RECOGNITION OF GN18 PURCHASE OF A MEMBER OWNED PENSION BY A PENSION, PROVIDENT AND RETIREMENT ANNUITY FUND

(AS DEFINED IN SECTION 1 OF THE INCOME TAX ACT FROM A LONG TERM INSURER AS DEFINED IN SECTION 1 OF THE LONG TERM INSURANCE ACT)

(A) On behalf of purchasing fund

1.  Particulars of purchasing fund

Full name of fund / Pf Registration no.
SARS Approval no. / 18 / 20 / 4/
The fund is an approved / Pension scheme / Provident scheme / Retirement Annuity scheme
The fund is a / Defined Benefit scheme / Defined Contribution scheme

2.  Particulars of member

Full names, surname / Mr / Mrs / Miss
Date of birth / Identity number
Income tax reference number / Revenue office
Date of retirement from purchasing fund / DD / MM / CCYY / Pensionable service to date of Retirement / Years / Months

3.  Particulars of pension to be purchased

Member’s gross benefit

/

R

Amount to be applied to purchase a pension /

R

Details of any portion of gross benefit not being used to purchase this pension are as follows /
The pension is purchased in the name of /
The pension is purchased on the following special conditions /

4.  Statement on behalf of purchasing fund

The amount to be utilised for the purchase of the pension (as per 3. above) will be paid by means of electronic fund transfer to the insurer’s bank account as soon as –

This Recognition of GN18 purchase form is returned, fully completed and signed, to the contact person as stated in 5 below.

Confirmation of payment will be provided as soon as this has been done.

5.  Particulars of contact person

Name / Company / Liberty Corporate Benefits
Phone no / (011) / Fax no / (011)
Cell no / e-mail
Postal address / PO. Box 2094, Johannesburg
Postal code / 2000
Signed at / Braamfontein / this / day of / 20
Signature / (on behalf of purchasing fund)

Please note that in the event of any modification or variation of this standard form Liberty Corporate will regard this form as being

invalid and of no force and effect. Do not sign blank or incomplete forms.

LCB101/0401 Page 2

Particulars of member:
[FOR LIBERTY LIFE USE] / Full names, surname
scheme code / reference number

(B) On behalf of receiving insurer

1.  Particulars of receiving insurer

Full name of insurer
Member’s application no./policy no. or other reference

2.  Banking details

Name of owner of Bank account into which the amount in A(3) is to be paid
Account number
Name of bank
Name of branch
Branch code

3.  Particulars of contact person

Name / Company
Phone no / Fax no
Cell no / E-mail
Postal address
Postal code

4.  Statement on behalf of receiving insurer

·  The pension as set out in (A)(3) above will be applied for the benefit of the person(s) specified in (A)(2) above.

·  Such pension shall be a life long pension in the name(s) of the person(s) specified in (A) (2) above.

·  Such pension shall not be commutable, transferable or allowed to being pledged, hypothecated or ceded by anyone.

·  If any request is received to deal with the benefit as set out in (A)(3) above in any manner other than that set out in (A)(3) above, including any request to cancel the purchase to the insurer, such request shall not be implemented by the insurer without the prior written consent of the purchasing fund.

Signed at / this / day of / 20
Signature
Print name
(ON BEHALF OF RECEIVING INSURER)

Please fax the fully completed and signed Recognition of GN18 Purchase form to the contact person in A.5 above within 48 hours of receipt.

Please note that in the event of any modification or variation of this standard form Liberty Corporate will regard this form as being

invalid and of no force and effect. Do not sign blank or incomplete forms.

LCB101/0401 Page 2