application for a collective investment …...this section applies to top-ups only; if you are...

*APIPC0700F*

The flowchart overleaf will help you understand which sections of this application form you need to complete.

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APPLICATION FOR A COLLECTIVE INVESTMENT BOND (CIB)– trust and corporate 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 onCharge Basis 3. For new or top-up investments into the MPS, please speak to your financial adviser.

• individual or joint applicants, for which there is a separate form, available from your financial adviser.

We have three charge bases. They are:

* 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.

These are bonds opened before 18 December 2012, that have not been converted to Charge Basis 2 either by request or automatically.*

These bonds are subject to the Investor Charge and financial advisers are entitled to receive commission.On Charge Basis 1 you can only invest in our SelfSelect investment range.

These are bonds opened from 18 December 2012.

These bonds 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).

These are bonds that have been converted from Charge Basis 1, either by request or automatically.*

These bonds 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.

CHARGE BASIS 1 CHARGE BASIS 3CHARGE BASIS 2

CHARGE BASIS INFORMATION

New bonds will be on Charge Basis 3.Topping up an existing bond – You need to know the Charge Basis for 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.

IMPORTANT DOCUMENTS YOU NEED TO HAVE RECEIVED BEFORE PROCEEDING• 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.

!

CHARGE BASIS 1 To remain on Charge Basis 1,

please ignore sections 11, 12b) and 13.

CHARGE BASIS 3 Your bond will remain on

Charge Basis 3.

Please ignore sections 11 and 12a.

CHARGE BASIS 2 Your bond will remain on

Charge Basis 2.Please ignore sections 11

and 12a.

CHARGE BASIS 2 To convert to Charge Basis 2,*

please complete section 11 and ignore section 12a).

Your new bond will be opened on Charge Basis 3.

Please ignore sections 11 and 12a.

This top-up application willconvert your bond to

Charge Basis 2,*please ignore sections 11

and 12a).

IS YOUR APPLICATION FOR A

NEW BOND?

WHICH CHARGE BASIS IS YOUR BOND CURRENTLY ON?

DO YOU WISH TO REMAIN ON CHARGE BASIS 1 OR CONVERT TO CHARGE BASIS 2?

HAVE YOU RECEIVED ADVICE FROM YOUR FINANCIAL ADVISER FOR THIS APPLICATION?

* Once you convert to Charge Basis 2, you cannot revert to Charge Basis 1.

YES

YES

NO

NO

CHARGE BASIS 1

2 of 12 PDF5415/220-1084/July 2020 (CIB app trust/corp)

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 14, 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 [email protected].

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.

1 FINANCIAL ADVICE

Please tick/complete this form, as applicable, using BLOCK CAPITALS and blue or black ink.

u�Complete the form carefully; errors or omissions by you or your financial adviser will not be corrected retrospectively

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Type of applicant

Top up into this bond number:New bond*

Type of investment

* For a new bond, you must also complete the separate tax information form at the end of this application.If the form is not returned with your application, the investment could be delayed.

CorporateTrust

2 APPLICANT DETAILS

Registered UK office address

Company registration number u if applicable Country of registration

Name of person dealing with correspondence u please note the Personal Data Statement in section 14

Postcode

Full name of trust/company

Client reference number u if known

Correspondence address u if different from above

Names of all directors u private companies only

Postcode

Telephone number Email address

The financial adviser The applicant, using the details shown above.

Tick below to indicate whom we should contact if we have a query about this application:

OR

3 TRUST DETAILS u if applicable

Yes u please complete the beneficiary details in section 4

No u please state the class(es) of the beneficiary/beneficiaries:

Is/are the beneficiary/beneficiaries known?

Class(es) u eg grandchildren

Trust date u this is the date of the declaration of trust or the testator’s death

(dd/mm/yyyy)


4 DETAILS OF OTHER PARTIES

Use this section to give details of parties to the investment who fall into one of the categories listed.u If there are more than four related parties, please provide the same information for any others by using a copy of this page.

Other u please specifyMr Mrs MissTitle

Full forename(s)

Surname/ company name

Permanent UK residential address/registered office address

Date of birth (dd/mm/yyyy)

Postcode

Company registration number u if applicable

Individual Trustee Corporate Trustee Director/Authorised Signatory BeneficiaryTick as applicable:


Full forename(s)




Postcode




Full forename(s)




Postcode




Full forename(s)




Postcode




5 LIFE/LIVES ASSURED

First life assured

Second life assured u if applicable

Third life assured u if applicable

Surname

Male Female

Gender


Full forename(s)

Date of birth (ddmmyyyy) Relationship to the applicant

/ /

Surname

Male Female

Gender


Full forename(s)


/ /

Surname

Male Female

Gender


Full forename(s)


/ /

u Please provide the same information for any additional lives assured by using a copy of this page.

This section must be completed with details of any third party paying for your investment.

u please provide the same information for any additional third-party payers by using a copy of this page.

Full forename(s) u if applicable

Surname/Company name

Full postal address

Company registration number u UK companies only

6 INVESTMENT DETAILS

7 THIRD-PARTY PAYER DETAILS

Postcode

CIB investment amount £

please enclose cheque payable to Old Mutual Wealth Life & Pensions Limited

Select payment method

Cheque number*

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 applicant name to help us process your application.

(minimum £10,000 for new bonds, no minimum for top ups)

*If you are sending payment for more than one application, please send a separate payment for each one.

If this investment is being paid by a third party, please complete section 7.

Date of birth (ddmmyyyy)

/ /

u the payer must be at least 18 years of age.


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

Investment %Unit/Share type ie Inc/Acc†

† 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.

An investment choice continuation sheet is available on request.

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)

Full name of fund or portfoliou the funds must all be from the same investment range, not a mixture from both

B PHASED INVESTMENT u not available in conjunction with automatic rebalancing

C AUTOMATIC REBALANCING u not available in conjunction with Phased Investment

Phase every month for:

Automatically rebalance every:

Starting on:

Starting on:

3 months

3 months

6 months

6 months

12 months

12 months

8 FUND CHOICE

*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.

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.

NOTE

• 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 monthover 3, 6 or 12 months. To request phased investment, complete the required frequency and start date below:

• 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. Torequest automatic rebalancing complete the required frequency and start date below:

• 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.

• 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 ContactCentre on 0808 171 2626.

0 1

1 5

Complete part A, then B or C if required

TOTAL 1 0 0 %


Please tick to indicate which of these options you require

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.* A monthly Death Benefit Charge - may apply depending on the value of your bond. More information is in the CIB Terms and Conditions.ORWithout Capital Protected Death BenefitThis 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.

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 12b• 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.

9 CAPITAL PROTECTED DEATH BENEFIT

11 CONVERTING TO A NEW CHARGE BASIS (only applicable if you are topping up an existing bond on Charge Basis 1)

• Payments will be made by direct credit and we CANNOT make withdrawal payments to third parties.• Some banks or building societies cannot accept direct credits.• 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.

Fixed amounts of (minimum payment £25)£

• Automatic withdrawals will be deducted proportionally across all life policies in your bond.

Fund name

10 AUTOMATIC WITHDRAWAL INSTRUCTION u if required

FREQUENCY OF AUTOMATIC WITHDRAWAL PAYMENTS

BANK DETAILS FOR AUTOMATIC WITHDRAWALS

AMOUNT

• 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 adviser before requesting automatic withdrawals.

NOTE

Yes

Jan Feb Mar Apr May Jun

Jul Aug Sep Oct Nov Dec

When would you like payments to start? 2 8 u if left blank it will be the next available of the months you selected

Do you want to receive payments every month? No – tick below the months in which you would like to receive payments:

• If neither option is ticked, Capital Protected Death Benefit will NOT apply.• The Capital Protected Death Benefit CANNOT be added at a later date.

NOTE

Postcode

Name and address of the bank/building society u this must be in the UK

Sort code

− −Bank account number Bank account holder’s name

Building society reference number u if applicable


We will sell units as follows to meet your automatic withdrawal payments:• Managed Portfolio Service (MPS) investors – we will sell units proportionally across all funds in your bond.• Other investors – we will sell units proportionally across all funds in your bond. However, you can instead choose to sell

proportionally from specific funds by selecting an alternative fund choice below or you can write `largest fund’ if preferred.

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%.

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.

Up to 0.5% depending on the funds selectedPayments will be met from rebates we receive from fund managers; they are not deducted from your bond.

The standard initial commission rate is

Fund-based trail (tick) Nominated trail of

Reduction of initial commission Use multiples of 0.05%%

%

%4.5

OR

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.

b) ADVISER CHARGING (CHARGE BASIS 2 OR 3)

Initial commission (If the reduction box is left blank, your adviser will receive the maximum commission amount under their agreed terms with us)

Trail commission option (Select one only; if neither option is selected, fund-based trail will apply.)

12 PAYMENTS TO YOUR FINANCIAL ADVISER (to be completed with your financial adviser)

• 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.

NOTE

Initial Fee for lump sum

Complete this section if you wish us to deduct fees for your financial adviser from your bond.

£ %ORServicing Fee required: each year

Tick the frequency required Monthly Half-yearlyQuarterly Yearly

Add VAT on top of the Servicing Fee? Yes

• 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.• Any Servicing Fee you authorise here will apply to the entire bond and will therefore override any existing Servicing Fee instruction.• 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.

Servicing Fee

• 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 servicing fees paid from your bond will count towards your 5% annual withdrawal allowance and may therefore have tax

implications.

NOTE

£ %ORInitial fee required: from your lump sum payment


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 12b.We will sell units as follows to meet the Product Charge and Adviser Servicing Fee (as applicable):

Managed Portfolio Service (MPS) investors – we will sell units proportionally from all of your funds.

Other investors – we will sell units proportionally across all funds in your bond. However, you can instead choose to sell proportionally from specific funds by selecting an alternative fund choice below or you can write ‘largest fund’ if preferred.

Fund name

13 OLD MUTUAL WEALTH PRODUCT CHARGE AND ADVISER SERVICING FEE DEDUCTIONS (where applicable)

• For each of these choices, deductions will be made proportionally across all life policies within your bond.NOTE

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 you do not understand anything before you sign and date below. This declaration is made by each trustee, authorised signatory or beneficiary shown in this application. 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:– the trust or corporate entity shown in section 2 is registered

in the United Kingdom and will inform Old Mutual WealthLife & Pensions Limited if this changes in the future.

c) I understand that Old Mutual Wealth Life & Pensions Limited willadminister the Collective Investment Bond in accordance withUK tax legislation.

d) I understand that incorrect information regarding lives assuredmay result in a reduced death benefit being paid.

f) I confirm that if withdrawals are to be paid to a beneficiary, thebeneficiary is 18 or over.

g) I am acting as a trustee, or on behalf of a corporate entitydescribed in section 2 and I confirm I am suitably authorised toinvest and deal in all aspects of this investment.

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 CollectiveInvestment Bond; and

b) to sell units or shares in investments within my bond to meet anycharges or fees for my financial adviser, in accordance with theTerms and Conditions; and

c) to give effect to my instructions in accordance with the Terms andConditions.

3. I understand that I will not receive confirmation relating totransactions involving the purchase or sale of investments whichare carried out on a periodic basis in the manner agreed to inthis application. Details of these transactions will be shown in theperiodic statement which will be sent to me. In particular, suchtransactions 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 mysatisfaction:a) Terms and Conditions, to which I agreeb) Key Features Documentc) Key Information Document about the Collective Investment Bondd) information including rebates, in respect of my chosen funds.

5. I confirm that I have seen and read the privacy notice atwww.oldmutualwealth.co.uk/privacy

6. I declare that this application has been completed correctly and tothe best of my knowledge and belief.

7. If I have completed section 12b of this form:a) I authorise Old Mutual Wealth to deduct any fees detailed in

section 12b from my investment and pay them to my financialadviser.

b) I understand that:i) the fees agreed will be met as follows (as applicable):

• Initial fee – by deduction from my payment before thebalance is invested into my choice of funds

• Servicing fee – by selling units as instructed in section 13.ii) if I have ticked ‘Yes’ in section 12b to add VAT to any

servicing fees, the amount of the agreed fee will be increasedto include VAT at the rate prevailing when the fee isdeducted.

iii) if I select a percentage amount servicing fee, the fee paid tomy financial adviser may go up or down depending on thevalue of my bond on the date the fee is calculated

iv) I will need to re-authorise any increases to fees that havebeen previously agreed.

c) I confirm that:i) I have completed and agreed section 12b 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 itsfuture value.

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 whethera refund is payable.

e) If I am converting to Charge Basis 2:i) I instruct Old Mutual Wealth to stop any commission

payments currently being paid to my adviser in respect of thisinvestment under Charge Basis 1 with immediate effect.

ii) I confirm that Old Mutual Wealth has brought to my attentionthe importance of reading and discussing section 12b of thisform with my financial adviser before signing below.

14 DECLARATION AND SIGNATURE(S)


14 DECLARATION AND SIGNATURE(S) (continued)

1. Signature

2. Signature

Date (dd/mm/yyyy)

Date (dd/mm/yyyy)

Print full name Capacity eg trustee, signatory

On behalf of u�state the name of the company, if applicable

u�in signing below you confirm that you have read and agree to the declaration on the previous page



All trustees/signatories for the account must sign.

u please continue on a separate sheet if necessary

3. Signature

4. Signature

Date (dd/mm/yyyy)

Date (dd/mm/yyyy)






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.

15 FINANCIAL ADVISER’S DECLARATION u to be completed by your financial adviser

Tax information • If this investment is for a new bond, you must include the tax information form available at the end of the application.• If the completed form is not returned with your application, the investment could be delayed.• Non UK Tax – if you are subject to tax in any country outside the UK, please contact your tax specialist, to understand whether you will be

liable for tax in that country.

Full name of regulated firm (or sole trader)

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 parties referred to in this application, other than any listed in (e) below(b) the information in this form was obtained by me in respect of those 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 requires anyfollow-up action from me.

Financial adviser’s signature

Financial Services Register Reference number

Date (dd/mm/yyyy)

Print name

Contact number

Position

*APIPC0700X*Send the completed form to:

Old Mutual WealthOld Mutual HousePortland TerraceSouthamptonSO14 7AY

Tel: Customer Service 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)

Signed cheque for the amount shown in section 6

Execution Only form (see section 1.2)

Third Party Payer details in section 7 (if someone else is paying for the investment)

Tax information at the end of the application (if the investment is for a new bond)


Network (if applicable)

TAX DECLARATION FOR TRUST AND CORPORATE INVESTORSFor use in the UKWe are required to obtain information from you to determine your tax status. This is to enable us to comply with regulations governing automatic exchange of information, including the US Foreign Account Tax Compliance Act (FATCA) and Tax Information Agreements (TISAs) between the UK and its Crown Dependencies and Overseas.

Collection and Disclosure of InformationJurisdictions in which we have regulated businesses have agreed a number of inter-governmental agreements (IGAs) to share tax information with tax authorities in other jurisdictions. The requirement to collect and report information about customers’ tax arrangements is now a legal requirement and as a financial services company we are legally obliged to comply. We are therefore asking for your tax residency and tax reference numbers (where applicable) and will note this information on our records.

Depending on the information collected we may be required to report details about you and your investment to our local tax authority who may exchange this information with overseas tax authorities.

Please complete and return this form so that we can determine if we need to report details about you and your investment.

Policy/bond/account number (if known)

Policy/bond/account holder name

Please tick to indicate below which of the following entity categories applies to you.

1.1 Financial Institution ..........................................................................................................................................................A Financial Institution is an entity which carries out activity related to deposit taking, investment activity, insurance or custody services. This includes:• Banks• Insurance Companies• Custodial Institutions• Investment EntitiesAn Investment Entity is one that primarily conducts as a business one or more of the following activities on behalf of a customer:• trading in money market instruments, foreign exchange, exchange, interest rate and index instruments, transferable securities or

commodity future trading• individual and collective portfolio management; or• otherwise investing, administering or managing financial assets or money on behalf of other persons

In some circumstances it may be possible that a trust holding an insurance policy will be treated as an Investment Entity, particularly where a professional trustee service provider is acting as trustee.

1.2 Non-trading entity (Passive Non-Financial Foreign* Entity) .........................................................................................This is an entity which is not actively trading, for example where the entity only exists to hold investments or income on behalf of another, such as:• a private company;• a partnership; and• other legal arrangements such as a non-professionally managed trust.

1.3 Actively Trading Entity (Active Non-Financial Foreign* Entity) ..................................................................................... This is an entity which actively engages in trading activity, trades or professions which generates the majority of the income of the entity. If the majority of the income of the entity is generated from passive investments then you should tick 1.2. If you are an entity which is established for religious, charitable, scientific, artistic, cultural, athletic or educational purposes please select 1.4.

1.4 Other Non-Financial Foreign* Entity ............................................................................................................................... If you do not fall into any of the above three categories please describe in the space below the nature of the activity carried out by the entity and if you are claiming exemption from FATCA, please detail the reason. Examples of such entities could be charitable trusts, organisations, sports, clubs, associations and government agencies.

Tick one

1 of 4

PART 1 – TYPE OF ENTITY

* For the purposes of this document ‘foreign’ means not in the USA or Crown Dependencies/Overseas Territories

PART 2 – TAX RESIDENCE

Tax residency rules for entities vary from country to country and can be complicated. For instance, companies may be tax resident in the country where they are incorporated but may also be tax resident in countries in which they operate. The rules relating to the tax residency for trusts can be equally complex. If you are in doubt as to your country of tax residence, you should seek professional advice.Please list below each country in which the entity is resident for tax purposes and the tax reference number of the entity, if relevant.

COUNTRY/COUNTRIES OF TAX RESIDENCE TAX IDENTIFICATION NUMBER (TIN) TYPE OF TIN

PART 3 – FURTHER INFORMATION

Part 3 MUST be completed if you ticked 1.1 or 1.2 in Part 1.

A FINANCIAL INSTITUTIONS

This MUST be completed if you ticked 1.1 in Part 1.

Please tick to indicate which of the following best describes the entity/trust, in accordance with the Regulations:

3.1 Financial Institution in a Model 1 or Model 2 IGA country* ......................................................................................... You can find a list of Model 1 and Model 2 countries at http://www.treasury.gov/resource-center/tax-policy/treaties/Pages/

FATCA-Archive.aspx

3.2 Participating Financial Institution in a non-IGA country* .............................................................................................. This is a Financial Institution in a non-IGA country that has entered into an agreement with the US Internal Revenue Service (IRS)

to comply with the FATCA Regulations.

3.3 Registered Deemed Compliant Financial Institution* ..................................................................................................... This is a Financial Institution that has registered in accordance with the FATCA regulations to declare its status. This includes certain

local banks, qualified collective investment vehicles (including non-profit organisations and certain retirement funds), restricted funds and Financial Institutions that comply with the regulations.

3.4 Certified Deemed Compliant Financial Institution .......................................................................................................... This is a Financial Institution which is not required to register under the regulations. For example, this includes non-registered local banks.

3.5 Exempt Beneficial Owner ................................................................................................................................................. The term Exempt Beneficial Owner means a government entity, an international organisation, a central bank or a UK registered

pension scheme, or non-UK pension scheme falling within the definition of Exempt Beneficial Owner for the purpose of the Regulations.

3.6 Non-Participating Foreign Financial Institution (NPFFI) ................................................................................................. An NPFFI is a Financial Institution that has not entered into an agreement to comply with the Regulations and is not a Registered

Deemed Compliant Financial Institution or a Certified Deemed Compliant Financial Institution.

Tick one

*IRS Global Intermediary Identification Number (GIIN)A GIIN is issued by the US Internal Revenue Service to Financial Institutions which are complying with the Regulations.

If you have ticked 3.1, 3.2 or 3.3 please provide your GIIN.

If you do not yet have a GIIN, please advise us when you have been issued with one.

This MUST be completed if you ticked 1.2 in Part 1.

We must obtain information about the underlying Controlling Persons. A Controlling Person is any individual who exerts control over, or has a majority ownership interest in, an entity.

• For companies this includes shareholders who own or control more than 25% of the shares or voting rights or otherwise exercise control over the company. For example, an individual who exercises control over a company is where an individual has less than 25% of the shares or voting rights but who has a percentage ownership or voting right which is significantly higher than other shareholders.

• For trusts this includes settlors, trustees, protectors (if any) and any beneficiary entitled to 25% or more of the trust property.

Please complete the relevant details in the following table in relation to the persons who have ownership or control of the entity.

B CONTROLLING PERSONS

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Settlor Trustee Protector Shareholder Beneficiary (or included in a class of beneficiaries)




Please complete the relevant details in the table below in relation to the persons who have ownership or control of the entity.If there are more than four controlling persons, please provide the same information for each one by using a copy of this page.

B CONTROLLING PERSONS (CONTINUED)

* In the UK and the Isle of Man this is known as a National Insurance Number. In Guernsey and Jersey this is called a Social Security Number. In the United States this is known as a Tax Identification Number (TIN).

Full name including title




Full address

Full address

Full address

Full address





Town/City and Country of birth




Postcode

Postcode

Postcode

Postcode

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Nationality(ies) Country(ies) of residence for taxation Tax identification number(s) (TIN)* Type of TIN*




www.oldmutualwealth.co.ukPlease 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 59.9982/220-0510/May 2020

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PART 4 – DECLARATION AND CERTIFICATION

1. We, as directors, controllers, trustees or persons acting on behalf of the entity declare that the information provided in this Tax Declaration is, to the best of our knowledge and belief, accurate and that the statements made by us are true and complete.

2. We agree to notify you if any information contained in this Tax Declaration changes, for example where the controlling persons change. We understand that this may require us to complete a new Tax Declaration form.

3. We understand that the information collected in this Tax Declaration may be disclosed to the collecting institution’s home state tax authority which may, under a relevant inter-governmental agreement, provide the information to an overseas tax authority.

By signing this declaration we confirm that we have read the above declaration and, if a third party has completed this form on behalf of the policy/bond/account holder that all the information provided within it is correct.

Signed on behalf of (entity name)

Signed by (please print name)


Capacity in which you are signing


Signature Signature

Date (dd/mm/yyyy)

Date (dd/mm/yyyy)





Signature Signature

Date (dd/mm/yyyy)

Date (dd/mm/yyyy)





Signature Signature

Date (dd/mm/yyyy)

Date (dd/mm/yyyy)