APPLICATION FOR ADVANCE PAYMENT



|RETIREMENT ANNUITY PAYMENT REQUEST FORM |

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|This form is used to instruct Liberty Life to pay money from your retirement annuity policy. |

|This form has 3 pages. |

|This form must be completed and signed by the member (owner of the policy). |

|SEND THE COMPLETED FORM TO LIBERTY LIFE BY: |

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|Fax: 086 683 9461 |E-mail: opspcd@liberty.co.za |Post: P O Box 10499, Johannesburg, 2000 |

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|Explanation of Retirement Annuities (Note these options are not applicable to Surrenders, Advances or Preservers) |

|A retirement annuity fund is established to provide life annuities to the members of the fund. A retirement annuity fund is defined in Section 1 of the Income |

|Tax Act. |

|Retirement Annuity Payments Option |

|Please choose the type of payment option by ticking (() one of the boxes below: |

|OPTION 1 |

|Retirement: on or after your selected retirement age on the policy (maturity of the policy). |

|Early retirement i.e. before the chosen retirement date on the policy, but after age 55. |

|OPTION 2 |

|Emigration withdrawal |

|The full fund value may be paid out on formal emigration, subject to approval from the South African Reserve Bank. |

|OPTION 3 |

|Paid-up withdrawal: Retirement annuities less than R7 000 |

|If all policies in a fund are paid-up and the total fund value is less than R7 000, the member may withdraw the total fund value, even prior to the member’s |

|55th birthday. |

|Member Personal Details (Member is the owner of the policy) |

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|Policy number/s: |      | |

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|Member’s full names |      | |

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|ID number: |      | |

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|Member’s contact details | |

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|Tel: |(H) |      |(W) |      | |

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| |Cell |      |Fax |      | |

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|E-mail |      | |

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|Physical address: |      |Code: |      | |

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|Postal address: |      |Code: |      | |

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|Bank Account Details for Payment |

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|Retirement values are calculated taking into account the payment and allocation of the current month’s premium. The member/account holder agrees that if the |

|last debit order collected for this policy is returned, Liberty can debit the bank account into which the value was paid in order to recover the outstanding |

|premium. |

|If payment is to be made into a bank account that belongs to the member and from which Liberty Life is collecting premiums for any other policy, please confirm |

|the policy number (provided this account has been used to collect premiums for at least 12 months): |

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|For your protection payments will only be made by electronic fund transfer (EFT). Cheque payments will not be made. Payments will be made directly into the |

|member’s premium paying account on debit order paid policies, subject to the member’s approval. If bank account details differ to the account details on |

|record, please provide proof of account in the member’s name i.e. a copy of a cancelled cheque OR copy of a current bank statement on a bank letterhead OR a |

|copy of printout from the bank with a bank stamp. |

|If payment is to be made into a bank account other than that from which premiums are collected, please complete the details below: | |

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|Account name/Account holder name: |      | |

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|Bank name: |      |Branch name: |      | |

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|Branch code: |      |Account number: |      | |

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|Account type: | |Current | |Savings | |Transmission |

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|Payments cannot be made into credit cards, call accounts, home loan accounts and money market accounts. | |

|Liberty Life’s requirement will not be finalised until SARS issues a tax directive for the member. | |

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|OPTION 1: EARLY RETIREMENT/RETIREMENT |

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|Your payment options depend on the total fund value of all the retirement annuity policies that you hold, and have held, with Liberty: |

|If the total fund value is more than R75 000, you must use at least two-thirds of the value of your retirement policy to buy an annuity. You can claim the rest|

|as a lump-sum payment. |

|If the total fund value is R75 000 or less, you can take the full value of your policy as a lump sum payment. |

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|Please choose your payment option by ticking (() one of the boxes below: | |

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|Use full fund value to buy an annuity |

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| From Liberty |Liberty annuity policy number: |      | |

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| From another insurer | |

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|Name of insurer: |      |Type of annuity: |      | |

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| |Policy number: |      | |

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|Withdraw full fund value |

|Total fund value must be R75 000 or less to take this option. |

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| Withdraw R |      |(full fund value) | |

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|Withdraw part of fund value and use remainder to buy an annuity |

|If the total fund value is greater than R75 000, no more than 1/3 of the value may be withdrawn (paid out as a lump sum). The remaining 2/3 must be used to buy|

|an annuity. |

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| Withdraw R |      |and use the balance to buy a Liberty annuity. | |

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| |Liberty annuity policy number: |      | |

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| Withdraw R |      |and use the balance to buy an annuity from another insurer. | |

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|Name of insurer: |      |Type of annuity: |      | |

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| |Policy number: |      | |

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|LIBERTY ANNUITY OPTIONS |

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|There are a number of annuity options for different financial needs. Speak to your financial adviser or call us on 011 408 4841 to discuss the annuity best |

|suited to you. |

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|OPTION 2: EMIGRATION WITHDRAWAL |

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|The emigration option is only open to members of retirement annuity funds who have formally or is in the process of emigrating from South Africa. Certain SARS |

|requirements must be submitted prior to the tax directive being applied for. |

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| |Please commute the after-tax lump sum for emigration purposes |

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|Note: Members over age 55, wishing to commute retirement annuities for emigration purposes, may do so prior to reaching selected retirement age. Once selected|

|retirement age has been reached, the member may only elect to retire from the fund. Normal retirement process and requirements will take place. |

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|OPTION 3: PAID-UP WITHDRAWAL (Retirement annuities less than R7 000) |

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|Recent tax legislation changes now allow retirement annuity fund members with a paid-up fund value less than R7 000, to withdraw at any time. Tax directives |

|will still be required to process this request . |

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| |Please commute the total paid-up value (of less than R7 000) for all my retirement annuities in the fund. |

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|Financial Advisory and Intermediary Services (FAIS) – Act 37 of 2002 |

|The purpose of this Act is to protect consumers and relgulates the business of Financial Services Providers (FSP) and their representatives, by providing you |

|with enough information to make an informed decision. |

|Financial Adviser’s Details |

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|Only to be completed if a financial adviser assisted the member with the completion of this form. |

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|Full name: |      | |

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|Commission code: |      | | | |

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|Contact number: |      | |Signature of financial adviser | |

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|Record of Advice (ROA) (To be completed by the financial adviser if Blueprint online is not used.) |

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|In terms of FAIS, the adviser must provide a brief summary of the basis of their recommendation. |

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|IMPORTANT NOTES |

|In this document Liberty Life means Liberty Group Limited and all of its subsidiaries and associated companies. |

|The value of your benefits may be adjusted on withdrawals or early retirements. |

|If you withdraw funds from your policy, the value of your benefits may be adjusted downwards to bring it in line with current market values. This is known as a|

|market value adjustment (MVA). Market value adjustments are only taken into account on profit policies and policies with smoothed bonus portfolios. |

|If you withdraw early, we may need to recover expenses that have not yet been paid for. |

|In all instances documentation is required, either by your Financial Adviser if processed via Blueprint, or by Liberty Life Head Office if you choose to deal |

|directly with us.. |

|Note: Requirements will be required in all instances. |

|Liberty Life reserves the right to call for any additional requirements deemed necessary to protect the interests of both our clients, and Liberty Life. |

|In the event of the member being sequestrated/insolvent, legally incapacitated or a deceased Estate, Liberty Life will confirm further requirements. |

|Replacing a policy with another policy is potentially prejudicial, and where a replacement is considered, you are legally entitled to comprehensive information |

|regarding the consequences of replacement. |

|No payment to a third party i.e. anyone other than the member, will be allowed under any circumstances. |

|If the product you have chosen is a Linked Life Annuity, please note the following: |

|The investment risk is borne by the investor and depending on the performance of the portfolios selected, there is a possibility of capital erosion. |

|The Investor who requires an income that exceeds inflation plus 2% should contact his/her Financial Adviser for further advice in this regard. |

|The ownership of the underlying assets rests with the Insurer and not the Annuitant. |

|The Annuity may be transferred to another Insurer free of any costs. |

|The Investor needs to understand the implications of a downturn in markets on the sufficiency of future payments. |

|By signing this form you acknowledge the following: |

|Upon payment/transfer the Lifestyle Retirement Annuity Fund will be discharged from any further obligations. |

|Any annuity purchased in your name shall constitute a Compulsory Life Annuity that cannot be commuted. |

|DECLARATION |

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|I, the undersigned, |      |hereby declare that I am the member under the above policy and |

|confirm that I wish to defer payment of the proceeds at the option date in accordance with the instructions. |

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|Signed at |      |on this |      |day of |      | |

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| |Signature of Member | | | | | |

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