Name in Full Mr Mrs Ms Other

Address

Sex Male Female Date of Birth PPS No

E-mail Home Tel No Mobile No

Marital Status Occupation Normal Retirement Age

Country of Residence Country of Tax Residence

Salary/Remuneration

Are you a Politically Exposed Person* Yes No *Please see PEP Definition at http://nrfm.ie/pep-definition/

Please indicate which one of the following best describes your occupation status:

Employee: Self Employed:Manager, professional, technical & administrative AgriculturalClerical and secretarial Not Economically Active/UnemployedTrade, craft and related Other Self-EmployedPersonal and protective service SalesPlant and machine operative Other employee

Commencement Date: Contribution Frequency:

Regular PRSA Contribution Per Month Quarterly Half Yearly Annually

Single Contribution

All contributions must be paid into your PRSA working bank account, the account details of which will be provided to you after your PRSA is set up. You can either hold funds in your PRSA working bank account or transfer these funds to the Default Investment Strategy (DIS) fund or make other allowable investments. The Default Investment Strategy (DIS) of the Self Invested PRSA is the New Ireland Assurance PRIME 3 Fund. Please refer to the Self-Invested PRSA Brochure and Terms and Conditions for more details.

I confirm that I do not wish to invest in the Default Investment Strategy. All funds, including cash transfers are to remain in the working bank account for the PRSA until I issue further instruction as to where they are to be invested.

Signed PRSA Holder

Non Standard PRSA Type:

AVC PRSA PRSA Vested PRSA

Personal Details

Contributions

€

€

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€

Note: If you are a member of an Occupational Pension Scheme you must take out an AVC PRSA to be eligible to apply for income tax relief.

Please confirm where the funds are being transferred from:

Existing PRSA Personal Pension Occupational Pension Scheme *

* In order to be able to transfer benefits already held in an Occupational Pension Scheme (OPS) you must have less than 15 years active pension scheme service with the same employer (or an associated employer), AND you must also be able to confirm one of the following: The transfer value is less than €10,000 The transfer is coming from an OPS that is being wound up A Certificate of Benefits Comparison has been completed (if you select this option please contact our company for further information) The transfer represents a refund of the employee’s own contributions The transfer relates to a non-preserved benefit from an OPS

Is this a Vested PRSA Yes No If yes, please complete Appendix 1 on page 4 of this application, if no, please provide us with the name of your existing PRSA provider as we require confirmation from them that this is not a vested PRSA. PRSA Provider: , Policy No:

A transfer is not possible where the individual’s benefits have become payable under an OPS.A transfer is not possible from an OPS for non-AVC benefits if:

• The member has 15 years or more active pension scheme service.• The member continues in employment and the scheme is not being wound up.

In the case of a transfer from a UK scheme where there is a transfer into your PRSA of funds that benefitted from UK tax relief, you shall not be allowed to draw benefits before your 55th birthday except on grounds of ill health and in any case subject to Revenue requirements being met. By transferring funds into this PRSA you are confirming that you agree to adhere to all of the contract rules under QROPS.

* Investment Manager as required and defined under the Pensions Act 1990, section 96(1)(a)

Transfers In

Transfers In / Investment Split

Investment Type Investment Manager * Policy No Value

Newcourt Retirement Fund Managers LimitedFather Mathew Hall, 131 Church Street, Dublin 7

Telephone: 01 8280091 Fax: 01 8726038 Email: info@nrfm.ie Web: www.nrfm.ie

2

Warning: If you propose to enter into this PRSA contract in complete or partial replacement of an existing PRSA contract or a retirement annuity contract, please take special care to satisfy yourself that this PRSA contract meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing PRSA contract or retirement annuity contract. If you are in doubt about this, please contact your PRSA provider.

Declaration of PRSA Provider or Intermediary I hereby declare that in accordance with Article 3 of the Personal Retirement Savings Accounts (Disclosure) Regulations 2002, a Preliminary Disclosure Certificate has been provided to and that I have advised the person concerned as to the financial consequences of replacing an existing PRSA contract or retirement annuity contract with this PRSA contract by cancellation or reduction and of possible financial loss as a result of such a replacement.

Signed: Date:

Name of PRSA Provider or Intermediary:

Declaration of Person or Contributor I confirm that I have received in writing the information specified in the above declaration

Signed: Date:

Name of PRSA Client:

I can confirm that I have been provided with the following items:

• NRFM Data Privacy Notice• NRFM Terms of Business for Trustee and Pension Services• PRSA Terms and Conditions• Preliminary Disclosure Certificate (which is incorporating sample details rather than details appropriate to me)• Investment Management Agreement

I hereby apply to set up a PRSA with Newcourt Retirement Fund Managers Limited (NRFM). I have read and fully understand, and agree to be bound by the attached Terms and Conditions.

NRFM Trustee and Pension Services are categorised as unregulated services and are not subject to the supervision of the Central Bank. The Consumer Protection Code (CPC), Client Asset Regulations (CAR) and the Investor Compensation Scheme do not apply to such services.

I understand that the value of my investment may go down as well as up and that the past performance is not a reliable guide to future performance. NRFM accept no responsibility for investment losses which may occur. All investment carries risk.

I declare that the information supplied in this PRSA application form is correct. I agree that if any of this information should change, I will confirm to NRFM in writing.

Signed: Date:

Name of PRSA Client:

Declaration under Article 3(5) of the Personal Retirement Savings Accounts (Disclosure Regulations 2002)

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Declaration of PRSA Holder

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Appendix 1 - Vested PRSA

This must be completed if you are transferring a Vested PRSA.If you cannot answer ‘yes’ to at least one of question A, B or C below, you must have €63,500 ring-fenced in a PRSA account until you reach age 75, or buy an annuity with the same amount.

(A)

Are you currently receiving a guaranteed pension/annuity for life of at least €12,700 per annum (including any state pension entitlements)?

Annual State Pension Entitlement*:

Other Pension Income:

Name & Address of Provider:

Policy Reference Number:

*This is the PRSA Holder’s individual state pension entitlement only, and does not include spouse’s pension.Please provide us with a copy of the payslip / P60 confirming receipt of income.

(B)

Have you used at least €63,500 from any pension fund to buy an annuity? Yes NoIf yes, please supply details:

Purchase Amount:

Name of Provider:

Reference Number:

Date of Purchase:

Please provide us with a copy of the confirmation of the purchase of the annuity.

(C)

Do you have €63,500 invested in an Approved Minimum Retirement Fund? Yes NoIf yes, please supply details:

Name of Qualifying Fund Manager:

AMRF Policy No/Plan No:

Amount of original AMRF investment:

Date you invested in your existing AMRF:

Please provide us with a copy of the policy document.

Client Signature: Date:

Name in Capitals:

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Newcourt Retirement Fund Managers LimitedFather Mathew Hall, 131 Church Street, Dublin 7

Telephone: 01 8280091 Fax: 01 8726038 Email: info@nrfm.ie Web: www.nrfm.ie

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Data Protection Notice - Consents and AuthorisationThe ‘Data Controller’ for the purposes of the General Data Protection Regulation 2016 (“GDPR”) (“effective 25 May 2018”) is Newcourt Retirement Fund Managers Limited (NRFM). The personal data being collected on this form is for the purposes of processing your application.NRFM may not, except for the purposes of carrying out our obligations under the relevant terms and conditions of a product or service offered by us or as required or permitted by law or regulation or as required by any regulatory body or governmental authority in any country or territory, disclose any confidential information relating to you to a third party.

By signing your name below you acknowledge that in providing products or services to you we may receive personal data and sensitive personal data about you, each as defined under the General Data Protection Regulation 2016 (“GDPR”) (“effective 25 May 2018”). Data shall include, but shall not be limited to, information contained in this application (or provided subsequently in discussion or otherwise) and any information arising in relation to your terms and conditions and your business relationship with NRFM. We undertake to use all reasonable commercially justifiable efforts to maintain the security of Data you provide to us.

By signing your name below you consent to us (NRFM) and our Intermediaries, holding, using, disclosing and processing Data in the following ways:

(a) To comply with legal and regulatory obligations;(b) To comply with the relevant terms and conditions for the products and services provided to you;(c) For direct marketing purposes, to advise you of products or services of NRFM or selected third parties, unless you have indicated to the contrary in writing;(d) To contact you or your personnel by post, telephone, email, fax, SMS message or other means, unless you indicate to the contrary in writing;(e) To carry out statistical analysis and market research;(f) To disclose to any (or any proposed) assignee, disposer or successor;(g) To hold, use, disclose and process Data for any other specific purposes where you or your personnel on your behalf have given NRFM your specific consent to do so.

By signing your name below you also consent to us and our Intermediaries, sharing Data with your nominated Financial Intermediary to enable them to administer your contracts with NRFM.

I agree that NRFM may contact me in person, by phone, letter, e-mail or other electronic means to provide me with general information and regulatory updates relating to this contract at any time.

I agree that the Information may be held and used by NRFM for Marketing purposes, including Marketing by e-mail or other electronic means. Yes No

You acknowledge that at any time you can ask us to stop or change the methods by which we may send you marketing materials. This can be done free of charge by writing to Newcourt Retirement Fund Managers Limited, Father Mathew Hall, 131 Church Street, Dublin 7. Our full privacy notice is available at www.nrfm.ie/data-privacy-notice/ Consents and Authorisation

I consent to the holding, use and disclosure of Data concerning me in the manner set out above.I authorise the Department of Employment Affairs and Social Protection and/or the Revenue Commissioners to advise NRFM of my most recent address on their records at any future time.

Client Signature

Name in Capitals Date

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Declaration

Section ATO BE COMPLETED BY THE CONSUMER

• I declare that I understand that the charges payable on a non-standard PRSA may be higher than those for a standard PRSA.

• I declare that I understand that the investment risks associated with a non-standard PRSA may be higher than those for a standard PRSA.

• I declare that I am satisfied that I require a pension product and that, having reviewed the differences between standard and non-standard PRSAs, a non-standard PRSA is the most appropriate pension product for me.

Signed: Date:

Print Name:

SECTION BTO BE COMPLETED BY THE INTERMEDIARY

• I declare that in my opinion it is in the best interests of the above named to purchase a non-standard PRSA rather than a standard PRSA.

• I declare that in my opinion the non-standard PRSA, I propose to sell the above named customer, is the product most suited to this consumer from among all those I am able to advise on.

• I declare that I have fully explained to this consumer the differences between this non-standard PRSA and standard PRSAs, and, where this is the case, focussed on the fact that the charges are higher and the investment risks are greater for this non-standard PRSA.

Signed: Date:

Print Name:

Name of Firm: Position Held:

The Central Bank of Ireland requires that prior to the sale/purchase of a non-standard PRSA both the customer and the PRSA provider/intermediary must complete this declaration.

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Newcourt Retirement Fund Managers LimitedFather Mathew Hall, 131 Church Street, Dublin 7

Telephone: 01 8280091 Fax: 01 8726038 Email: info@nrfm.ie Web: www.nrfm.ie

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Warning: The value of your investment may go down as well as up. Past performance is not a reliable guide to future performance. NRFM accept no responsibility for investment losses which may occur. All investment carries risk and your capital is not guaranteed. If you invest in this product you may lose some or all of the money you invest. This PRSA may be affected by changes in currency exchange rates depending on the underlying assets held in your PRSA.

NRFM Trustee and Pension Services are categorised as unregulated services and are not subject to the supervision of the Central Bank. The Consumer Protection Code (CPC), Client Asset Regulations (CAR) and the Investor Compensation Scheme do not apply to such services.

Newcourt Retirement Fund Managers LimitedFather Mathew Hall, 131 Church Street, Dublin 7

Telephone: 01 8280091 Fax: 01 8726038 Email: info@nrfm.ie Web: www.nrfm.ie

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• Enclose certified evidence of age* (one of the following: Driving Licence or Passport) * Please note that this must be certified by a Financial Intermediary, an Accountant, Solicitor, Gardaí or Bank Official as required by most banks.

• Enclose two Original Utility Bills or certified copies*. Please note that this must be certified by a Financial Intermediary, an Accountant, Solicitor, Gardaí or Bank Official as required by most banks.

• Enclose evidence of PPS number (one of the following: P60, P45, Tax Free Allowance Cert, P21 Balancing Statement, Payslip, Social Services card, Other)

• Enclose a copy of bank statement confirming where any retirement lump sum and distributions are to be paid into, if applicable.

• In the case of an AVC PRSA, please include a copy of the Scheme Booklet for your main Occupational Pension Scheme.

Agents Details

Client Checklist

Errors and omissions excepted - 05/2018

Company Name:

Address:

Telephone No:

Financial Intermediary Name:Email Address:

The Self Invested PRSA, (Non Standard PRSA) is an approved Non Standard PRSA contract as defined under Section 94 of the Pensions Act 1990. The Pensions Authority Ref No is APP/A/345/NS.

Newcourt Retirement Fund Managers Limited is regulated by the Central Bank of Ireland.

Father Mathew Hall, 131 Church Street, Dublin 7Telephone: 01 8280091 Fax: 01 8726038 Email: info@nrfm.ie Web: www.nrfm.ie