planholders get closer to their selected pension age, we will automatically gradually adjust and move the pension funds into lower risk investment funds. The proposed planholder can change the investment choice at any time or stop the gradual adjustments. If they wish to do so they should contact us. 2. Fund Selection (if not choosing a Pension Investment Approach in part 1) You can choose up to 10 funds at any one time for the initial investment(s) of all the proposed planholders. Restrictions may apply on the amount that can be invested in certain funds. Please contact us for further details of any restrictions that may apply. For further details of the funds available please refer to our Pension Funds Investor s Guide. The proposed planholder can change the investment choice at any time once the plan has been set up. Fund Percentage Fund Percentage TOTAL 100% 3. Bespoke Lifestyle Approach (if not choosing 1 or 2) Yes No 3

C. DECLARATION BY ADVISER (ONLY COMPLETE IF THE TRUSTEES HAVE PAID A FEE TO THE ADVISERS.) I confirm that the Trustees will be paying a fee for the services I have provided to them. Where adviser services are being offered to proposed planholders these are optional and not a condition of being transferred into the Trustee Buyout Plan. Signature Name Date (DD MM YYYY) Agency Code D. SCOTTISH WIDOWS WARRANTY We warrant to you that: We are an Insurance Company authorised to carry on ordinary long term insurance business in the United Kingdom. If any part of a proposed planholder s transfer value is accepted by us to provide benefits then it will be applied under a Trustee Buyout plan that will conform with Section 150 (1) and (2) of the Finance Act 2004. If any part of a proposed planholder s transfer value is accepted by us it will be applied by us to provide only those pension benefits that provide money purchase benefits and those death benefits described in the Trustee Buyout plan. 4

E. DECLARATION BY TRUSTEES OF THE SCHEME We apply for a Buyout Plan for each proposed planholder in accordance with the statements in this application (including the Member Schedule). For each proposed planholder a Buyout Plan should be written in the name of the proposed planholder. We confirm that the Transfer Payment does not include any Section 9(2B) rights or an obligation to provide a Guaranteed Minimum Pension in respect of any of the proposed planholders. We declare that the particulars of this application (including the Member Schedule) and declaration, together with any other declaration or statement made by us in connection with this application, whether in our own handwriting or not, are true. We declare that we understand that the Buyout Plan(s) will provide money purchase pension benefits for the proposed planholder(s). We declare that we have satisfied ourselves that it is appropriate for us to transfer Scheme benefits to the Buyout Plan(s) to be issued. We declare that we have observed and implemented all the requirements relating to our Scheme that relate to the transfer of Scheme benefits in respect of the proposed planholder(s). We agree to pay the Transfer Payment to Scottish Widows. We will forward payment by either direct transfer (BACS or CHAPS) or by cheque made payable to Scottish Widows crossed A/C payee only. We agree that Scottish Widows may decide to decline this application for one or more proposed planholders and return the whole or part of the Transfer Payment to us. We have received the Important Notes for Applications document. For your own benefit and protection Scottish Widows recommends that you read each of the statements in that document before you sign this application as these statements may later be relied on. If you do not understand any point, please let us know. Lloyds Banking Group companies will not use this information supplied in this form to contact you or the members of the Trustee Buyout Plan by mail, telephone, email or text message about products and services that may be of interest to you or the members. I certify that I am authorised to sign this application. Signature Name for and on behalf of the Trustees of the Scheme Date (DD MM YYYY) Position Scottish Widows Limited. Registered in England and Wales No. 3196171. Registered office in the United Kingdom at 25 Gresham Street, London EC2V 7HN. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number 181655. 53406 12/15