If applicable, dependant s marriage or civil partnership certificate (if we haven t already received these documents)

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1 Income Drawdown plan Dependant s application form From age 75 (alternatively secured pension) Agent code Illustration ref no When to use this form You can use this form to apply for a dependant s alternatively secured pension fund, following the death of an Income Drawdown planholder. The form can t be used: for dependants under the age of 75 (ie, a dependant s unsecured pension). to take out the plan with a transfer of an existing dependant s alternatively secured pension fund. How to fill in the form Please write in the boxes provided in black ink using BLOCK CAPITALS. Unless your adviser has told you otherwise, please return your completed form to: Aviva, PO Box 520, Norwich NR1 3NG. It is important that you and/or your adviser fully complete all the sections. If any information is missing, it will delay your application. If you have any questions about this application form, please call us on The lines are open from 9 am to 5 pm, Monday to Friday. Have you attached the following? If any information is missing, it will delay your application. Illustration Dependant s birth certificate If applicable, dependant s marriage or civil partnership certificate (if we haven t already received these documents) P45 Parts 2 and 3 for the current tax year, if available. (We can t return this form.) 1. Existing plan details Existing Income Drawdown Plan number Original planholder s name 2. For financial adviser use only It is an FSA requirement that we provide data on whether advice was given on the sale of this product. Have you given financial advice in this case? Yes No If your answer is no, we are unable to provide this plan to the applicant. We want to provide you with a great and responsive service. To help us with this, please tell us below how you would prefer us to contact you. Adviser Telephone no address Administrator Telephone no address

2 3. Applicant s details This should be the details of the dependant applying for this plan. Title Mr/Mrs/Miss/Ms/Dr/Other Surname Forename(s) Date of birth Sex Male Female National Insurance number* * We can t accept your application without a National Insurance number. If you don t have a National Insurance number, please contact us on Your permanent UK residential address (if your permanent address is outside the UK, please see section 3.1 below) House name (if applicable) Street name House number Postcode Town County Country Daytime tel no Evening tel no Mobile tel no Your relationship to the planholder Spouse/civil partner Other financial dependant 3.1 Eligibility To ensure you are eligible, you must be able to tick the following: I confirm that I am resident in the UK for tax purposes. If you are not resident in the UK for tax purposes, please contact us for further details. You could still be eligible, but we may need to ask you for some further information. 2

3 4. Charity nomination If the original planholder died aged 75 or over and had already made a charity nomination, you can t override that nomination in the section below. If you die aged 75 or over and before you have used the funds under the plan to buy an annuity, we can pay the remaining fund as specified below. You should make sure that you regularly review any nomination you make, especially if the nominee dies or your relationship with them changes. Important notes General If you are unsure how to complete this section or would like to discuss the implications of making your nomination, we recommend that you speak to your adviser. Non-protected rights funds If there are no other dependants of the original planholder when you die, we can pay your remaining fund to a charity nominated by you, unless the original planholder died after age 75 and had nominated a charity. If neither you nor the original planholder have nominated a charity, we will pay the money to a charity of our choice. If there are other surviving dependants of the original planholder when you die, we will choose how to split benefits between them. We can only pay such benefits as income. If you are able and want to nominate a charity, please complete the details below: Charity name Charity number 5. Investment details The total minimum investment amount is 15,000. Quoted value of non-protected rights fund This includes any former pension credit funds held by the original member. Quoted value of protected rights fund The actual amount(s) invested may be different as it will depend on the fund value at the date we set up the plan. 5.1 Investment choice Please consider your investments carefully. The pension fund guide and pension fund charges leaflet have full details of the funds available to your plan. If you don t make an investment choice, we won t be able to process your application. You can choose up to 10 funds initially. Please enter the full name of the fund(s) you have chosen and your chosen percentages using whole percentages only. These must add up to 100%. If the payment includes protected rights, the investment choice will apply to the entire fund. We will set up any protected rights funds as a further separate arrangement under the plan. Full fund name Amount (%) Example Aviva Balanced Managed 100% Total 100% 3

4 5. Investment details continued 5.2 Pension fund withdrawals Details of regular pension fund withdrawals: If your fund includes protected rights benefits, you must complete and return the National Insurance Contributions Office form CA1872. Please show the amount of income you want to take each year, before tax: If your fund is made up of non-protected rights and protected rights, we will set up a separate arrangement for each element. Please specify the income you would like to take from each element of the fund Please remember that this is subject to the minimum income requirements shown in your illustration. Specified amount (non-protected rights) Specified amount (protected rights if applicable) OR, Percentage of Government Actuary s Department limit (in whole percentages) This must be between 55% and 90%. Non-protected rights Minimum Maximum or other Protected rights (if applicable) Minimum Maximum or other % % 5.3 Benefit payment details Payment start date: Please show the month and year you want payments to start: Month Year If we don t receive all our requirements to set up the plan until after your requested start date, we will have to start your income on the first available payment date after we have received them. Payment frequency for regular pension fund withdrawals: Monthly Quarterly Half-yearly Yearly Day of the month from which payments will be made (between 1st and 28th) If you already receive pension fund withdrawals or annuity payments from Aviva, this should be the same as your existing payment date. If the payment date changes in future, the payment date for this plan will also change. Your bank or building society account details You can leave this section blank if you are already taking pension fund withdrawals or annuity payments from Aviva and your account details have not changed. If you complete this section and are already taking withdrawals or annuity payments from Aviva, we will use your new account details to pay ALL of your income. Name(s) of account holder(s): Name of bank or building society: Sort code: Account number: Building society roll number (if applicable): 4

5 5. Investment details continued 5.4 Income tax Income payments will be subject to income tax under the PAYE system. Please send us your original P45 Parts 2 and 3 for the current tax year, if available, so that we can operate the correct tax code. We can t return the P45 as we will send it to our tax office. If your P45 is not available, please provide the following information. Tax district Tax reference number We may temporarily deduct income tax on an emergency basis until we receive a coding notice from your local tax office. 5.5 Specific funds for pension fund withdrawals Please show the name(s) of specific investment fund(s) from which you would like to take pension fund withdrawals. Proportion of your income to be Full name of specific fund(s) taken from each specific fund (%) Non-protected/ Protected rights non-safeguarded rights (if applicable) Example Aviva Balanced Managed 100% 100% Total 100% 100% If you don t give details of a specific fund or funds, we will cancel units in all of your investment funds to pay pension fund withdrawals. We will cancel units proportionately across all funds. If you make a specific fund choice and there aren t enough units in the specified investments funds, we won t be able to pay the pension fund withdrawals from those funds. Instead, we will revert to taking withdrawals proportionately across all funds. 5

6 6. Applicant s declaration Please make sure that the information that you give us is correct as false statements can lead to prosecution by HM Revenue & Customs. Declaration to become a member of the Aviva Personal Pension Scheme Aviva will administer the Scheme in line with the rules of the Scheme. Please read the following carefully before signing and dating this application. I apply to be a member of the Aviva Personal Pension Scheme and agree to be bound by the Scheme s rules. I want the benefits allocated to me on the original policyholder s death to be invested in a new Income Drawdown Plan in my name, which will be held under the Scheme. I want any existing arrangements of the original planholder that have been allocated to me to be consolidated and a single arrangement to be created for me from the start for non-protected rights. I want a further separate arrangement to be set up for any protected rights funds allocated to me. I understand that this plan does not accept any contributions, whether or not they would be eligible for tax relief under Part 4 of the Finance Act I agree that funds under this arrangement will be held solely for the purposes of providing an alternatively secured pension fund within the meaning of paragraph 25 of Schedule 28 to the Finance Act Benefit declaration I request and consent to the payment of the benefits set out in this form. The payment of benefits as requested will discharge Aviva of all liability in respect of the payments made. Where alternatively secured pension payments are made, liability for future payments will remain with Aviva unless a transfer is made from this plan. Pension fund withdrawals I understand that: it is my responsibility to ensure that there are sufficient units held in specified investment funds to pay the withdrawals if there are not enough units in specified investment funds, Aviva will be unable to pay the pension fund withdrawals from those specific funds, and will instead take withdrawals proportionately across all funds I may change the frequency of payments and the amount of income from the next payment due date by giving at least one month s notice in writing if, at any time, the amount of income selected exceeds the upper limit or falls below any lower limit which may apply to this plan, Aviva will pay the maximum or minimum permitted amount if the total funds under this plan fall below the minimum value, I must use them to buy a lifetime annuity or scheme pension. I declare that, to the best of my knowledge and belief, the information on this application, including any additional sections and any information not provided by me, is correct and complete, and has been included with my agreement. I will tell Aviva at once if any of it changes. If anything proves to be wrong, I will pay for any resulting tax charges, penalties or Aviva costs. If applicable, I authorise Aviva to deduct advice charge payments from my plan to cover the cost of the adviser payment paid by Aviva to my financial adviser on my behalf, as specified in the plan terms and conditions. 6 Customer due diligence prevention of money laundering In line with EU and UK legislation relating to the prevention of money laundering, we are obliged to verify the identity and address of all parties (for example, planholder, premium payer, settler, third parties including beneficial owners) to this contract. In the case of legal arrangements, we are also required to establish the identity of any controllers that are not named parties as well as individuals who have specified a beneficial interest in the contract. How this will be carried out? Identity and address can be verified either by electronic verification or through submission of documentary evidence. Electronic Verification Aviva may verify your identity with a third party identity verification company. This identity verification check will leave a footprint on your credit file but it is NOT a credit check and will NOT impact your credit rating. This check can be carried out whether you are applying to us through a financial intermediary, an Aviva sales consultant or via direct business. Documentary Verification In certain circumstances you may be required to provide further evidence of your identity and confirmation of address. Where a financial adviser or Aviva Representative is involved they will let you know what evidence you need to produce. Where you are applying to Aviva direct, we will contact you and let you know what additional evidence is required. How we use your details I consent to Aviva using the information supplied on this application to administer my plan. I acknowledge that it will be held and my plan may be processed by any company within the Aviva group or by third parties who provide services to Aviva. It may be transferred to any company, including those outside the European Economic Area, for any of these purposes. Any information may be used for claims handling purposes and disclosed in confidence to regulatory bodies, other insurance companies (directly or via shared databases), other Aviva group companies and your financial adviser or the business partner that introduced you to the company (including third parties providing services to them). In addition, Aviva, or, if applicable, the business partner that introduced me to the company may use some of my information to advise me by post, telephone or of other products and services offered by Aviva group companies or of the business partner. Please tick the box if you do not wish to receive this material. I understand that you may undertake a search with third party companies, who provide identity verification services for the purposes of verifying my identity and the details I have submitted as part of this application. To do so, the third party companies may check the details I supply against any particulars on any database (public or otherwise) to which they have access. They may also use my details in the future to assist other companies for verification purposes. A record of the search will be retained. Signature Date

7 7. For financial adviser use only Financial adviser remuneration To make sure we process this application as efficiently as possible, please choose the basis on which you d like us to pay the commission. Adviser payment basis Is the basis of remuneration for this plan: Standard commission Explicit charge Standard commission options: If you are being paid directly by your customer, please select the explicit charge option above. Commission Commission Extra annual Please tick % of Office type basic fund required FBC use description charge option required only 1. Nil commission Nil 0.00% 2. Fund-based commission Between 0% and Between 0% and (FBC) only 2% in 0.01% steps 2% in 0.01% steps We will automatically adjust the amounts shown for any special terms we have agreed. Explicitly charged commission options: 1. Advice charge payments The maximum amount you can choose is 7.00% of the transfer payment. Please select the payment type(s) from which we should make the adviser payment. Adviser payment () You can find this on the personalised illustration. Transfer payment 2. Fund value advice charge payments The maximum you can choose is 2.00% each year in steps of 0.01%. Please select the payment type(s) from which we should make the fund value adviser payment. Amount of fund (%) For how long will payments be made? When will this start? You can find this on the personalised illustration Transfer payment % months OR plan term How frequently should we make payments? Monthly Quarterly Half-yearly Yearly

8 Aviva Life & Pensions UK Limited. Registered in England No Rougier Street, York, YO90 1UU. Aviva Life & Pensions UK Limited is authorised and regulated by the Financial Services Authority. FSA Registration No Member of the Association of British Insurers. SP /2010 Aviva plc