This form should be completed in block capitals by the ...



|AUCO |

AUC Offshore Retirement Investment Plan - Leavers/Retirement form

This form should be completed in block capitals by the company Human Resources Department in conjunction with the member. When complete [Please fax the form to Fidelity on: +44 1737 837 751.] or [Please email to Fidelity at: dcadministration@]

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|Section A – Participant details |

|This section should be completed in block capitals by local company representative. |

| | |

|Full Name: | |

|(As shown on passport. Please do | |

|not use initials or abbreviations.| |

|This MUST include ALL names.) | |

| | | | |

|Title: | |Employee/Payroll | |

|Mr/Ms/Mrs/Miss | |Number: | |

| | | | |

| | |

|Correspondence address: | |

|(please note a ‘care of’ or | |

|employer address is not | |

|acceptable) | |

| |N/A | | |

|Postcode/Zip code: | |Date of leaving/retirement: | |

| | |Delete as applicable | |

| | |DD/MM/YYYY | |

| | | | |

|Date of last contribution: | |Is the member vested: | |

|DD/MM/YYYY | | |Yes No |

| |

|Section B – Leaving employment |

|This section should be completed by the Employer of the member leaving the company. |

| |

|Please mark relevant box: |

| |

|I instruct Fidelity to leave the value of the member’s account invested within the plan. |

|Please sign below |

| |

|I instruct Fidelity to disinvest the value of the member’s account and make payment to [the member’s/my] bank account. |

|Please sign below and complete Sections D. |

| |

| | |

|[Member/Employer/Trustee] signature: | |

| |

|Section C – Retirement |

|This section should be completed if the member is approaching their selected retirement age. |

|Please note that the value of the members account will be paid in full. (Please also complete section D). |

|I confirm that I am retiring and request that Fidelity (on the instruction from the company in Section E below) disinvest my account and pay benefits in full.|

| | | | |

|Signature: | |Date: | |

|To be signed by member | |DD/MM/YYYY | |

| |

|Section D – Member bank account details |

|The Member should complete this section in block capitals. Please note that if the member wishes to retain the value of their account with Fidelity then this |

|section should not be completed. |

|Please note that all funds will be paid in the plan’s currency. |

| | |

|Full name of account holder: | |

|(As shown on passport. Please do not use | |

|initials or abbreviations. This MUST include ALL| |

|names.) | |

| | | | |

|Account holder’s full telephone number | |Account holder’s date of birth | |

|including any dialling codes required | | | |

| | | | |

|Account holder’s full residential address | |Account holder’s email address | |

|Including postcode or zip code. Please note a | | | |

|‘care of’ or employer address is not | | | |

|acceptable. | | | |

| | | | |

|Nationality | |Passport number: | |

| | | | |

|Passport place of issue: | |Passport expiry date | |

| | |

|Bank/ building society name: | |

| | |

| | |

| | |

|Bank/ building society full address: | |

|Including postcode or zip code | |

| | | | |

|Bank account number/Building Society account | |Branch Sort Code/ Routing | |

|number: | |number/Building Society number: | |

| | | | |

| | | | |

| | | |

|Swift number: | |Example of a SWIFT Code: |

|For international transfers to banks outside of| |APNYUS33 XXX |

|the UK a SWIFT code my be provided | | |

| | | | |

|Member signature: | |Date: | |

|I confirm that the above details are correct | |DD/MM/YYYY | |

| | | | |

| | | | |

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|Section E – Company/Trustee declaration |

|This section should be completed by company representative. |

| |

|Please mark relevant box: |

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|I instruct Fidelity to disinvest the member’s account and to make the payment to the member’s bank account. |

| |

|I confirm that the member has left the plan. I instruct Fidelity to leave the value of the member’s account invested within the plan. |

| | | | |

|Signature: | |Date: | |

|Authorised signatory on behalf | |DD/MM/YYYY | |

|of the company | | | |

| | | | |

|Signature: | |Date: | |

|Authorised signatory on behalf | |DD/MM/YYYY | |

|of the company | | | |

Issued and approved by FIL Pensions Management (FSA registered number 144345). Authorised and regulated by the Financial Services Authority. Registered in England and Wales No.2015142. Registered offices at: Oakhill House, 130 Tonbridge Road, Hildenborough, Kent, England TN11 9DZ. Fidelity, Fidelity Worldwide Investment, the Fidelity Worldwide Investment logo and F symbol are trademarks of FIL Limited. April 2012. CI3231 

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