Customer Identification Form Joint accounts, Company, SMSF, Trust, Estate, Partnership PremiumChoice Investment Service 2 October 2010 Please complete this form in BLACK INK using BLOCK letters. Australian anti-money laundering and counter-terrorism financing legislation ( AML/CTF Law ) requires the providers of financial products and services to conduct customer identification. This form must be completed by the investor s financial adviser. Please also attach copies of appropriate identification documentation used to verify the identity of the investor(s). If this form is not completed and copies of identity documents are not provided, processing times for certain transactions may be affected (for example we may not be able to process the application if we are not provided with suitable identification when requested). We will not be liable if we delay or refuse any transaction or request due to any AML/CTF Law requirement. Investor details PremiumChoice Investment Service account type Joint Company SMSF Trust Estate Partnership Other Please complete section (i) for Joint holdings, sections (i) and (ii) for Company, sections (i) and (iii) for SMSF or Trust, and sections (i) and (iv) for Estate, Partnership or Other. (i) Investor 1/ Director 1/ Trustee 1/ Executor 1/ Partner 1 Any other name the investor is known by If the investor is known by any further names, please provide details in the additional information section on page 5. Date of birth / / Residential address 1
Investor 2/ Director 2/ Trustee 2/ Executor 2/ Partner 2 Any other name you are known by If the investor is known by any further names, please provide details in the additional information section on page 5. Additional information attached Date of birth / / Residential address (ii) Company If the investor is a proprietary company, the individual details of each Director must also be completed in section (i) above. If the company has more than two directors, please provide details in the additional information section on page 5. If the beneficial owners of the company are different to the Directors, please also provide their individual details in the additional information section on page 5. Name of company (as registered by ASIC) Proprietary company Public company Registered address Address of place of business* (only required if the company s place of business is different from the company s registered office) (iii) SMSF or Trust Please provide details of individual Trustee(s) in section (i) above and details of any corporate trustee in section (ii) above. If there are more than two Trustees, please provide details in the additional information section on page 5. If the beneficiaries of the Trust are different to the Trustees, please provide their individual details in the additional information section on page 5. Full name of Trust Business name of Trustee (if any) Type of Trust 2
(iv) Estate, Partnership, or other If the partnership has a business name, please provide details of the Company details in section (ii). Please also provide the details of each executor/partner in section (i). If there are more than two executors/partners, please provide their individual details in the additional information section on page 5. Full name of estate, partnership, or other Registered business name of partnership (if any) Adviser declaration I have identified the investor(s) from original or certified copies of appropriate identification documents in accordance with AML/CTF Law; I am satisfied that the investor(s) is who they claim to be; and copies of the appropriate identification document(s) outlined on the verification checklist on page 4 have been attached to this form. Financial adviser signature Date / / Adviser name Adviser code Office Trustee: NULIS Nominees (Australia) Limited ABN 80 008 515 633 AFSL 236465 Operator: Navigator Australia Limited ABN 45 006 302 987 AFSL 236466 PremiumChoice Retirement Service ABN 70 479 285 132 3
Verification checklist The adviser must have seen the original or certified copy of the following customer identification documentation. A copy of the documentation must be provided with the Customer Identification Form. 1. If the investor is a joint investor For both investors, an original or certified copy of either: Australian passport or or State or Territory driver s licence Proof of age card (issued by an Australian State or Territory bearing the investor s photograph, name and date of birth) If the investor does not have any of the above, an original or certified copy of one item of documentation from Column A and one item of documentation from Column B: Column A Australian birth certificate Australian citizenship certificate Pension card issued by Centrelink Column B Letter from Centrelink within the last 12 months regarding a government assistance payment showing your name and address Utilities bill or local government notice issued within the last three months showing your name and address Notice issued by the ATO within the last 12 months showing your name and address Notice from school principal showing name, address and period of attendance of person under 18 years of age issued within previous three months 2. If the investor is a proprietary company At least one director of the company must provide the documentation listed in 1 above. 3. If the investor is a Trust (including an SMSF) certified copy of the Trust Deed (including any amendments) the documentation listed for individuals in 1 above for at least one trustee (or for corporate trustees, the documentation listed for individuals in section 1 above for at least one director) 4. If the investor is an Estate or Partnership Partnership a certified copy of the partnership agreement or minutes of a partnership meeting; and the documentation as detailed in section 1 above for at least one partner Estate a certified copy of the grant of probate; and the documentation as detailed in section 1 above for at least one executor If the investor cannot meet any of the above requirements please contact Adviser Services on 1300 128 482. 4
Additional information Please use this section to provide any additional information required under the Investor details section. A136311-0617 5