THE INSIDE VIEW TAX FREE SAVINGS ACCOUNT APPLICATION FORM NATURAL PERSONS DOCUMENT CHECKLIST INVESTOR DETAILS

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1 TAX FREE SAVINGS ACCOUNT APPLICATION FORM THE INSIDE VIEW NATURAL PERSONS No instruction will be processed unless all requirements have been met, all relevant documentation received and the money is reflected in Sygnia s bank account. Completed forms are to be faxed to us on or ed to instructions@sfs.sygnia.co.za. Should you have any queries regarding this application, please contact the Sygnia Client Service Centre on (0860 SYGNIA). The daily cut-off for receipt of instructions is 14h00. Please read the Terms and Information that apply to this investment. This is available from your financial advisor, the Sygnia Client Service Centre or Note: Should you be completing this form online please note that you have to save the form to your computer prior to filling in any details to ensure a copy for your records. DOCUMENT CHECKLIST FICA and business requirements as set out in Annexure A Proof of deposit/transfer in to the relevant Sygnia bank account For the authorised representative FICA and business requirements as set out in Annexure A Proof of authority to act (e.g. power of attorney) INVESTOR DETAILS Title: Surname: First name(s): ID number: Date of birth: South African resident: X Yes Are you a registered taxpayer? Yes No If yes, specify income tax number: Occupation: Postal address: Residential address: SYGNIA FINANCIAL SERVICES (PTY) LTD Registration No. 2010/015491/07 Directors: N. Giles S. Peile M. Wierzycka CAPE TOWN 7th Floor The Foundry Cardiff Street Green Point 8001 T F info@sygnia.co.za JOHANNESBURG Unit 40 6th Floor Katherine and West Building West Street Sandton 2196 T F info@sygnia.co.za Sygnia Financial Services is an authorised financial services provider, FSP number 44426

2 Home telephone number: ( ) Work telephone number: ( ) Cellphone number: Fax number: ( ) address: Please select only one of the following communication methods. If no selection is made, or both are selected, we will communicate with you via . Communication Method: Post Language Preference: English Afrikaans (Please note not all communication is available in Afrikaans.) If you have a financial advisor, you may choose to have your communication sent to you, your financial advisor or to both. Send communications to: Me My financial advisor Both If no selection is made we will send communication to you only. DETAILS OF PERSON ACTING ON BEHALF OF INVESTOR *Capacity: (* e.g. Guardians/Persons with Power of Attorney or mandate acting on behalf of investor.) Title: Surname: First name(s): Occupation: ID or Passport number (if foreign national): Postal address: Residential address: Home telephone number: ( ) Work telephone number: ( ) Cellphone number: Fax number: ( ) address: SYGNIA ALCHEMY PLATFORM SELECTION SYGNIA BOUTIQUE PLATFORM Administration Fee: There is no initial or annual administration fee. INVESTMENT DETAILS Existing Sygnia account Salary Savings Bonus Inheritance Other If other, please specify: Note: Sygnia Financial Services (Pty) Ltd reserves the right to request proof of source of funds. LUMP SUM CONTRIBUTION: MINIMUM R AND MAXIMUM R PER TAX YEAR Rands Cents Date of deposit/transfer / / Electronic / Internet transfer 1 Electronic collection by the Administrator (Maximum of R30 000) 2 Note: 1. Sygnia Financial Services (Pty) Ltd ( Sygnia ) requires proof of transfer or deposit before this application can be processed. Electronic transfers may not reflect immediately. 2. I hereby instruct and authorise Sygnia or its assignees to draw against my account the above electronic collection instruction with the bank account noted in this form. PAGE 2/7

3 FUND SELECTION Please refer to the Fund Summary for the list of available funds. Funds Class Rand Amount Percentage Sygnia Skeleton Balanced 70 Fund A R OR % Sygnia Skeleton Balanced 60 Fund A R OR % Sygnia Skeleton Balanced 40 Fund A R OR % Sygnia SWIX Index Fund A R OR % Sygnia DIVI Index Fund A R OR % Sygnia Top 40 Index Fund A R OR % Sygnia Listed Property Index Fund A R OR % Sygnia All Bond Index Fund A R OR % Sygnia Skeleton International Equity Fund of Funds A R OR % Sygnia Skeleton Worldwide Flexible Fund A R OR % TOTAL R TOTAL % DEBIT ORDER CONTRIBUTION MINIMUM R500 PER MONTH AND A MAXIMUM OF R2500 PER MONTH. Rands Cents per month Commencement Month Collection date: 1 st 15 th I hereby instruct and authorise Sygnia or its assignees to draw against my account the above debit order instruction with the bank noted in this form (or any other bank or branch to which I may transfer my account). Note: that a debit order fee of R3.50 will be applicable for contributions less than R1 000 per month. Fund Selection For the fees relating to the underlying investment managers please refer to the Fund and Fee Summary. Funds Class Rand Amount Percentage Sygnia Skeleton Balanced 70 Fund A R OR % Sygnia Skeleton Balanced 60 Fund A R OR % Sygnia Skeleton Balanced 40 Fund A R OR % Sygnia SWIX Index Fund A R OR % Sygnia DIVI Index Fund A R OR % Sygnia Top 40 Index Fund A R OR % Sygnia Listed Property Index Fund A R OR % Sygnia All Bond Index Fund A R OR % Sygnia Skeleton International Equity Fund of Funds A R OR % Sygnia Skeleton Worldwide Flexible Fund A R OR % TOTAL R TOTAL % PAGE 3/7

4 INVESTOR BANKING DETAILS The details specified below must be in the investor s name and will be used for all future banking transactions until such time as we are notified in writing of any changes. Bank: Branch: Account number: Branch code: Type of account: Current Transmission Savings Name of account holder: A recent bank statement must accompany this application form as confirmation of proof of bank details. No payments will be made to third parties (i.e. payments will only be made to the bank account in the name of the registered investor). We are unable to facilitate payments to credit cards or market-linked accounts. The Administrator executes all payment instructions electronically. No payment will be made by cheque. THIRD PARTY BANKING DETAILS This section must be completed where a third party makes payment on behalf of the investor. In the event that the payment is a debit order/electronic collection the third party must authorise Sygnia by providing a signature below. Bank: Branch: Account number: Branch code: Type of account: Current Transmission Savings Name of account holder: A recent bank statement must accompany this application form as confirmation of proof of bank details. No payments will be made to third parties (i.e. payments will only be made to the bank account in the name of the registered investor). We are unable to facilitate payments to credit cards or market-linked accounts. The Administrator executes all payment instructions electronically. No payment will be made by cheque. Signature of third party: SYGNIA BANK ACCOUNT DETAILS Account holder: Sygnia Tax Free Savings Products Inflow Bank: Nedbank Branch code: Account number: The Administrator requires proof of deposit or transfer together with receipt of the applicable documentation as set out in this form, before this application can be processed. PAGE 4/7

5 FINANCIAL ADVICE FEES I hereby confirm that the Financial Advisor whose details are completed in the Financial Advisor Details and Declaration section below, is my appointed Financial Advisor and agree to payment of fees as follows: Initial advice fee: (Lump sum) % excluding VAT (Negotiable to maximum 1.50% exclusive of VAT. Applied to each lump sum contribution and deducted before investment is made). Initial advice fee: (Debit order) % excluding VAT (Negotiable to maximum 1.50% exclusive of VAT. Applied to each debit order contribution and deducted before investment is made). Annual advice fee: % excluding VAT (Negotiable to a maximum of 1.50%) 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. This authority may be withdrawn by written notice to the Fund. Signature of investor: FINANCIAL ADVISOR DETAILS Financial advisor full name and surname: FSP name: FSP number: Investor Declaration (only applicable where an FSP holds a Category II discretionary licence) I/We confirm that: I/We have entered into a mandate with the FSP Yes No The mandate gives the FSP Full Limited discretion to act on my/your behalf Note: A copy of the signed mandate must accompany this application form. FSP Declaration I/We declare that I/we am/are a licensed Financial Service 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, to the investor. warrant what I/we have established and verified the identity of the investor(s) (and persons acting on behalf of the investor) in accordance with the Financial Intelligence Centre Act, No. 38 of 2001 ( FICA ) and subordinate legislation thereto, and I/we will keep records of such identification and verification according to the provisions of FICA. 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 may be involved in any unlawful activities or money laundering. Should we subsequently become aware of suspicions of this nature, we shall immediately inform Sygnia Financial Services (Pty) Ltd. Signature of financial advisor: PAGE 5/7

6 DECLARATION BY INVESTOR I/We acknowledge, understand and accept the Sygnia Terms and Information Document. I/We acknowledge, understand and accept that Sygnia may use the information I/we have provided in this form for either of the following purposes: - to effectively process my/our transactions; - to detect and prevent fraud; - to comply with auditing and record-keeping requirements; - to comply with legal and regulatory requirements; - to verify my/our identity; - to share information with service providers with whom Sygnia has a business agreement to process such information on Sygnia s behalf or to those who render services to Sygnia. I/we acknowledge and understand that I/we may access the personal information Sygnia have on record and that I/we may request that Sygnia correct any errors or delete my/our information. I/we acknowledge and understand that I/we can view Sygnia s full privacy policy on Sygnia s website on I/we confirm that I/we was/were provided with the MDD prior to transacting. Signature of investor: PAGE 6/7

7 FOREIGN TAX DECLARATION Important notes: 1. This declaration is required to be completed by all investors, including South African citizens. 2. The following information is required to ensure correct reporting and/or withholding of taxes as required by the US tax authorities in terms of the Foreign Account Tax Compliance Act (FATCA). For more information on FATCA, please contact your financial advisor. 3. Other jurisdictions will in future also require us to provide similar reporting to their tax authorities. Consequently this form is not restricted to determining only US tax residency. INVESTOR DETAILS Full name(s): ID or Passport number: Tax residency: Tax residence refers to the country in which you pay tax on your income. Please indicate in which country (ies) you are a resident for tax purposes (including South Africa). If you are not resident in any country for tax purposes please tick this box ** TIN refers to the US Tax Identification Number I declare that all the above information supplied by me is true and accurate and I agree to notify Sygnia of any changes to the information supplied herein. Signature of investor: PAGE 7/7