Retirement instruction for company pension and buy out bond

Retirement instruction for company pension and buy out bond Filling in this form OPSBRET V14 0615 Complete this form if the member is retiring now and have their policy proceeds paid according to these instructions. Before completing this form, read the Annuity Key Features document (RIOTAKF1) and/or Synergy approved retirement funds Key Features document (SYARFKF1), Investment options guide (SYIO1), Self-Directed options guide (SYSDO1) and Illustration, given to you by your financial adviser. Part 1a Member personal details Title First names (in full) Surname Address * Proof of member s date of birth (for example, a certified copy of passport or driving licence) must be submitted with this instruction, unless already submitted. Email We'll use your email address to set you up for My Standard Life online so that you can check your policy value online at a time that suits you. When your policy is set up, you ll get an email from us with your User ID. Soon after, you ll get your temporary password by post so that you can complete your online registration and view your policy details. Landline phone number Date of birth* Mobile phone number Personal Public Service number N N N N N N N L (L) ** ARF income, annuity payments, tax free and/or taxed lump sum will be lodged to this account. Please allow at least 5 bank working days for payments to reach your account. Payments must be lodged to your own or jointly owned Irish personal bank account. Payments cannot be made by cheque. Please provide your bank account details below. Any benefits requested by you will be lodged to this account** Your International Bank Account Number (IBAN) Your Bank Identifier Code (BIC) Name on your account Your IBAN and BIC are shown on your bank statement. (The last 14 characters of your Irish bank account's IBAN are your old 6 digit branch sort code (1st digit = 9) and old 8 digit account number). Scheme name (for company pension) Plan number (for company pension and/or buy out bond) Date of joining relevant employment rmal Retirement Age of relevant employment Date of leaving relevant employment Relevant employment means the employment relating to this pension plan. Is the member still in service with this employment? Is this pension the subject of, or as a result of family law proceedings (for example, Pension Adjustment Order)? If yes, you must enclose a copy of the tice/order and complete Additional information about Pension Adjustment Order form (PAO1). Retirement instruction for company pension and buy out bond 01/12

Part 1b Salary details There are numerous definitions of Final Remuneration that one can use for pension purposes and it is important for you to take advice on the most appropriate one to adopt. For employees you must provide at least one years details. For 20 directors you must provide at least 3 consecutive years details. Year Remuneration (Schedule E) Verified by (please tick) P60 (Please attach) Accountant (Sign verification) Other (Specify and attach) Was the member a proprietary director (20) at any time within 3 years of leaving the relevant employment? Were you made redundant from this employment? If yes did you waive your right to tax free cash as part of the agreement?* Verification If you are having your remuneration figures verified by an accountant, please have them complete this section. We confirm that the remuneration details set out here are accurate. Accountant signature Date * Evidence may be required. Signature Company stamp Part 1c Member options Tick/complete one or more, as appropriate: (t all options may be available) (i) Take a lump sum*: (ii) Purchase a Standard Life retirement annuity** (complete Parts 1d, 5, 6, 8-10) (iii) Invest in a Standard Life Synergy approved retirement fund (complete Parts 1d, 2-4, 6, 8-10) (iv) Take an additional lump sum (taxed as earned income) (complete Parts 1d, 2, 8 and 10) (v) Send the remaining policy proceeds to Maximum (based on salary and service) 25 of fund Only open where lump sum option 25 of fund is chosen, subject to eligibility rules in Part 2. Only open where 25 of fund option is taken as a lump sum. * See Part 1d for tax limits. ** Where 25 lump sum is chosen, the annuity purchase price will be invested in an ARF and the ARF will immediately purchase the annuity. Annuity provider/qualifying Fund Manager Address To invest in (give product name) 02/12 Retirement instruction for company pension and buy out bond

Part 1d Member s other benefits By law, at retirement, if the value of all of your pension arrangements is more than the Standard Fund Threshold (2 million), the excess is taxed at 40. There are also lump sum tax limits from all your pension funds: - the first 200,000 will be tax free - the next 300,000 is taxed at 20 - any amount over 500,000 will be treated as income and taxed under the PAYE system The Revenue requires us to check these limits and calculate the member s pension benefits. Please give details of all the member s pension arrangements, regardless of whether they have taken benefits or not. Does the member have benefits in any of these categories? (i) Any concurrent retirement benefits from this employer? (for example, another scheme from this employer and/or another plan with a different provider) (ii) Any retirement benefits from other employments? (for example, employments before and/or after this employment) (iii) A concurrent employer? (for example, another employment at the same time as this employment) (iv) Any other pension arrangements? (for example, personal pension (RAC), PRSA, retirement trust) If yes to (i), (ii), (iii), or (iv), please give full details Benefit category (i), (ii), (iii), and (iv) Insurer Scheme name (or policy type: personal pension, PRSA, buy-out bond) Benefits taken Cash lump sum, annuity, dependant s annuity, ARF/AMRF investments) (v) If yes to (i), (ii), (iii), or (iv), is the current value of all the member s pension funds more than 2 million? If yes to (v), please give details of all the member s pension arrangements, regardless of whether they have taken benefits or not. Insurer Policy number Fund value Date member took or proposes to take their benefits Cash lump sum received If the member has a personal fund threshold certificate from the Revenue please provide us with a copy. Retirement instruction for company pension and buy out bond 03/12

Part 2 ARF/taxed cash eligibility You need to satisfy the eligibility conditions for investing in an ARF. 1. Do you have an existing ARF, AMRF or Vested PRSA*? 2. If no to question 1, have you a guaranteed pension income for life of 12,700 per annum?** If yes to 1 or 2, please give details and provide evidence acceptable to Revenue (for example, copy of payment slip, letter from provider) Provider Policy type (Annuity/AMRF/ARF /Vested PRSA) Amount invested Start date Policy number * Vested PRSA is a PRSA where you have started drawing down benefits. ** The Revenue accepts your State pension and pension annuities as guaranteed income for life. Income in respect of your spouse/civil partner or dependent is not taken into account. Neither is your salary, State assistance, allowances or benefits, rental income, or maintenance order payments. The Revenue also require us to hold evidence on file. Until you provide satisfactory evidence, your money will not be invested. If you have answered to all of questions 1 and 2, you need to (a) Invest in an AMRF which when added to your existing AMRF (if applicable) brings the total AMRF investment to 63,500 (b) Purchase an annuity that, when added to your existing guaranteed pension income (if applicable), brings the total guaranteed pension income to 12,700 per annum, or (c) Invest in a combination of an AMRF and an annuity to bring the total investment in an annuity and an AMRF to 63,500. 04/12 Retirement instruction for company pension and buy out bond

Part 3a ARF investment ARF (minimum 10,000) AMRF ((minimum 10,000, maximum 63,500) Part 3b Your ARF investment choice In order to complete this section, refer to the Investment Options guide (SYIO1) and the Self-Directed Options guide (SYSDO1) Indicate how your total premiums as set out in Part 3a are to be allocated Funds and/or Self-Directed Options If you choose to invest in Self-Directed Options, your investment will initially be placed in your Policy Cash Account. You must have enough money in this account to enable us to carry out your instructions and to pay the charges related to the Self-Directed Options that you have selected. If you have different investment choices for your ARF and AMRF premiums, please make a copy of this section and complete it for each policy type. Funds Choose from the following funds Absolute Return Global Bond Strategies Cautious Managed China Equity Corporate Bond Fixed Interest Japanese Equity Global Absolute Managed Return Strategies Global Inflation rth American Equity Linked Bond Global REIT Pacific Basin Equity If you wish to invest in funds, indicate the relevant percentage in the table below. For example, if you indicated above that you wish to invest 10,000 in funds, and you want all of this amount to be invested in the Standard Life Managed Fund, you would insert 100 beside Managed. Euro Global Liquidity European Equity Global Selector Property Global Smaller Companies UK Equity European Ethical Equity European Smaller Companies MyFolio Active India Equity Irish Equity UK Smaller Companies MyFolio Active I MyFolio Active II MyFolio Active III MyFolio Active V MyFolio Active IV MyFolio Market MyFolio Market I MyFolio Market II MyFolio Market III MyFolio Market V MyFolio Market IV Retirement instruction for company pension and buy out bond 05/12

Self-Directed Options Direct property Tick this box if you are purchasing a property. Please provide details of the property you wish to purchase by completing the Property Information Questionnaire (SYPIQ). Execution only stockbroking Tick this box if you are selecting execution only stockbroking. We will pass your details to Stocktrade who will contact you directly. Online dealing If you want to deal or view your Stocktrade account online, please give us your email address. Email address You are only allowed to trade in investments that are permitted by Standard Life. If it comes to our attention that you have bought non-permitted investments, we will instruct Stocktrade to sell those investments. In these circumstances, your policy will be charged the cost of selling those investments. If you are uncertain as to whether a particular investment is permitted, contact your financial adviser or Standard Life. Please note that when choosing this option you must also complete Parts 9a and 9b. Stocktrade will use your email address to set up your online account. Deposits Deposit provider Deposit amount Deposit account term There are minimum investment amounts applied by the Deposit providers. Please see www.standardlife.ie for the minimums that apply. Authorising Standard Life to accept instructions from your financial adviser on your behalf te that we will only accept instructions from authorised persons once we are satisfied that we have verified the identity of the authorised person, and it is the responsibility of the authorised person and/or yourself to verify that your instructions have been carried out properly. I authorise Standard Life to accept instructions from my financial adviser named in Part 1, to buy or sell Funds and Deposits under this policy. This authorisation will apply until Standard Life receives a written instruction from me changing or withdrawing my authorisation. Member signature Date Please speak to your financial adviser before completing this section. Signature Part 4a PRSA/ARF income amount or p.a. (max of 5 per annum of policy value before tax applies) p.a. (max of 5 per annum of premium before tax applies) You must withdraw a certain percentage of the value of your ARF policy on an annual basis. The percentage is: 4, if you're 60 years of age or over for the full tax year, or 5, if you're 70 years of age or over for the full tax year, or 6, if you've combined ARF and vested PRSA assets of 2million or more, and aged 60 or over for the full tax year. If you do not make withdrawals of at least this amount during each year, in December, we will make a withdrawal and lodge it to your bank account. 06/12 Retirement instruction for company pension and buy out bond

Part 4b - minee Qualifying Fund Manager (QFM) Have you appointed a nominee QFM? If yes, please provide the following details: Name of QFM Address Reference number to be used on correspondence Part 5a Annuity details Purchase price Increase in the annuity The annuity can increase at a fixed rate each year 0 3 Guaranteed period ne 5 years Gross annuity at outset (refer to quote) (maximum 5) years (minimum 2,500) (maximum 10 years. If more than 5 years, you can t choose a spouse/civil partner s annuity.) The annuity is payable throughout the greater of the lifetime of the Principal Annuitant (you) and the guaranteed period chosen. The guaranteed period applies to the Principal Annuitant s annuity only, not to any Spouse/civil partner s annuity. If Spouse/civil partner s annuity chosen, the maximum guaranteed period is 5 years. Payment to be In arrears In advance Part 5b Spouse/civil partner s annuity details (if applicable) Amount 1/2 of Principal annuity 2/3 of Principal annuity Title First names (in full) Surname If Spouse/civil partner s annuity chosen, the maximum guaranteed period is 5 years. Date of birth* Personal Public Service number N N N N N N N L (L) If you have chosen a guaranteed period of 5 years or less, this annuity will be with overlap. If more than 5 years it will be without overlap. With overlap: The spouse/civil partner s annuity starts on the Principal Annuitant s death. Without overlap: The spouse/civil partner s annuity starts on the later of the Principal Annuitant s death or the end of the guaranteed period. Male Female * Proof of your spouse/civil partner s date of birth (for example, a certified copy of passport or driving licence) must be submitted with this application. Retirement instruction for company pension and buy out bond 07/12

Part 6 Annuity and ARF income payments Frequency Every month Every 3 months Every 6 months Once a year Your annuity payments will normally be credited to your bank account on the 1st of the month in which your payment is due. The minimum annuity payment each frequency is 65 (treated as income and taxed under the PAYE system). ARF first payment date 0 6 To ensure the correct taxes are deducted from your payments, the Revenue require us to have an up to date Certificate of Tax Credits. Contact the Revenue on (01) 702 3011 or on their PAYE helpline, based on where you live (Standard Life s employer number for PRSAs and ARFs is 9578247P and for Annuities is 0064349F). Dublin region: 1890 333 425 Border Midlands West region: 1890 777 425 South West region: 1890 222 425 East and South East region: 1890 444 425 Please tick to confirm you have contacted the Revenue (earliest: 1 month after start date.) ARF payments are processed on the 6th of the month (or following working day) and payments take at least five bank working days to reach your account. Emergency taxes will be deducted if we don t receive your Certificate on time.the minimum ARF income per annum is 900 (before PAYE taxes deducted). The minimum annuity payment each frequency is 65 (before PAYE taxes deducted). If you are taking an income from an annuity of ARF, we will assume the same payment instructions apply, unless you tell us otherwise. Separate payments will be made, regardless of payment dates. Only complete Part 7a and Part 7b if you have chosen the Self-Directed option of execution only stockbroking. Part 7a Your occupation and annual income before tax Your occupation Please indicate which income band applies to you Under 20,000 20,000 to 34,999 35,000 to 49,999 50,000 to 74,999 75,000+ Part 7b Proof of your identity and address To comply with anti-money laundering regulations, attach certified copies of one of each of the following: Proof of identity (photo ID) for example Current passport and Proof of address for example Recent bill (electricity, phone or gas) Current EU driving licence Recent statement (bank or credit union), or Recent document from Revenue or Dept of Social Protection showing your name, address and PPSN Current means not expired and recent means issued in the last 6 months. If you don t have a particular document, talk to us or your financial adviser about alternatives. 08/12 Retirement instruction for company pension and buy out bond

Part 8 Revenue declaration If you have a Personal Fund Threshold Certificate, issued by the Revenue, please enclose a copy with your completed declaration. Where your personal fund threshold includes a defined benefit arrangement, please state the valuation factor used. Information in relation to payment of the State pension from the Department of Social Protection is not required. This declaration should be completed in respect of benefits arising on or after 7 December 2005. 1. Did you become entitled, on or after 07/12/2005, to any pension, lump sum or any other pension related benefit? 2. Prior to, or on, the date of receiving benefits from this pension arrangement, do you expect to become entitled to any pension, lump sum or any other pension related benefit from another pension arrangement? 3. Have you directed, on or after 07/12/2005, or do you intend to direct prior to the date of receiving benefits from this pension arrangement, that a payment or transfer be made to an overseas pension arrangement? If yes to any of the above please provide details below. Scheme name Annuity provider/ Qualifying Fund Manager Policy number Policy type Date of entitlement to benefits Benefit amount Transfer amount or Payment to an overseas arrangement and Contact details for the receiving pension arrangement If a defined contribution arrangement, the value of the fund on the date of benefit entitlement. If a defined benefit arrangement the amount of annual pension, (a) the amount of any lump sum, and (b) the factor used for calculating the capital value of the pension. (c) The amount or market value of any assets transferred by exercise of an ARF option. I declare that to the best of my knowledge and belief, the information in this declaration is correct Member signature Date Signature Retirement instruction for company pension and buy out bond 09/12

Part 9 Your financial adviser s declaration To be completed by your financial adviser 1. I confirm that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, my client has been given in writing the information specified in Schedule 1 of those Regulations, and that 2. I have advised my client as to the financial consequences of replacing an existing policy with this policy of cancellation or reduction, and of possible financial losses as a result of such replacement. 3. I have explored the available investment options with my client and taking into account their circumstances, long term needs, age and attitude to risk, I am satisfied that this policy is suitable for them. 4. I confirm that I will retain the appropriate evidence regarding any instructions I give to Standard Life or any third party providers on behalf of my client. 5. If your client has chosen to deal or view their Stocktrade account online, and you want view access, give us your email address. Email address 6. I have verified the identity and address of: Member s name to the standards set out in the anti-money laundering regulations, which will be forwarded to Standard Life on request*. Financial adviser signature Date Financial adviser s name Stocktrade will use your email address to set up or add this client's policy to your agency's online account. * Enclose verification if Self- Directed Option of executiononly stockbroking chosen. Signature Financial adviser s company name Financial adviser s Standard Life agency code 9/ Commission details Annuity Initial ( of premium) Nil renewal ARF/AMRF (Max 2.00. If nil, insert 0) Financial adviser s Standard Life agency code 9 / Please select your Flexible and clear pricing option (tick the appropriate box) For more information on Flexible and clear pricing refer to Products from Standard Life for financial advisers (SYAPS). A B C D E F G H If you are taking FBRC, please choose the payment frequency Monthly Quarterly Half-yearly Yearly Initial ( of premium) FBRC ( of fund) (Max 4.00. If nil, insert 0) (Max 1.00. If nil, insert 0) Issue policy to Financial adviser Client For office use only FPPC 10/12 Retirement instruction for company pension and buy out bond

Part 10 Your authorisation and declaration Please read carefully before signing. WARNING: If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or insurance intermediary. Member declaration 1. I have read the Data Protection tice in the Key Features document and I agree that my personal information may be used for the purposes described. 2. I declare that the information provided in this and other related forms (if any) are true and complete to the best of my knowledge and belief. 3. I agree that a copy of this application can be treated as the original for all purposes. 4. I consent to Standard Life seeking relevant information relating to my past, present, future employments and pension arrangements from any employers, trustees, administrators, qualifying fund managers or pension providers and I authorise the giving of such information. 5. If I have applied for an AMRF/ARF, I agree that the contract will be governed by the Policy Schedule, Statement of reasonable projection and Policy Provisions (SYARF60), together with this Application Form and any associated statements or questionnaires submitted in connection with this application. 6. If I have applied for an annuity, I agree that the contract will be governed by the Policy Schedule, Quotation and Policy Provisions (RIOTA60), together with this Application Form and any associated statements or questionnaires submitted in connection with this application. 7. I have received in writing and read the information specified in my financial adviser s declaration (Part 9). 8. I am beneficially entitled to the assets of the pension fund used to apply for my chosen retirement options and this investment consists only of assets from a Revenue approved pension arrangement, AMRF or ARF. 9. I agree that the contract will be governed by Irish law. Trustees declaration 1. We have read the Data Protection tice in the Key Features document and we agree that our personal information may be used for the purposes described. 2. We agree that a copy of this application can be treated as the original for all purposes. 3. We declare that the information provided in this and other related forms (if any) are true and complete to the best of our knowledge and belief. 4. We have received in writing and read the information specified in our financial adviser s declaration (Part 9). 5. We instruct you to retire the member s Standard Life policy numbers quoted and to distribute the proceeds as detailed in this retirement instruction. Member signature Date Member s name Signature and (if applicable) for and on behalf of, as Purchaser: Trustees of (BLOCK CAPITALS) pension scheme Trustees signatures Date Scheme address Signature If you are receiving advice from a financial adviser, remember that the adviser is acting on your behalf, not only by giving you advice, but also regarding how this form is filled in and sending us this completed application. By filling in this form you are applying to enter into a contract with Standard Life. This application will be the basis of this contract if it is accepted by us. A copy of this completed application will be sent to you on request. Retirement instruction for company pension and buy out bond 11/12

Checklist Have you included proof of date of birth (member and spouse/civil partner) if setting up an annuity? Have you provided the PPS number? Have you told us the date of joining this company and the date of leaving service? If this policy has received any transfers from other company pension schemes, have you provided salary and service details in respect of those employments too. Have you provided us with salary details? Have you provided us with copies of P60s or had the verification section completed? Have you told us what benefits the member wants to take? Annuity, ARF or AMRF? Have you provided details of any other pension arrangements? Have you completed the member's bank details so that we can lodge payments? If investing in an ARF, have you provided evidence of income, or details of AMRF or Annuity? Have you told us what funds to invest in? Have you told us how the annuity is to be set up (if applicable)? Has the financial adviser signed the form (Part 9)? Have both the member and the Trustees signed the relevant parts of the form (3b if applicable, 8 and 10)? (01) 639 7398 www.standardlife.ie customerservice@standardlife.ie Standard Life Assurance Limited is authorised by the Prudential Regulation Authority in the UK and is regulated by the Central Bank of Ireland for conduct of business rules. Standard Life Assurance Limited is registered in Dublin, Ireland (905495) at 90 St Stephen s Green, Dublin 2 and Edinburgh, Scotland (SC286833) at Standard Life House, 30 Lothian Road, Edinburgh EH1 2DH. Calls may be monitored and/or recorded to protect both you and us and help with our training. Call charges will vary. OPSBRET V14 0615 2015 Standard Life 12/12