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1 Application reference number For office use only Benefit Crystallisation Event Request applying for an annuity with another provider *SFBCY0400F* For use with the Collective Retirement Account (CRA) For use by financial advisers only This form should be used where the whole of your CRA is to be used to provide an annuity, with or without a tax-free lump sum, or where part of the crystallised amount is to be used to purchase an annuity. Before completing this form you should seek guidance from your financial adviser, who will be able to make available the latest valuation statement of your CRA. NOTE Guidance notes It is important that you read the guidance notes at the back of this form. They explain how to complete each section and contain details of any additional documents we need. The amount of money you must retain in your account following any withdrawal is the greater of 10 of the entire fund value or x any outstanding Phased Initial Charge. If you are using your whole fund to purchase an annuity, any outstanding Phased Initial Charge will be deducted from your plan. Please complete this form using BLOCK CAPITALS only in blue or black ink. Once you have completed this form: Please sign the declaration and return the form to: Old Mutual Wealth Old Mutual House Portland Terrace Southampton SO14 7AY Please tick here if the annuity provider will be applying for your funds via the Options service. They will be able to confirm this to you. 1 Personal details Please quote your client reference number u if known Collective Retirement Account number Title Mr Mrs Miss Surname Other u please specify Full forename(s) Date of birth u ddmmyyyy National Insurance number Address Telephone number address Evidence of Age NOTE: If this is the first time you have taken benefits from the Collective Retirement Account, we must have evidence of your age. Please refer to the accompanying guidance notes at the back of this form for more information. 1 of 6

2 Please tick one of the following: 1) I wish to use all of my pension fund for annuity purchase (with pension commencement lump sum, where applicable) Ignore section 4. 2) I wish to use part of my pension fund for annuity purchase Ignore section 3. 2 Financial Adviser Statement this statement must be completed in order for Old Mutual Wealth to carry out the instruction on behalf on the client This is to confirm that I have provided my client with advice and discussed the appropriate risks in relation to this transaction. Financial Adviser Name Firm Name Signature Date u ddmmyyyy 3 Using all the pension fund for annuity purchase Pension commencement lump sum If you have uncrystallised funds in your account you can choose to receive part of these as a tax-free lump sum (a pension commencement lump sum). Please indicate the amount of pension commencement lump sum you wish to receive. Maximum Specified amount Nil Bank details Please indicate which bank account you wish your pension commencement lump sum to be paid into. We cannot make payments to third parties. Name of bank account holder BankBuilding society name Branch address of bankbuilding society u this must be a UK bankbuilding society account. BankBuilding society account number Sort code - - Building society roll number u if applicable. go to section 5 NOTE: Before we can make payment, we need to see proof of the bank account ownership. The proof can be a voided cheque or a copy of your bank account statement (certified as a true copy by your financial adviser). If you have online bank account statements, a printed copy certified by your adviser will suffice. 4 Partial annuity open market option NOTE: If you are purchasing an annuity using only part of your account, you can only use crystallised funds. The amount of crystallised funds that you can use for annuity purchase is subject to certain conditions. A minimum amount of the crystallised funds must remain in your CRA. The guidance notes for Section 4 describe these conditions in more detail. Please confirm how much of your crystallised funds you would like to use: go to section 5 2 of 6

3 5 Annuity provider details Provider name Address of annuity provider Annuity reference Annuity provider bank details Name of bank account holder Bank name Branch address of bank BankBuilding society account number Sort code Protection benefits u If you are not applying for any form of protection go to section 7 Tick to indicate the protection required Enhanced Protection Enhanced Lifetime Allowance Block Transfer Protection Primary Protection Individual Protection 2014 Fixed protection Fixed Protection 2016 Fixed Protection 2014 Individual Protection 2016 Please state your HM Revenue & Customs (HMRC) certificate number u you must enclose a copy of the certificate if this is the first application for protection made on Old Mutual Wealth s platform I confirm that my entitlement to protection indicated above has not been revoked Block Protection Please indicate which protection you wish to claim u you may tick both if you require both options Tax-free cash Low pension age Primary Protection Tax-free cash received to date Date u dd mm yyyyy Tax-free cash paid For office use only Date u dd mm yyyyy Tax-free cash paid Date u dd mm yyyyy Tax-free cash paid 3 of 6

4 7 Previous retirement events We cannot process this form if this section is not completed the guidance notes at the end will help you. You must tickcomplete ONE of the following: 7a i have never taken pension benefits from any provider, OR I have only taken pension benefits from my Old Mutual Wealth Collective Retirement Account OR 7b I have only taken pension benefits that started before 6 April 2006 The current annual pension I am receiving is Where this income is paid by income withdrawal, please show the current annual maximum income you are allowed to take. OR 7c I have only taken pension benefits since 5 April 2006 The total percentage of the Standard Lifetime Allowance used up by pension benefits started after 5 April 2006 is OR 7d I have taken benefits both before and after 5 April 2006 The total percentage of the Standard Lifetime Allowance used up by pension benefits started after 5 April 2006 is The first time I took pension benefits after 5 April 2006 was u ddmmyyyy Please tick one of the following: On this date I had already started taking pension benefits, and these are included in the Lifetime Allowance percentage provided above. On this date I was already receiving an annual pension of is not included in the Lifetime Allowance percentage given above., which started before 6 April 2006 but Only complete the following if you have ever taken a scheme pension from a money purchase scheme and this is not included in any lifetime allowance figure provided above. Your financial adviser will be able to confirm whether this applies to you. Please state: (a) The purchase price of the scheme pension from the money purchase scheme. (b) The tax free cash lump sum taken with this. (c) The date this occurred. u ddmmyyyy 8 Insufficient Lifetime Allowance You do not need to complete this section if you are claiming Enhanced Protection. If the amount being used to provide benefits is greater than your remaining Lifetime Allowance, please specify how the excess is to be paid: to be taken as cash lump sum.u only applicable before age 75. to be taken as income Total u these percentages must total 100. Please note that a tax charge will be due on the excess amount, more information is in the guidance notes. 9 Declaration I request and consent to the payment of benefits set out in this form. I declare that: 1. I have read the attached guidance notes and I understand the figures quoted in my valuation are subject to change. 2. The information supplied by me is true and complete to the best of my knowledge as at the date of this Declaration. 3. I will inform Old Mutual Wealth Life & Pensions Limited of any change to the information provided occurring after the date of this Declaration and before the Benefit Crystallisation Event takes place. 4. I understand that any false statement may result in HM Revenue & Customs imposing penalties on me. 5. I understand that a Lifetime Allowance Charge, where applicable, will be deducted from my CRA and paid to HM Revenue & Customs. 6. I agree that I will indemnify Old Mutual Wealth Life & Pensions Limited against any liability to pay any tax or other charges which occur due to the provision of false or misleading information. 7. Any payment by Old Mutual Wealth Life & Pensions Limited of the benefits under this CRA shall constitute a full discharge from all liabilities and claims arising in respect of the pension monies applied in this Benefit Crystallisation Event request. 8. Any tax-free cash will not be used to fund further contributions to any registered pension scheme to the extent that either Old Mutual Wealth Life & Pensions Limited or I will suffer a tax liability. 9. If appropriate, Old Mutual Wealth has my authority to check with HM Revenue & Customs the details of any certificate I supply. Name u please print Signature Date u ddmmyyyy *SFBCY0400X* 4 of 6

5 Guidance notes Section 1 - Personal details Enter your details in this section. Evidence of Age If this is the first time you have taken benefits from the Collective Retirement Account, we must have evidence of your date of birth. We will require one of the following: your photocard driving licence your passport (Your driving licence or passport must be valid and must not have expired.) your birth certificate (If your name is currently different from your birth certificate, we will require evidence of the change of name for example your marriage certificate or change of name deed) a Confirmation of Verification of Identity (CoVI) from your financial adviser If you are making this application through a financial adviser, there is no need to send your original document to us in the post. You can provide the relevant document to your financial adviser, who can then either: declare that they have seen the appropriate evidence of your age using the option on our online system, or provide us with a certified copy of the document for our files. Section 2 - Financial Adviser Statement This statement must be completed by your financial adviser. Section 3 - Using the pension fund for annuity purchase Complete this section if you wish to use ALL of your pension fund to purchase an annuity. Section 4 Partial annuity open market option If you are purchasing an annuity using part of your account, you can only use the crystallised part of your CRA. If you do not have sufficient crystallised funds to cover the annuity purchase you will have to move further money into your crystallised funds by completing the form Benefit Crystallisation Event Request Income Drawdown. The amount of money you must retain in your account following any withdrawal is the greater of 10 of the entire fund value or x any outstanding Phased Initial Charge. Section 5 Annuity provider details Please enter the details of the annuity provider that you would like us to send your funds to. We will need their bank details to make the payment to them electronically. Section 6 Protection benefits If you have claimed Lifetime Allowance Protection (ie Enhanced, Primary or Fixed Protection, Fixed Protection 2014 or Individual Protection 2014, Fixed Protection 2016 and Individual Protection 2016) please complete this section and supply a copy of your Certificate of Lifetime Allowance Protection provided by HM Revenue & Customs (HMRC). Block transfer protection If you have a right to a tax-free cash lump sum greater than 25 or to take benefits earlier than age 55, please tick the relevant box under the heading Block Transfer Protection. Please note you will lose your right to block protection by taking a partial open market option. We recommend you speak to your financial adviser for further information on any protection you may be entitled to. Section 7 Previous retirement events Only complete section 7 if you are receiving, or have received in the past, any benefits from any pension arrangements not including any State Pension payments. You will only need to complete one part, 7a, 7b, 7c or 7d as applicable to you. Part 7a I have never taken pension benefits from any provider, or I have only taken pension benefits from my Old Mutual Wealth Collective Retirement Account Select this option if you have never taken pension benefits with any provider OR all of your crystallised pension funds are held in Collective Retirement Accounts with Old Mutual Wealth. We will then use the information we hold in respect of your Lifetime Allowance usage. Part 7b I have only taken pension benefits that started before 6 April 2006 If you are in receipt of a pension benefit that started before 6 April 2006, and have not taken any other pension benefits since then, please complete part 7b. Complete the total current annual pension payable to you currently. If this pension is from an income withdrawal arrangement we need to know the maximum annual gross income you are allowed to take each year. If in doubt about this figure check with the pension provider or your financial adviser. Part 7c I have only taken pension benefits since 5 April 2006 If you have taken benefits since 5 April 2006, please complete part 7c. The pension provider will have given you a letter showing you the percentage of the Standard Lifetime Allowance used up when you started to take pension benefits after this date. Please state the total percentage of the Standard Lifetime Allowance used to date in respect of pension benefits started after 5 April Part 7d I have taken benefits both before and after 5 April 2006 Please state the total percentage of the Standard Lifetime Allowance used up when you started to take pension benefits after this date (as outlined above in Part 7c). If you are also receiving a pension that started before 6 April 2006, please tell us how much it was paying you when you first took other pension benefits after 5 April For example, if the first pension benefit you took after 5 April 2006 was on 5 June 2007, and at that date the value of a pension you started to take in 2005 was paying you 10,000 per year, you would enter 5 June 2007 and 10,000. Section 8 Insufficient Lifetime Allowance The Standard Lifetime Allowance will be 1 million from 6 April. This is the value of tax privileged pension savings each individual is able to make in their lifetime. Some individuals have a higher Lifetime Allowance (see Section 5 Protection benefits). If the amount you accrue exceeds your Lifetime Allowance, the excess will be subject to a tax charge. If you choose to take the excess funds above the Lifetime Allowance as a cash lump sum, a charge of 55 will be deducted before the balance is paid to you. If you choose to take the excess funds as income, the charge will be 25 and the income will be subject to income tax. The charge will be deducted by Old Mutual Wealth and paid to HMRC. For example, if your account is valued at 500,000 and you use all of it to provide benefits and your available Lifetime Allowance is 400,000, the excess would be 100,000. Please indicate whether you require any excess to be paid as a cash lump sum, income or a combination of both. Please note that it is not possible to take a lump sum in respect of funds which are already crystallised. Section 9 Declaration This section is for you to sign, declaring that you understand and agree various points. The information given on this form is based on our understanding of pension and taxation legislation. Old Mutual Wealth Life & Pensions Limited does not accept any liability for any loss arising from the misunderstanding of the information provided or omissions therein. All benefits are payable in accordance with the Terms and Conditions of the Collective Retirement Account. To make a false statement knowingly may be considered tax evasion by HMRC and could result in legal action against you. Old Mutual Wealth Life & Pensions Limited recommends that investors seek financial advice when instructing a Benefit Crystallisation Event. 5 of 6

6 Calls may be monitored and recorded for training purposes and to avoid misunderstandings. 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 and 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 and respectively. VAT number When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well-managed, sustainable forests. PDF April of 6