Southern Charter Financial Services/ Suite 2 Constantia House / Steenberg Office Park / Steenberg Road / Tokai / Tel: +27 (021) 700 1000 / Fax: +27 (021) 700 6145 APPLICATION FORM Current account number (if any) RU For office use CT: A. General Investment Procedures: You are referred to the terms and conditions applicable to this investment, as set out in the deed and supplementary deed of the MET Collective Investments Scheme prior to completing this application form. Complete the relevant forms and attach the necessary documentation before forwarding them to MET Collective Investments Limited. An investment statement, confirming the purchase of participatory interest in the portfolio/s, will be forwarded to the investor as soon as possible. B. The submission of documents The application and all supporting documentation are to be transmitted by email to: ci.clientservice@momentum.co.za or fax to (012) 675 3889 C. Administrative Process In the event that this application form, or any other written instruction is faxed or e-mailed to MET Collective Investments, the responsibility for ensuring that the instruction has been received and actioned, will lie with the instructor (investor or financial advisor). If you wish to confirm receipt of an instruction, please contact our Client Service centre on 0860 111 899. MET Collective Investments will only place investments once all the supporting documentation set out below has been supplied. D. ANNEXURE A: If the Company has any shareholders with more than 25% of the voting rights at a general meeting. (Not required for individual investors) E. ANNEXURE B: Beneficial owner declaration of status (Dividends withholding tax) FICA AND NEW BUSINESS REQUIREMENTS FICA is a process followed by all accountable institutions to identify and verify investors and the source of their funds in an effort to combat money laundering reduce fraud and prevent the possible use of money for acts of terrorism. FICA protects the interests of investors, and investment providers, globally. From time-to-time, we may request that you resend documentation in order to validate the records we keep on our administration system, and to safeguard your investment. When making a new investment, MET Collective Investments Limited requires the following documentation: 1. A full completed and signed original application form 2. Copy of a deposit slip or proof of electronic transfer for the new investment 3. Original bank statement indicating your bank details 4. Proof of residential address (not older than 3 months) In addition to this, we require the following information: If an individual 5. Certified copy of ID for South African citizens or, if not available, valid certified copy of passport or valid driver's licence 6. Certified copy of valid passport for foreign nationals If a company An original copy of the Directors' Resolution authorising the investment and nominating a person(s) to sign all documents 5. Original sample signature of the nominated person(s) 6. Certified copy of ID(s)/passport(s) for signatory(ies) 7. Certified copy of proof of residential address for each signatory 8. Certified copy of the Company's Certificate of Incorporation (CM1) 9. Certified copy of the Notice of Registered Address of the company (CM22) 10. Proof of residential address, contact details and certified copy of ID for the executive officer as well as all individuals holding 25% or more of the voting rights at a general meeting of the company If a close corporation 5. Original copy of the Member's Resolution authorising the investment and nominating a person(s) to sign all documents 6. Original sample signature of the nominated person(s) 7. Certified copy of ID(s) for signatory(ies) 8. Certified copy of proof of residential address for each signatory 9. Certified copy of ID for each member 10. Certified copy of proof of residential address for each member 11. Certified copy of the CK1 and if applicable, certified copy of CK2 12. Proof of approval by the Registrar of CCs 13. Certified copy of proof of residential address of the CC Southern Charter Application Form - 1 -
If a trust 5. Certified copy of the Letter of Authority 6. Original copy of the Trustees' Resolution authorising the investment and nominating a Trustee(s) to sign all documents 7. Original sample signature of the nominated Trustee(s) 8. Certified copy of ID(s) for signatories and certified copy of proof of residential address 9. Certified copy of ID, certified copy of proof of residential address and contact details for the a) Founder, b) each Trustee and c) each Beneficiary 10. Certified copy of the Trust Deed If a partnership 5. Certified copy of ID for each partner and certified copy of proof of residential address 6. Original copy of the Resolution authorising the investment and nominating a person(s) to sign all documents on behalf of the Partnership 7. Original sample signature of the nominated person(s) 8. Certified copy of ID(s) for signatory(ies) 9. Certified copy of proof of residential address for each signatory 10. Copy of the Partnership agreement, if available If a sole proprietor 5. Certified copy of ID for South African residents or if investor is a foreign national, certified copy of a passport 6. Certified copy of proof of residential address (not older than three months) 7. Sample signature of the Sole Proprietor 8. Letter of Introduction setting out the nature and constitution of the business If you fall into the category Other Legal Persons 5. Certified copy of Constitution or other founding document 6. Certified copy of a Resolution from the Chairperson authorising the investment and nominating a person(s) to sign all documents 7. Original sample signature of the nominated person(s) 8. Certified copy of ID for signatory(ies) 9. Certified copy of proof of residential address for each signatory (not older than three months) 10. Letter of Introduction setting out the nature and constitution of the business Examples of proof of residential address The document provided must reflect the investor's name and residential address and not the postal address. Copies of the following, less than three months old, are acceptable: Water and electricity statement Telephone account Rates and taxes document Lease or rental agreement Municipal rates and taxes invoice SARS tax return/irp5 Bond statement Life insurance policy document Correspondence from a body corporate or share-block association Pay slip or salary advice Bill/statement from a company contracted for services at the property given at the person's address, e.g.: o Installation of satellite television followed by ongoing subscriptions o Garden/pool service, regularly billed o Security monitoring services, regularly billed Television licence Motor vehicle licence Short-term insurance documentation Notification of the registered residential address issued by the Department of Home Affairs Utility bill from Telkom/Eskom or a local authority. The bill will be acceptable as long as the investor's name and the erf/stand and township details are reflected Tenants may verify their physical address by presenting a declaration from the property owner/landlord, or a permit to occupy the premises, or a site rental certificate, or a letter from the employer where the customer is housed in/on employer premises A letter from a traditional authority confirming that an individual (or business) is permitted to reside (or operate) on communal land. The letter would need to be signed and stamped by the relevant traditional authority with the stamp issued by government for official documents In the case of a married couple, the spouse of the homeowner may present a marriage certificate proving the relationship to the homeowner Unidentified deposits and incomplete applications received No monies will be invested and/or paid out whilst any required investor information is outstanding. You assume responsibility to ensure that all your information on record with us is up to date at all times. We will contact our bank to try and trace the investor, but cannot guarantee that such action will result in any success. The unidentified deposits account balance will be invested in Manager s name in a bank or money market fund, on which the Manager earns class A fees. Once identified, the Manager will refund the investor interest on such deposit for the period starting from the date that all requirements in order to confirm the validity of the investment has been received. The interest rate to be applied will be the same as the FNB current account deposit rate. If you have any questions about this Application Form, please contact our hotline at 0860 111 899 for assistance. The portfolios are registered with the FSB as part of the MET Collective Investments Scheme. MET is a Full member of the Association for Savings & investments SA (ASISA). Company Reg. No. 1991/003741/06 METCI s contact details are: P O Box 925 Bellville 7535; (0860) 111 899 Fax: (012) 675-3889 Email: ci.clientservice@momentum.co.za.. If your complaint has not been resolved to your satisfaction, kindly contact our Complaints Resolution Committee, Tel: (021) 940 5880 Fax: (021) 940 6969 Email: emoruck@metropolitan.co.za. A FULL MEMBER OF THE ASSOCIATION FOR SAVINGS & INVESTMENT SA Southern Charter Application Form - 2 -
1. PERSONAL DETAILS Please tick and complete where applicable Title Full names Surname Physical address Postal address Income tax reference number Income tax office ID number Date of birth Registration number (CC/Company/Trust) Does the Company have any shareholders with more than 25% of the voting rights at a general meeting (not applicable to companies listed on the JSE) If YES please complete Annexure A for each individual/institution holding more than 25%. Telephone number (H) Telephone number (W) Cellphone number E-mail Resident Non-resident Country of Residence YES NO SA emigrant 2. BANK DETAILS Account to be used for repurchases (No payments will be made by cheque) Account holder Name of bank Branch code Branch Account number Account type Current OR Savings I consider myself to be, or to be associated with a Politically Exposed Person (PEP)* YES NO If YES, please give details *Politically exposed persons (PEPs): PEPs are people who are entrusted, or have been entrusted in the past with a prominent public function locally or in a foreign country, or a family member or a close associate of theirs. This includes any beneficiary you may have nominated. The international regulator of anti-money laundering, the Financial Action Task Force, and the South African Financial Intelligence Center places a duty on us to identify our PEP investors. Please refer to their websites: www.fatf-gafi.org and www.fic.gov.za. A PEP status does not only apply to members of government or persons involved in politics, but includes union leaders, influential functionaries in nationalised industries and government administration including local government and municipal administration structures, senior judges, senior members of prosecuting and investigative authorities, senior political party functionaries, senior and/or influential officials, functionaries and military leaders and people with similar functions in international or supranational organisation (a method of decision making in a multinational political community where power is delegated to specific members to act on behalf of the community, e.g. the European Union or World Trade Organisation) and members or known acquaintances of ruling or royal families, senior and/or influential representatives of religious organisations. 3. INVESTMENT PLAN I/we select the following investment plan(s): PORTFOLIO NAME MINIMUM LUMP SUM MINIMUM MONTHLY LUMP SUM* MONTHLY Southern Charter MET Balanced Fund of Funds R10 000 R 500 R R Southern Charter MET Defensive Fund of Funds R10 000 R 500 R R Southern Charter MET Growth Fund of Funds R10 000 R 500 R R Southern Charter MET Worldwide Flexible Fund of Funds R10 000 R 500 R R * Please note that no cash will be accepted. Cash can be paid directly into the bank account as instructed below. In the case of lump sums, please fax through copy of bank deposit slip with the application form # Use the contract number, starting with RU followed by a 9 digit number beginning with 5, as the reference number on the bank deposit or EFT. FIRST NATIONAL BANK Account holder: MET Collective Investments Ltd-METCI Client Deposit Trust Branch Name: Global Transactional Banking Account number: 623 614 33784 Branch Code: 253-145 Source of funds Southern Charter Application Form - 3 -
SARB exchange control classification (indicate with an X ) - will be regarded as retail if not indicated: Retail Institutional 4. DEBIT ORDER AUTHORITY Retail Institutional I SARB authorise exchange MET control Collective classification Investments (indicate to effect with an the X ) drawings - will beagainst regarded my/our as retail account if not indicated: on day of each month in accordance with this debit order, commencing on D D M M Y Y Y Y Account holder Name of bank Branch code Branch Account number Account type Once-off debit order Y N Amount R Date D D M M Y Y Y Y Note: We do not cater for debit orders linked to foreign bank accounts. Optional annual automatic increase % Signature of account holder 5. INCOME INSTRUCTION Please select one option. If no selection is made, income will automatically be re-invested Reinvest my income in further units Pay my income into my bank account detailed in Bank details 6. FACSIMILE INSTRUCTION I wish the following authorisation to apply: (If NO is selected only original instructions received will be acted upon) I/We, the undersigned hereby authorise MET Collective Investments Limited to act upon instruction by facsimile with regard to my investment in collective investments without liability in respect of any transfer, payment or other act done in accordance with such instructions and notwithstanding the absence of proof that the same was signed or sent by me. 7. TERMS AND CONDITIONS Y N 1. The investor applies to invest in the collective investments managed by MET Collective Investments Limited and/or Southern Charter Wealth Management (Pty) Limited in accordance with the provisions of MET Collective Investments Limited Scheme at the ruling purchase price at the close of business on the date of receipt of the funds by MET Collective Investments Limited, or being placed in receipt of this application, whichever is the later, provided it is received by the daily cut off time of 13h00 (South African time). If received after 13h00 (South African time) then the following business day s ruling prices shall be used to calculate the purchase value of the investment. Fund of Funds withdrawal transfers may be delayed if funds have to be liquidated from the underlying portfolios. 2. The investor undertakes to forward the original documents, as required for FICA as laid down on page 1/2, to MET Collective Investments Limited and/or Southern Charter Wealth Management (Pty) Limited simultaneously with the application form. 3. In the event of participatory interests being redeemed, payment will only be made into the investor s bank account as set out in the banking details section. 4. All fees and expenses applicable to the investment as explained to the investor shall be deducted from the investments. Without prejudice to any rights which MET Collective Investments Limited may have in terms hereof or by law, the investor agrees that MET Collective Investments Limited shall be entitled to recover from the investor any amount of money paid to the investor which the investor is not entitled to for whatever reason. 5. The investor s chosen service address ( domicilium ) for the receipt of all notices and processes given in terms hereof, is the physical address detailed on this application form or as detailed in writing. 6. The risk profile of the investment has been explained to the investor in terms of the underlying assets (equities, bonds and cash). Collective Investments should be considered a medium to long term investment. Collective Investments are sold at ruling prices. Forward pricing is used to determine the nett asset value. Commission and incentives may be paid and are included in the overall costs. The value of the participatory interests may go down as well as up and past performance is not necessarily a guide to the future performance. MET Collective Investments Limited is a Full member of the Association for Savings & Investments SA(ASISA). 7. Investments will only be accepted and processed on receipt of a completed application form, a cheque or copy of a deposit slip or proof of electronic transfer, recent bank statement indicating the investor s banking details AND all other additional documentation as required for FICA as laid down on page 1/2 AND the funds reflect in the bank account. 8. Collective Investments prices are calculated on a Net Asset Value basis and auditor s fees, bank charges and trustee levies are levied against the portfolio. 9. All repurchases must be requested in writing and will be disinvested following receipt and acceptance of such written instruction and subject to MET Collective Investments requirements having been met. The proceeds from the redemption of units will be paid within 2 business days from receipt of a written request. The reflection of the payment in the investor s account may only appear at a later date, depending on which bank the investor makes use of. If the units to be repurchased are subject to a pledge, written consent for the transaction is required. 8. DECLARATION 1. I/We acknowledge that MET Collective Investments Limited may not cede or assign any of its rights to any third party without my/our prior written consent and that I/we may not delegate any of my/our obligations in terms of this contract/authority to any third party without prior written consent of the authorised party. I/we agree to accept the number of participatory interests sold to me by virtue of this application and warrant that I/we have full power and authority to enter into and conclude this transaction. I/we am/are aware that a collective investment is a medium to long term investment (3 to 5 years). 2. I/We warrant that in respect of this investment I/we have not contravened any anti-money laundering legislation and regulations applicable to me/us. 3. I/we have read and understood the contents of this application form and agree to be bound by the terms and conditions obtained herein. 4. I/We understand that it is my/our obligation to familiarise myself/ourselves and accept the risk associated with this investment. 5. I/We have attained the age of majority in terms of the laws applicable to me/us and there are no legal encumbrances which prohibits me/us from entering into this agreement without the consent of my/our parent/guardian. Southern Charter Application Form - 4 -
8. DECLARATION CONTINUE 6. I/We confirm that information pertaining to my/our account (including duplicate statements, valuations and other information that may be required from time to time) may be released to the agent identified below in electronic or written format (delete if not required). 7. I/We confirm that the information on my/our account, (including investment valuations and other information that may be required from time to time) may be made available to me in a secure electronic format. 8. I/We are the beneficial owner(s) of the account OR I/We are acting on behalf of the beneficial owner in a representative capacity (delete whichever is not applicable). 9. I/We hereby permit MET Collective Investments Limited and/or Southern Charter Wealth Management (Pty) Limited to conduct any necessary investigation to verify that the information and documentation included in this application are correct and in the case where such investigation results in conflicting information, I understand that MET Collective Investments Limited and/or Southern Charter Wealth Management (Pty) Limited is obliged to report the transaction as a suspicious transaction to the relevant authorities. 10. I/We hereby waive any claim, of whatsoever nature, that I/we may have against MET Collective Investments Limited in future relating to or arising from the investments, save insofar as it arises from any dishonesty, theft or gross negligence of the company s employees, agents or representatives. 11. I/We acknowledge that I/we have fully acquainted myself/ourselves of the fee and expense structure that are to be charged in respect of the investment from time to time. 12. I/We confirm that all information contained in this application form and the supplied documentation are true and correct and that full disclosure of all relevant facts known to me/us have been made. I/We acted in accordance with the fully complied laws applicable to me/us. 13. I/we do recognise that MET Collective Investments do not provide financial advice and that if such advice is required, that I/we have to consult a qualified financial advisor. I/we hereby confirm that we have received the following information from my/our advisor and/or the manager before completing the application. Investment objective* Info on NAV* Charges * Risk factor* Income accruals* Date D D M M Y Y Y Y Signature of investor 9. INCOME PLAN If applicable I/We, the undersigned, hereby authorise MET Collective Investments Limited to transfer from my investment account DAY OF EACH MONTH TO MY BANK ACCOUNT LISTED ABOVE. 10. INTRODUCER S DETAILS To be complete by the investor R RAND ON THE DAY 1. I DO NOT APPOINT A FINANCIAL ADVISOR: OR I APPOINT NAME AS MY FINANCIAL ADVISOR (S). I hereby confirm that the individuals whose details are completed above, is my appointed Financial Advisor and I agree to the payment of fees as indicated in point 5 below. 2. I confirm that my financial advisor(s) is an approved investment manager/discretionary financial service provider, in terms of the Financial Advisory and Intermediary Services Act, 37 of 2002 ( FAIS ), with full discretion to manage my investments. I instruct MET Collective Investments Limited ( METCI ) to accept instructions given by my financial advisor(s) on my behalf. 3. I instruct MET Collective Investments to provide my financial advisor(s) with a copy of my Yes Y No N TICK APPLICABLE BOX valuation statements. 4. In consideration for the execution of the financial advisors duties in respect of the investment(s), I acknowledge that the financial advisor(s) shall receive payment of such fees as are reflected in the application form or any variations thereof, which fees shall be charged against the investment(s). 5. Annual advice fee (excl VAT) % per annum of the market value of the investment portfolio, charged by way of unit reduction and paid to the Financial Advisor monthly in arrears. Negotiable to maximum 1% exclusive of VAT. If initial advice fee greater than 1.00% is selected, then the maximum annual advice fee is 0.5%.) this annual advice fee is not part of the normal annual management fee charged by the relevant portfolios. This authority may be withdrawn by written notice to MET Collective Investments. 6. I expressly agree that I will have no claim or cause of action against MET Collective Investments in connection with my relationship with my financial advisor(s), this mandate, or for any other reason including the advice given to me by the financial advisor(s). I/we opt for option indicated above with an X. I/we agree that participatory interest to the value of the indicated options ongoing fee plus VAT be redeemed from my account on a monthly basis to be paid as an ongoing advisory fee to the financial advisor stated below. AT PLACE ON THIS DAY DAY OF MONTH YEAR YEAR ATURE OF INVESTOR NAME OF LEGAL GUARDIAN (Where applicable) Southern Charter Application Form - 5 -
TO BE COMPLETED BY THE FINANCIAL ADVISOR: CONTACT NAME BROKER HOUSE NAME / CODE BROKER NAME / CODE FSP LICENCE NUMBER TELEPHONE FAX NUMBER EMAIL I/we declare that I/we am/are licensed Financial Services Provider(s) and have made the disclosures required in terms of the Financial Advisory and Intermediary Services Act, No. 37 of 2002, and subordinate legislation thereto. Warrant that I/we have explained all fees that relate to this investment to the investor and I/we understand and accept that the investor may withdraw his/her authority for payment to me/us in writing to MET Collective Investments. I hereby confirm that I/we RECEIVE* DON T RECEIVE additional income from the manager, the distributor and/or the portfolio manager. *if, the FSP is deemed to be a related party and the nature and extent of the said income is FICA DECLARATION BY FINANCIAL ADVISOR I/We hereby certify and warrant that: 1. I/We have met with the investor prior to the investment being placed with MET Collective Investments Limited and the necessary due diligence process as required by legislation has been satisfactorily carried out. 2. I/We have established and verified the true identity of the investor and confirm that identity checks have been undertaken to confirm that the investor s name, address and identity as shown on this Investment Application Form are true and correct. Attached please find certified copies of the documents evidencing the legal structure and existence of the investor as required in Section 13 FICA and business requirements. 3. I/We are not aware of any activities in which the investor is involved which may lead us to suspect or reasonably suspect that the investor is or maybe involved in any unlawful activities or money laundering. Should we subsequently become aware of suspicions of this nature, we shall immediately inform MET Collective Investments Limited. 4. I/We confirm that I/we subscribe and adhere to the fit and proper requirements and other statutory obligations and criteria imposed by legislation covering advice dispensed and/or intermediary services rendered to investors. 5. I/we understand that I/we are the primary accountable institution under the Act. 6. I/we understand that if I/we have selected No, MET Collective Investments Limited will be responsible for the primary Know Your Client requirements of the Act and that the application will be delayed until MET Collective Investments Limited receives all the required Know Your Client documentation. 7. I/We further confirm that we will keep record of the verification documents as required in terms of the said Act and will make available copies of these documents and details of the verification procedures followed on request to any party entitled thereto in terms of the Act. I confirm that I have identified the client, including the investment owner, insured life/lives, contribution/premium payer and cessionary, their residential address and business address where applicable and verified his/her/their details on this contract under the requirements that Section 21 of the Financial Intelligence Centre Act, No. 38 of 2001, sets out and also that I have stored all the verification documents in terms of Section 22 of the same Act. I further confirm that I have established the source of the client s income and/or the source of the funds that the client has used/will use to conclude this transaction. I am satisfied that the applicable income or source of funds is consistent with the client s business activities. YES NO Yes No AT PLACE ON THIS DAY DAY OF MONTH YEAR YEAR ATURE OF FINANCIAL ADVISOR (who accepts his/her appointment) Southern Charter Application Form - 6 -
11. FAIS CONFLICT OF INTERST DISCLOSURE Please note that in most cases where the FSP is a related party to Southern Charter Wealth Management (Pty) Limited and/or MET, Southern Charter Wealth Management (Pty) Limited and/or distributor earns additional fees apart from the FSP s client advisory fees. It is the FSP s responsibility to disclose additional fees to you as the client. Such fees are paid out of the portfolio s service charge and range anything between (excl VAT): CIS Manager Up to 0.20% Southern Charter Wealth Management Up to 0.80% Distribution/LISP 0.00% Performance Fee 100% to portfolio manager Total Service Charge 1.00% 12. MAXIMUM COST & CHARGES (Vat inclusive) PORTFOLIO NAME Manager s Charge Initial Advice Fee Ongoing Service Charge Risk Southern Charter MET Balanced Fund of Funds* 0.00% 0.00% 1.14% Moderate Southern Charter MET Defensive Fund of Funds** 0.00% 0.00% 1.14% Conservative/Moderate Southern Charter MET Growth Fund of Funds* 0.00% 0.00% 1.14% Moderate/Aggressive Southern Charter MET Worldwide Flexible Fund of Funds* 0.00% 0.00% 1.14% Moderate/Aggressive The investor pays for the value of the ruling underlying investments as on the day the investment deposit is received after deduction of the following manager s charges, where applicable: (refer note 7.1): Service Charge An annual service charge is levied daily on the market value of the portfolios. In the case of fund of funds, the underlying portfolio managers levy an ongoing service charge as well detail on request. Performance Fee * 15% (Sharing rate) of out performance above benchmark (hurdle rate), over a 2 year rolling period, capped at 2% p.a **15% (Sharing rate) of out performance above benchmark (hurdle rate), over a 2 year rolling period, capped at 1,5% p.a If you have any questions about this Application Form, please contact our hotline at 0860 111 899 for assistance. The portfolios are registered with the FSB as part of the MET Collective Investments Scheme. MET is a Full member of the Association for Savings & investments SA (ASISA). Company Reg. No. 1991/003741/06 METCI s contact details are: P O Box 925 Bellville 7535; (0860) 111 899 Fax: (012) 675-3889 Email: ci.clientservice@momentum.co.za.. If your complaint has not been resolved to your satisfaction, kindly contact our Complaints Resolution Committee, Tel: (021) 940 5880 Fax: (021) 940 6969 Email: emoruck@metropolitan.co.za. A FULL MEMBER OF THE ASSOCIATION FOR SAVINGS & INVESTMENT SA Southern Charter Application Form - 7 -
Annexure A Not required for individual investors Please complete a separate Annexure A form for each authorised representative, founder/donor, trustee, beneficiary, member, partner, executive, manager and shareholder of each entity. Investor Details NAME OF INVESTING ENTITY: Designation: Authorised representative Founder Trustee Beneficiary Partner Executive Manager Shareholder Title: First name(s): Physical Address: Postal Address: Please tick relevant box for method of identification: Identity document or Passport ID no./passport no. Date of birth D D - M M - Y Y Y Y Signature of investor If you have any questions about this Application Form, please contact our hotline at 0860 111 899 for assistance. The portfolios are registered with the FSB as part of the MET Collective Investments Scheme. MET is a Full member of the Association for Savings & investments SA (ASISA). Company Reg. No. 1991/003741/06 METCI s contact details are: P O Box 925 Bellville 7535; (0860) 111 899 Fax: (012) 675-3889 Email: ci.clientservice@momentum.co.za.. If your complaint has not been resolved to your satisfaction, kindly contact our Complaints Resolution Committee, Tel: (021) 940 5880 Fax: (021) 940 6969 Email: emoruck@metropolitan.co.za.
Annexure B Beneficial owner declaration of status Dividends tax: Declaration and undertaking to be made by the beneficial owner of a dividend (exemption from tax) DTD (EX) Notes on completion of this form: This form is to be completed by the beneficial owner (of dividends, including dividends in specie) in order for the exemptions from dividends tax referred to in section 64F read with sections 64FA(2), 64G(2) or 64H(2)(a) of the Income Tax Act, 1962 (Act No 58 of 1962) (the Act) to apply. In order to qualify for an exemption this declaration and written undertaking should be submitted to the withholding agent (declaring company or regulated intermediary) within the period required by the latter (provided it is before payment of an affected dividend) - failure to do so will result in the full 15% dividends tax being withheld/payable. Non South African residents seeking to qualify for a reduced rate should not complete this form. Please use Form DTD (RR). Part A: Withholding agent This part is to be pre-populated by the company or regulated intermediary Registered name: MET Collective Investments Dividends tax reference number: 9350/138/71/6 Contact details: Address: PO Box 925, Bellville, 7535 Share call number: 0860 111 899 Fax: +27 (0)12 675 3889 Email: ci.clientservice@momentum.co.za Part B: Beneficial owner This part is to be completed by the person entitled to the benefit of the dividend attaching to a share(s) Full names & surname / registered name: Nature of person / entity: Please tick the most appropriate box: An individual Listed company Unlisted company Trust (any type) RSA Government, Provincial Administration, Municipalities Retirement Fund (Pension, Provident, Benefit, RA etc) Other If other, please provide a description / explanation of nature of the entity /person:
Identity / Passport / Registration number: South African income tax reference number: Physical address Postal address Country in which resident for tax purposes: Part C: Exemption This part is to be completed by the person entitled to the benefit of the dividend attaching to a share(s) Please indicate the reason why the beneficial owner is exempt from the dividends tax by ticking the appropriate box: Par (a) Par (b) Par (c) Par (d) Par (e) Par (f) Par (g) Par (j) Par (i) a company which is resident in South Africa the government, provincial government or municipality (of the Republic of South Africa) a public benefit organisation (approved by SARS ito section 30(3) of the Act) a trust contemplated in section 37A of the Act (mining rehabilitation trusts) an institution, body, or board contemplated in section 10(1)(cA) of the Act a fund contemplated in section 10(1)(d)(i) or (ii) of the Act (pension fund, pension preservation fund, provident fund, provident preservation fund, retirement annuity fund, beneficiary fund or benefit fund) a person contemplated in section 10(1)(t) of the Act (CSIR, SANRAL, etc) a shareholder in a registered micro business as defined in the Sixth Schedule to the Act to the extent that the aggregate amount of the dividends paid by that registered micro business to its shareholders during the year of assessment in which that dividend is paid does not exceed R200 000 a person that is not a resident and the dividend is a dividend contemplated in paragraph (b) of the definition of dividend in section 64D (i.e. a dividend on a foreign company s shares listed in SA, such as dual-listed shares) D e c l a r a t i o n i n t e r m s o f s e c t i o n s 64 F A ( 1 )( a )( i ), 64 G ( 2 )( a ) ( a a ) o r 64 H ( 2 )( a )( a a ) o f t h e A c t : I (full names in print please), the undersigned hereby declare that dividends paid to the beneficial owner is exempt, or would have been exempt had it not been a distribution of an asset in specie, from the dividends tax in terms of the paragraph of section 64F of the Act indicated above. Date D D M M Y Y Y Y ATURE (Duly authorised to do so) Capacity of signatory (if not the beneficial owner): U n d e r t a k i n g i n t e r m s o f s e c t i o n s 6 4 F A ( 1 )( a )( i i ), 64 G ( 2 )( a )( b b ) o r 64 H ( 2 )( a ) ( b b ) o f t h e A c t : I (full names in print please), the undersigned undertake to forthwith inform the withholding agent in writing should the circumstances of the beneficial owner referred to in the declaration above change. Date D D M M Y Y Y Y ATURE (Duly authorised to do so) Capacity of signatory (if not the beneficial owner):