SURRENDER REQUEST. 1. Copy of a cheque, or a cancelled cheque, or certification of account details from the bank (including full name and ID number)

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1 SURRENDER REQUEST The following documents must be attached: 1. Copy of a cheque, or a cancelled cheque, or certification of account details from the bank (including full name and ID number) 2. Legible and clear copy of ID card. Non-Israeli citizens please attach a copy of your passport and another official form of ID. A. DETAILS OF THE INSURED / MEMBER Name of insured / member: ID no.: address: Full address and postcode: Telephone no.: * Mobile telephone no. (essential for prompt attention to your request): * I am aware of the possibility that text messages may also be sent this number In the event of a legal guardian or power of attorney, the following must be attached: Copy of the ID card of the legal guardian / representative Authenticated or original power of attorney / court appointment (as applicable) B. WITHDRAWAL DETAILS I wish to withdraw the funds which have accumulated to my credit as stated hereunder: 1. Personal funds (funds which are not subject to provident fund rules) (after this section, section 3 must be completed) Full surrender From policy no. All policies Partial surrender From policy no. in the sum of NIS The balance should be frozen Grant surrender From policy no. N.B.: On the surrender date capital gains tax will be deducted from these funds, in accordance with the provisions of the legislative arrangement. 2. Benefit funds for self-employed / salaried individuals (funds subject to the provident funds regulations) (In the event of benefits for self-employed persons, section 3 must be completed) From a life assurance policy From a pension fund (code 15) Please tick one of the following: Full surrender from policy no. and this even if part of the funds are liable for tax deduction at source due to a premature withdrawal. Grant surrender from policy no. and this even if part of the funds are liable for tax deduction at source due to a premature withdrawal. Partial surrender of benefits from policy no. in the sum of NIS The balance should be frozen even if part of the funds are liable for tax deduction at source due to a premature withdrawal. Redemption of benefits from policy no. constituting a lawful withdrawal only in redeeming benefits for salaried employees, please complete one of the following declarations: In accordance with the Income Tax Regulations (Rules for the Authorisation and Management of Provident Funds) 1964 and my request to redeem the benefit funds which have accumulated in the policy I hereby declare: Effective from until, being a period of at least 6 consecutive months, I did not work at all. Effective from until, being a period of at least 6 consecutive months, I am self-employed, and do not have an employer who makes contributions for me. In my place of work, effective from until, being a period of at least 13 months, my employer does not make any contributions for me into any type of provident fund and/or pension fund. The employer must sign here: Date : Stamp and signature of employer: I have reached the age of 60 and (please tick at least one of the following): The policy has been in force for at least 5 full years I have retired I have cut-back my work by at least 50% 1

2 3. December of the beneficiary in accordance with the Anti-Money Laundering Act 2001: I (name of the beneficiary), ID no. hereby declare: I am self-employed and do not work for anyone else. I work for someone else (name) ID no. Date of birth Address The controlling owners in the company are (to be completed where the declaration is provided by a company) Name ID no. Date of birth Address I undertake to notify the insurer of any change to the particulars I have provided above. Date: Signature: Name of authorised signatory (beneficiary / company) ID no.: (If the beneficiary is a company the declaration must be signed by an authorised signatory and stamped with the company stamp) 4. Severance pay funds From a life assurance policy From a pension fund (code 15) Please tick at least one of the following: Withdrawal of severance pay from my current employer Withdrawal of severance pay from my previous employer, name of employer Full redemption of severance pay after deduction of statutory tax from policy number/s: Partial redemption of severance pay in the sum of NIS from policy number/s: Redemption of severance pay on confirmed continuity of rights basis זכויות] [רצף please find attached a tax assessors certificate. Redemption of severance pay on confirmed continuity of annuity basis קצבה] [רצף please find attached a tax assessors certificate. Confirmation of the insured to refund severance pay funds from the pension fund: Contributions at a rate of 6% Contributions at a rate of 2.33% Contributions at a rate of % 5. Loans There are no loans under the policy If there are any loans under the policy Please deduct the loan from the surrender amount Please transfer the lien to another policy of mine In the event of a full surrender, the loan amount will be deducted from the surrender amount 6. Surrender due to termination of the insurance Policy no. Policy no. Policy no. C. PAYMENT RECEIPT METHOD Please remit the surrender amount to my bank as follows: Name of the account holder Name of the bank Bank code Branch name Branch no. Account no 1. Copy of a cheque, or a cancelled cheque, or certification of account details from the bank (including full name and ID number) 2. Legible and clear copy of ID card. Non-Israeli citizens please attach a copy of your passport and another official form of ID. 2

3 D. DECLARATION AND UNDERTAKING OF THE POLICYHOLDER / MEMBER A. I wish to withdraw all of my funds which have accumulated in the New Mivtachim and/or New Mivtachim Plus pension fund and I hereby declare and undertake as follows: 1. I am aware that the pension fund includes disability insurance cover (income protection) and that insurance cover for survivors has been provided (in the event of death) and this in accordance with the provisions of the pension fund rules ( the rules ) as may be amended from time to time. 2. I am aware that as soon as I sign this request, I will be considered to have withdrawn all of the funds from the pension fund (even if the funds I have requested to withdraw have not yet been transferred to my bank account), thereby leading to cancellation of my pension rights, and in this context (I) claiming a disability pension will no longer be possible (II) my family members will no longer be able to claim a survivors pension in the event of death (III) I will not be entitled to receive the retirement pension I am due to receive in the future. 3. I am aware that the funds I am requesting to withdraw will be paid according to the calculation mechanism (the formula) stated in the rules, and subject to the provisions of the Supervision of Financial Services (Provident Funds) Law 2005 and the provisions of the Income Tax Regulations (Rules for Approving and Managing Provident Fund) 1964, such that the amount I will receive may be lower than the amounts stated in my pension fund. 4. I am aware that the amounts I am requesting to withdraw will be subject to the deduction of any debt, refund to the employer and attachment which materialises on withdrawal of the accumulated funds in the pension fund, including balances of any loans I have taken from the pension fund and amounts which are refunded to the employer in accordance with the provisions of the agreements applying to me. 5. I am aware that the amount stated in this withdrawal request are not final and may change depending on yield revisions up until the actual payment date. 6. I declare that I was not entitled to a disability pension from the pension fund in the three years which preceded the date of submitting this request, and that to the best of my knowledge I am not entitled to a disability pension relating to the last three years and that I am not entitled to a disability pension at present. 7. I undertake that this request is final and I am aware that my decision as aforementioned is irrevocable, effective from the date of signing this request, and that I will not be able to return the funds I have withdrawn to the pension fund after they have been paid to me. 8. I am aware that you are required to deduct income tax at source and any other statutory payment, to the extent that they apply, from the funds I have requested to withdraw, including deducting tax at source from the benefits components of the accumulated amount I have requested to withdraw which arises from contributions into the pension fund from the year If I have not attached a tax exemption certificate for the funds which are liable for tax I declare that even though I have been advised that I am entitled to approach the tax assessor to receive an exemption / gradual exemption (to the extent that such a right exists), I hereby advise you that I have decided not to approach the tax assessor and I agree to the deduction of the maximum tax from any balance of severance pay in the fund in respect of which I have not presented a tax exemption certificate or Form 161. B. At the time of withdrawing the funds which have accumulated in the insurance policy of Menora: 1. I am aware that after a partial withdraw of the funds, a proportional share of the policy will be cancelled whilst the remaining part will remain valid in accordance with the general conditions for life assurance of the aforementioned policy. 2. I am aware that performing the aforementioned action will result in cancellation or reduction of the insurance cover currently in force in the policies in my name as a result of which my future rights under the policy will be detrimentally affected. 3. I am aware that the surrender is subject to the policy conditions: 3.1 If the date of terminating premium payments is not identical to the date of leaving the work, the surrender value amount will equal the regular surrender value and not the special surrender value. 3.2 The surrender value will be calculated in accordance with the premium contributions which have been actually received by the company from the employer. 3.3 A premature surrender penalty will be deducted from the surrender as stated in the general policy conditions 4. I am aware that in the event of renewal / increase (subject to the directives of the Commissioner of Insurance) of the aforementioned insurance covers the matter will be subject to proof of my health condition as a result of which the premium will increase according to my age which will be calculated as of the renewal / increase date. 5. I am aware that if the policy / policies are subject to provident fund rules, tax will be deduced at source, tantamount to a premature withdraw. 6. I am aware that the request will be dealt with subject to any law and in accordance with the policy conditions effective from the date of its receipt in the company offices and not in the agent s offices. 7. In the event of a full withdraw of amounts which have accumulated to my credit, I am aware that the policy and all of the insurance covers, including the life assurance element will be cancelled. 8. If the declaration is provided by a legal guardian: I hereby declare that I act on behalf of the ward, and in their best interest in accordance with and subject to the Legal Competency and Guardianship Law I am aware that on the surrender date, capital gains tax will be deducted in accordance with the provisions of the legislative arrangement. Signature of the policyholder / member / legal guardian: Date: Name of the policyholder / member / ID no.: beneficiary / guardian: Signature of the policyholder / member / beneficiary / guardian: Name of the agent who has verified the signature: Agents stamp: 3

4 INFORMATION PAMPHLET REGARDING THE LAWFUL WITHDRAWAL OF BENEFITS INSURED S DECLARATIONS FOR THE LAWFUL WITHDRAW OF BENEFITS FOR SALARIED EMPLOYEES (AND ALL SUBJECT TO THE INCOME TAX PROVISIONS) If you comply with any of the aforementioned rules the surrender will be a lawful withdrawal Type of fund Capital oriented fund Annuity oriented fund Non-annuity paying fund Period of time Before Receipt of funds as a lump-sum: Receipt of funds as a lumpsum: 1. Left work and did not start working in another place within 6 months. Age 67 + the total funds in all 2. Left work and became selfemployed of the annuity pension funds of after 6 months. the insured (other than an old 3. Moved to a new employer after 13 months in which no contributions were made. fund) does not exceed NIS 80,000 as of the 2008 March inflation index + if an annuity 4. Age 60 + retired or cut-back is paid it needs to be higher working by 50%. than the minimum annuity 5. Age 60 + member of the fund for at amount NIS 3,850 as of the least 5 years (even without leaving 2008 March inflation index From Before Left work and did not start working in another place within 6 months. 2. Left work and became self-employed basis after 6 months. 3. Moved to a new employer after 13 months in which no contributions were made. 4. Age 60 + retired or cut-back working by 50%. 5. Age 60 + member of the fund for at least 5 From Age 60 + member of the fund for at least 5 the place of Receipt of funds as an annuity: * 1. Age 60. * If the monthly annuity amount is less than 5% of the minimum wage, a capital amount may be withdrawn subject to authorisation by the tax assessor. A person who has accumulated an annuity higher than the minimum pension is entitled to capitalise the annuity balance to a lump sum. * Authorisation of the employer for the withdrawal of the funds is required in accordance with the legislative arrangement and the company procedures. 4

5 THE CONDITIONS FOR THE LAWFUL REDEMPTION OF BENEFITS FOR SELF-EMPLOYED INDIVIDUALS (AND ALL SUBJECT TO THE INCOME TAX PROVISIONS) If you comply with any of the aforementioned rules the redemption will be a lawful withdrawal Type of fund Capital oriented fund Annuity oriented fund Non-annuity paying fund Period of time Policies issued up to 30 th April 1997, in respect Receipt of funds as a lump-sum: Funds which were deposited up until can be withdraw: Receipt of funds as a lumpsum: Age 67 + the total funds in all of funds which 1. For a fund at least 15 years old. of the annuity pension funds of were deposited until 2. Age 60 + member of the fund for at least 5 years. the insured (other than an old fund) does not exceed NIS 31/12/ ,000 as of the 2008 March Policies issued Receipt of funds as an annuity: * inflation index + if an annuity up to 30 th April 1. Age 60. is paid it needs to be higher 1997, in respect of funds which were deposited * If the monthly annuity amount is less than 5% of the minimum wage, a capital amount may be withdrawn subject to than the minimum annuity amount NIS 3,850 as of the 2008 March inflation index from 1/1/2000 authorisation by the tax assessor. or policies which were issued from May 1997 Before For a member of the fund for at least 15 years. 2. Age 60 + member of the fund for at least 5 years. From Age 60 + member of the fund for at least 5 Contributions from 2006 will be considered as annuity and the limitations of withdrawing as annuity, or as capitalised annuity after minimum pension proof will apply to them. Social conditions which are not subject to tax, even in the event of an premature withdrawal; 1. Permanent disability exceeding 75% subject to confirmation from the tax assessor. 2. Medical expenses in a year, exceeding half of the income in the same year subject to confirmation from the tax assessor. 3. Income of couple less than the minimum wage the provident fund is entitled to pay in accordance with the rules and subject to provision of documentary evidence. 4. There will be no tax liability in the event of death exemption for beneficiaries. 5