CIRCULAR

Chairperson: Dr C. Mini Acting Chief Executive & Registrar: Dr S. KabaneBlock A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion, 0157

Tel: 012 431 0500 Fax: 086 206 8260 Customer Care: 0861 123 267Information@medicalschemes.com www.medicalschemes.com

Reference: Vetting of medical scheme officersContact person: Loyiso Mdlalose and Viaan PullenTel: +27 (0)12 431 0587 / 0498Fax: +27 (0)86 206 0053 / +27 (0)86 242 1158E-mail: l.mdlalose@medicalschemes.com or v.pullen@medicalschemes.comDate: 2018/10/12

CIRCULAR 49 OF 2018: VETTING OF MEDICAL SCHEME OFFICERS

In terms of section 57 (1) of the Medical Schemes Act, No. 131 off 1998 (the Act), it’s incumbent that every medical schemehas a board of trustees consisting of persons who are fit and proper to manage the business contemplated by the medicalscheme, in accordance with the applicable laws and rules of such medical scheme. Section 57 (4) obligates the board of trusteesof a medical scheme to appoint a principal officer who is a fit and proper person to hold such office.

The Council for Medical Schemes (CMS) has in 2016 (see Circular 44 of 2016) resolved to embark on a joint exercise withmedical schemes in vetting its officers (trustees and principal officers) to determine their fit and proper status. Principal officerswere requested to assist by furnishing the CMS with details and documents relating to the vetting process; and to provide theCMS with completed signed copies of the CMS vetting form. The CMS would like to thank all medical schemes that cooperatedwith Circular 44 of 2016, however several medical schemes have alarmingly not fully complied with the request, without reason.

It is imperative to note that committees of the board of trustees are in essence an extension of the board of trustees and thereforemembers of such committees are required to be vetted to ensure compliance with section 57 (1) of the Act. To this end, theCMS has enhanced the current vetting form, and also compiled a vetting form specific for members of a committee of the boardof trustees (see attached).

Medical schemes are encouraged to utilise the CMS vetting forms as part of the vetting process, to avoid duplication. In addition,medical schemes subscribed to the Governance and Compliance Instrument (hosted by The Global Platform for IntellectualProperty) may access and complete the CMS vetting forms by logging onto the Governance and Compliance Instrumentwebsite.

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Chairperson: Dr C. Mini Acting Chief Executive & Registrar: Dr S. KabaneBlock A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion, 0157

Tel: 012 431 0500 Fax: 086 206 8260 Customer Care: 0861 123 267Information@medicalschemes.com www.medicalschemes.com

The CMS would like to emphasis the importance of complying with the provisions of section 57 of the Act, and an appeal ishereby made to all medical schemes to ensure that scheme officers are thoroughly vetted. Trustees and principal officers ofmedical schemes are required to assist the CMS in ensuring compliance with section 57 (1) and 57 (4) (a) of the Act and byfurnishing the CMS with details and documents that medical schemes utilised in vetting its trustees and principal officers. Inaddition, scheme officers are required to furnish the CMS with the applicable completed and signed vetting form.

Kindly note that the CMS undertakes to conduct its vetting process with utmost confidentiality and in accordance with section60 of the Act, which deals with preservation of secrecy by Council and its staff members.

Trustees and principal officers of medical schemes are hereby granted 30 days from the date of this circular to comply with theaforementioned directive, failing which enforcement action will be taken for non-compliance.

In addition, medical schemes shall within 30 days following the prospective appointment or election of a principal officer ortrustee, furnish the CMS with details and documents utilised in vetting such scheme officer, together with the applicablecompleted and signed CMS vetting form.

Kindly forward the required documents in respect of the above to complianceFiling@medicalschemes.com

Yours sincerely

STEPHEN MMATLIGENERAL MANAGER: COMPLIANCE AND INVESTIGATIONSCOUNCIL FOR MEDICAL SCHEMES

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TRUSTEE AND PRINCIPAL OFFICER

PERSONAL VETTING QUESTIONANRE AND DECLARATION

A. INTRODUCTION

Section 57 of the Medical Schemes Act 131 of 1998 (“the Act”), requires all medical schemes to have a boardof trustees consisting of persons who are fit and proper to manage the business contemplated by the medicalscheme, in accordance with the applicable laws and the rules of such medical scheme. This createsconfidence [in members] that trustees are persons that are competent, honest and sound.

The propriety and competence of the medical scheme officers (trustees and principal officers) are of stronginterest to the Council for Medical Schemes (“the CMS”). The CMS has periodically conducted vetting ofmedical scheme officers to determine their fit and proper status, on the understanding that medical schemesindependently vet their officers. It has emerged that not all medical schemes have methodical vettingprocesses. To this end, the CMS has decided to embark on a joint exercise with the medical schemes in thevetting of medical scheme officers.

The CMS undertakes to conduct vetting with utmost confidentiality and in accordance with section 60 of theAct, which deals with preservation of secrecy by the Council and its staff members. The information providedwill not be disclosed or used for any other purpose than to assess the proprietary and fitness of medicalscheme officers, except in so far as it may be required and permitted by law.

In the effective discharge of this obligation, trustees, principal officers and members of a committee of theBoard of Trustees are requested to furnish CMS with the applicable vetting questionnaire completedaccurately and legibly, together with a copy of the officer’s current curriculum vitae and identificationdocument. A separate sheet may be used to provide more details on any of the information provided or toprovide further information which you believe has a bearing in assessing whether you are fit and proper toserve as a trustee or a principal officer.

B. PERSONAL INFORMATION(Where applicable, mark the appropriate box with an X)

1. Full name(s) and surname:

2. Have you ever been subject to a name change? If yes, former name and reason for the name change.YESNO

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3. Identification (ID) number:

4. Have you ever been subject to identification (ID) number change? If yes, former identification numberand reason for the change.

YESNO

5. Current Age:

6. Gender:FEMALE

MALE

7. Nationality:

8. Race:Asian Black Coloured White Other

9. Postal address:

10. Permanent / residential address:

11. Have you obtained a National Senior Certificate (Matric certificate) or its equivalent:YESNO

If yes:InstitutionDate obtained

12. Other qualifications obtained:Date obtained Qualification details; Institution

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13. The full name and surname of your spouse(s), including life partner(s) and their Identification number:Name and surname Identification (ID) number

14. Current employment:Name of entity (employer)PositionDate of employment

15. Previous employment:Name of entity (employer)PositionDate of employment

C. MEMBERSHIP AND NOMINATION DETAILS

1. The name of the medical scheme for which you have been elected/ appointed as a trustee or principalofficer?

2. Were you elected or appointed as a trustee or principal officer and when?Elected

AppointedYEAR MONTH DAY

3. In what capacity are you elected/ appointed as a trustee (elected, co-opted, employer representative,union representative etc. )?

4. Are you a member of the medical scheme of which you are a trustee or principal officer? If no, whatmedical scheme are you a member of, if any?

YESNO

5. Membership number?

6. When did you become a member of the medical scheme?YEAR MONTH DAY

7. Have you undergone any training relevant to board governance since your appointment? If yes, providefurther details as requested.

YESNO

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Date Institution Qualification / Training details

8. Have you previously been appointed/ elected as a trustee or principal officer of any medical scheme? Ifyes, for which medical scheme and the period of such appointment?

YESNO

Medical Scheme Role Appointment dateYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTH

9. Do you currently serve as a trustee or principal officer of any other medical scheme? If yes, for whichmedical scheme and the period of such appointment?

YESNO

Medical Scheme Role Appointment dateYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTH

10. Do you serve or have you served on any committee of the board of trustees, for instance, the AuditCommittee, Risk Committee, and / or Remuneration Committee? If yes, please provide further informationas requested.

YESNO

Committee(Risk

Committee)

Role(Chair,

member)

Appointment date(2018; March)

Function(Contribute to the oversight of therisk management function.)

YEAR MONTHYEAR MONTHYEAR MONTHYEAR MONTHYEAR MONTHYEAR MONTH

11. Have you ever been associated, in ownership or supervisory capacity, with any business entity(Administrator, Managed Care Organisation, Brokerage or any other provider of service) that provides orprovided services to the medical scheme? If yes, provide further details as to the entity, role and durationof association.

YESNO

Entity namePosition/ interest held

Duration of association

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Otherrelevantdetails

12. Who nominated or approached you to serve on the BoT or to express interest in the role of principalofficer?

13. Were you nominated or approached to serve on the BoT or to express interest in the role of principalofficer by an employee, principal officer or trustee of the medical scheme or by an employee, director,officer, consultant, or associate of any person, who renders contractual services (administrator, managedcare organisation, or brokerage) to the medical scheme? If yes, provide further details as requested.

YESNOName of person who

approached/nominated you and

the entity theyassociated with

Other relevant details

14. Did you receive an award, payment or other consideration to be nominated to serve on the BoT or foraccepting such nomination? If yes, provide further details as to what was received, when and from whom.

YESNO

15. Other than payment of fee as a trustee or principal officer of the medical scheme, have you received anyother benefits, directly or indirectly, for yourself or any family member from the medical scheme or anyparty that contracts / contracted with the medical scheme? If yes, provide details on what was received,from who and when.

YESNO

D. SPECIFIC QUESTIONS TO ASSESS FIT AND PROPRIETY(Kindly tick the appropriate box, and if answered yes, please provide further details.)

1. Have you ever been declared insolvent, filed for bankruptcy, made any debt arrangements with (any of)your creditors, applied for debt review, had assets sequestrated or involved in any proceedings of thisnature?

YESNO

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Date YEAR / MONTH Type of proceedingsOther

relevantdetails

2. Have you ever been subject to any proceedings of a disciplinary, civil or criminal nature, or been notifiedof any proceedings or any investigation that may lead to such proceedings?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

3. Have you, or any business in which you have or had a personal interest or exercised influence, beeninvestigated, suspended or reprimanded by a professional or regulatory body, tribunal, or court, in SouthAfrica or elsewhere?

YESNO

Date YEAR / MONTH Type of proceedingsName of business if relevant

Otherrelevantdetails

4. Have you ever been associated, in ownership or supervisory capacity, with any business entity that hasbeen refused registration or accreditation to conduct business, or has had such registration oraccreditation suspended, revoked, or withdrawn?

YESNODate YEAR / MONTH Type of proceedingsName of business (if relevant)Otherrelevantdetails

5. Have you ever been associated, in ownership or supervisory capacity, with any business that has goneinto liquidation or insolvency while connected with that business or within five years after that connection,or is currently subject to an application of such proceedings?

YESNO

Date YEAR / MONTH Type of proceedingsName of businessOther

relevantdetails

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6. Have you ever been disqualified from serving in a managerial or director capacity or been removed fromsuch position by a professional or regulatory body, tribunal, or court, in South Africa or elsewhere or areyou aware of any matter against you or investigation which may lead to such removal?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

7. Were you ever removed, dismissed, requested to resign, or resigned from a position (of employment,trust, fiduciary or similar) because of questions about your integrity, incompetence, or mismanagement?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

8. Were you ever dismissed from a position of employment or removed as trustee or member of a committeeof the board of trustees by a medical scheme or the Council for Medical Schemes?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

9. Have you ever been declared mentally incapacitated?YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

10. Have you ever been subject to an adverse finding or judgement (i.e. a fine) that has not been satisfied asper the finding?

YESNO

Date YEAR / MONTH Judgement/ findingOther

relevantdetails

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11. Do you have any relationship, business or personal, with any officer (trustee, principal officer, member ofany sub-committee or any employee) of the medical scheme for which you a trustee? If yes, kindlystipulate the type of relationship and with whom.

YESNO

12. Are you a broker or do you have any affiliation with a broker or brokerage, other than for personalbrokerage services?

YESNOBroker/ brokerage namePosition/ interest held

Name of associate (if any)Other

relevantdetails

13. Are you an officer (employee or executive / director) of the medical scheme, or an employee, director,officer, consultant, or associate of any person, who renders contractual services to the medical schemeor? If yes, provide further details as requested.

YESNO

Entity namePosition/ interest held

Name of associate (if any)Other

relevantdetails

14. Do you hold any position or have any interest in any other entity regulated in terms of the Medical SchemesAct 131 of 1998? If yes, clearly state the name of the entity and the position or interest held.

YESNO

Entity namePosition/ interest held

Otherrelevantdetails

15. Is any of your immediate family (including spouse, life partner) or close affiliates an officer (employee,executive, or trustee) of the medical scheme, or an employee, director, officer, consultant, or associate ofany person, who renders contractual services to the medical scheme? If yes, provide further details asrequested.

YESNO

Entity namePosition/ interest held

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Name of associate (if any)Other

relevantdetails

16. Are you aware of any information not covered by the above questions but which, if known to the medicalscheme and/or to Council for Medical Schemes will render you not fit and proper to serve either as atrustee or a principal officer? If yes, kindly provide further details.

YESNO

DECLARATION

I hereby declare that:

1. All information provided was done voluntarily by me and is complete and correct to the best of my knowledgeand there are no other facts that are relevant for assessing my fitness and propriety;

2. I will in writing, within 60 days of an event or matter or learning of such event or matter that may affect myfitness and propriety to hold office as trustee, inform the Council for Medical Schemes thereof;

3. The Council for Medical Schemes may require or seek further information from myself and / or any third partyit deems necessary in assessing my fitness and propriety;

4. I understand that any false information provided by me may lead to my removal as a member of the Board ofTrustees or Principal Officer.

Printed full names:

Signature of scheme officer:

Place:

Date:

Date of submission of completed form to CMS _____________________

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BOARD OF TRUSTEE COMMITTEE MEMBERS

PERSONAL VETTING QUESTIONANRE AND DECLARATION

A. INTRODUCTION

Section 57 of the Medical Schemes Act 131 of 1998 (“the Act”), requires all medical schemes to have a boardof Trustees consisting of persons who are fit and proper to manage the business contemplated by the medicalscheme, in accordance with the applicable laws and the rules of such medical scheme. This createsconfidence [in members] that Trustees are persons that are competent, honest and sound.

The propriety and competence of the medical scheme officers (Trustees and Principal Officers) are of stronginterest to the Council for Medical Schemes (“the CMS”). The CMS has periodically conducted vetting ofmedical scheme officers to determine their fit and proper status, on the understanding that medical schemesindependently vet their officers. It has emerged that not all medical schemes have methodical vettingprocesses. To this end, the CMS has decided to embark on a joint exercise with the medical schemes in thevetting of medical scheme officers.

The CMS undertakes to conduct vetting with utmost confidentiality and in accordance with section 60 of theAct, which deals with preservation of secrecy by the Council and its staff members. The information providedwill not be disclosed or used for any other purpose than to assess the proprietary and fitness of medicalscheme officers, except in so far as it may be required and permitted by law.

In the effective discharge of this obligation, Trustees, Principal Officers and Members of a committee of theBoard of Trustees are requested to furnish CMS with the applicable vetting questionnaire completedaccurately and legibly, together with a copy of the officer’s current curriculum vitae and identificationdocument. A separate sheet may be used to provide more details on any of the information provided or toprovide further information which you believe has a bearing in assessing whether you are fit and proper toserve as a trustee or a principal officer.

B. PERSONAL INFORMATION(Where applicable, mark the appropriate box with an X)

1. Full name(s) and surname:

2. Have you ever been subject to a name change? If yes, former name and reason for the name change.YESNO

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3. Identification (ID) number:

4. Have you ever been subject to identification (ID) number change? If yes, former identification numberand reason for the change.

YESNO

5. Current Age:

6. Gender:FEMALE

MALE

7. Nationality:

8. Race:Asian Black Coloured White Other

9. Postal address:

10. Permanent / residential address:

11. Have you obtained a National Senior Certificate (Matric certificate) or its equivalent:YESNO

If yes:InstitutionDate obtained

12. Other qualifications obtained:Date obtained Qualification details; Institution

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13. The full name and surname of your spouse(s), including life partner(s) and their date of birth:Name and surname Identification (ID) number

14. Current employment:Name of entity (employer)PositionDate of employment

15. Previous employment:Name of entity (employer)PositionDate of employment

C. MEMBERSHIP AND NOMINATION DETAILS(Kindly tick the appropriate box, and if answered yes, please provide further details where applicable.)

1. The name of the medical scheme for which you have been elected/ appointed as a member of acommittee of the Board of Trustees?

2. Are you a member of the medical scheme for which you serve as a member of the committee of theBoard of Trustees? If no, what medical scheme are you a member of, if any?

YESNO

3. Membership number?

4. When did you become a member of the medical scheme?YEAR MONTH DAY

5. What committee(s) of the Board of Trustees have you been elected/ appointed to (for instance, theAudit Committee, Risk Committee, and / or Remuneration Committee) and when were you appointed?

Committee(Risk

Committee)

Role(Chair,

member)

Appointment date(2018 March)

Function(Contribute of the oversight of therisk management function.)

YEAR MONTHYEAR MONTHYEAR MONTHYEAR MONTHYEAR MONTHYEAR MONTH

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6. Have you previously served on any committee of the Board of Trustees?YESNO

Committee Appointment dateYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTH

7. Do you currently serve on any committee of the Board of Trustees of any other medical scheme?YESNO

Medical Scheme Committee Appointment dateYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTH

8. Have you previously served on any committee of the Board of Trustees of any other medical scheme?YESNO

Medical Scheme Committee Appointment dateYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTH

9. Have you previously been elected/ appointed as a trustee or principal officer of any medical scheme?YESNO

Medical Scheme Role Appointment dateYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTH

10. Do you currently hold office as a trustee or principal officer of any other medical scheme?YESNO

Medical Scheme Appointment dateYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTHYEAR MONTH to YEAR MONTH

11. Have you ever been associated, in ownership or supervisory capacity, with any business entity(Administrator, Managed Care Organisation, Brokerage or any other provider of service) that provides or

5Version 2

provided services to the medical scheme? If yes, provide further details as to the entity, role and durationof association.

YESNO

Entity namePosition/ interest held

Duration of associationOther

relevantdetails

12. Who nominated or approached you to serve on the committee(s)?

13. Were you nominated or approached to serve on any of the committees by any person, who renderscontractual services (administrator, managed care organisation, or brokerage) to the medical scheme? Ifyes, provide further details as to who.

YESNOName of person who

approached/nominated you and

the entity theyassociated with

Other relevant details

14. Did you receive an award, payment or consideration to serve on the committee or for accepting suchappointment? If yes, provide further details as to what was received and from whom.

YESNO

15. Have you undergone any training relevant to the committee(s) you serve on, since your appointment?YESNO

Date Institution Qualification / Training details

16. Other than payment of fee as a committee member of the medical scheme, have you received any otherbenefits, directly or indirectly, for yourself or any family member from the medical scheme or any partythat contracts / contracted with the medical scheme? If yes, provide details thereof.

YESNO

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D. SPECIFIC QUESTIONS TO ASSESS FIT AND PROPRIETY(Kindly tick the appropriate box, and if answered yes, please provide further details.)

1. Have you ever been declared insolvent, filed for bankruptcy, made any debt arrangements with (any of)your creditors, applied for debt review, had assets sequestrated or involved in any proceedings of thisnature?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

2. Have you ever been subject to any proceedings of a disciplinary, civil or criminal nature, or been notifiedof any proceedings or any investigation that may lead to such proceedings?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

3. Have you, or any business in which you have or had a personal interest or exercised influence, beeninvestigated, suspended or reprimanded by a professional or regulatory body, tribunal, or court, in SouthAfrica or elsewhere?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

4. Have you ever been associated, in ownership or supervisory capacity, with any business entity that hasbeen refused registration or accreditation to conduct business, or has had such registration oraccreditation suspended, revoked, or withdrawn?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

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5. Have you ever been associated, in ownership or supervisory capacity, with any business that has goneinto liquidation or insolvency while connected with that business or within five years after that connection,or is currently subject to an application of such proceedings?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

6. Have you ever been disqualified from serving in a managerial or director capacity or been removed fromsuch position by a professional or regulatory body, tribunal, or court, in South Africa or elsewhere or areyou aware of any matter against you or investigation which may lead to such removal?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

7. Were you ever dismissed, requested to resign, or resigned from a position (of employment, trust, fiduciaryor similar) because of questions about your integrity, incompetence, or mismanagement?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

8. Were you ever dismissed from a position of employment or removed as trustee or member of acommittee of the board of trustees by a medical scheme or the Council for Medical Schemes?

YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

9. Have you ever been declared mentally incapacitated?YESNO

Date YEAR / MONTH Type of proceedingsOther

relevantdetails

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10. Have you ever been subject to an adverse finding or judgement (i.e. a fine) that has not been satisfied asper the finding?

YESNO

Date YEAR / MONTH Judgement/ findingOther

relevantdetails

11. Do you have any relationship, business or personal, with any officer (trustee, principal officer, member ofany sub-committee or any employee) of the medical scheme for which you a trustee? If yes, kindlystipulate the type of relationship and with whom.

YESNO

12. Are you a broker or do you have any affiliation with a broker or brokerage, other than for personalbrokerage services?

YESNOBroker/ brokerage namePosition/ interest held

Name of associate (if any)Other

relevantdetails

13. Are you an officer (employee or executive / director) of the medical scheme, or an employee, director,officer, consultant, or associate of any person, who renders contractual services to the medical schemeor entity regulated in terms of the Medical Schemes Act? If yes, provide further details as to who.

YESNO

Entity namePosition/ interest held

Name of associate (if any)Other

relevantdetails

14. Do you hold any position or have any interest in any other entity regulated in terms of the Medical SchemesAct 131 of 1998?

YESNO

Entity namePosition/ interest held

Otherrelevantdetails

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15. Is any of your immediate family (including spouse, life partner) or close affiliates an officer (employee,executive, or trustee) of the medical scheme, or an employee, director, officer, consultant, or associate ofany person, who renders contractual services to the medical scheme? If yes, provide further details as towho.

YESNO

Entity namePosition/ interest held

Name of associate (if any)Other

relevantdetails

16. Are you aware of any information not covered by the above questions but which, if known to the medicalscheme and/or to Council for Medical Schemes will render you not fit and proper to serve either as atrustee or a principal officer? If yes, kindly provide further details.

YESNO

DECLARATION

I hereby declare that:

1. All information provided was done voluntarily by me and is complete and correct to the best of my knowledgeand there are no other facts that are relevant for assessing my fitness and propriety;

2. I will in writing, within 60 days of an event or matter or learning of such event or matter that may affect myfitness and propriety to hold office as trustee, inform the Council for Medical Schemes thereof;

3. The Council for Medical Schemes may require or seek further information from myself and / or any third partyit deems necessary in assessing my fitness and propriety;

4. I understand that any false information provided by me may lead to my removal as a member of the Board ofTrustees or Principal Officer.

Printed full names:

Signature of scheme officer:

Place:

Date:

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Date of submission of completed form to CMS _____________________