Page 1 of 41 Income Tax Return for Long Term Insurance ...

1 Year of AssessmentIncome Tax Return for long Term Insurance Companies ( Income Tax Act, No. 58 of 1962, as amended)Taxpayer Reference NumberITR14 LCompany DetailsRegistered NamePRSIF01 Trading NameCompany / CC Reg Registration (CCYYMMDD)Magistrate District of the Registered addressVATPAYE/SDLI ndividual Policyholder FundUntaxed Policyholder FundCompany Policyholder FundCorporate FundRisk Policy FundPhysical Address Details Postal Address Details Mark here with an X if same as above or complete your Postal Address Postal Agency or Other Sub-unit (if applicable) ( Postnet Suite ID)21PO BoxPrivate BagOther PO Special Service (specify)10 Number8 Post Office22 Postal Code10Is your Postal Address a Street Address?

2 YNCountry CodeORSelect from my addresses Select from my addresses Registered Postal AddressCreate new address Create new address Unit (if applicable)Street / Farm NameSuburb /DistrictCity / Town8332621 Country Code268 Postal Code10 Registered Postal AddressUnit (if applicable)Street / Farm NameSuburb /DistrictCity / Town8332621 Country Code268 Postal Code10 Registered Physical AddressMark here with an X if this is a Care Of addressPage 1 of declare that: I am the duly appointed Public Officer / Representative of the company The information furnished in this Return is to the best of my knowledge both true and correct I have disclosed the gross amounts of all Income received and / or accrued to this company during the period covered by this Return I have the necessary financial records and supporting schedules to support all declarations on this Return which I will retain for audit (CCYYMMDD)For enquiries go to or call 0800 00 SARS (7277)XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXP lease ensure you sign over the 2 lines of X s aboveDeclarationDECPIR esidential AddressPublic Officer DetailsFirst NamesBus Tel No.

3 1 SurnameBus Tel No. 2 Cell Address53535327ID Ref (if applicable)Street / Farm NameSuburb /DistrictCity / TownPostal Code2433102421 Country Code2 Account Holder Name (Account name as registered at bank)Bank Account Details Account Type:ChequeSavings Bank NameBranch NameTransmissionBank Account Status16106505049 Page 2 of AddressDetails of the person responsible for completion of this returnFirst NamesBus Tel No. 1 SurnameBus Tel No. 2 Cell Address53535327ID declare that all the information, details and schedules furnished in this Return are to the best of my knowledge correct, complete and fully discloses the Income from all (CCYYMMDD)Declaration by ApplicantSignatureFor Office use OnlyYNRequest Financial StatementsYNRequest Complete Questions as per returnYNAudit IndicatorReason for referallYNSend to AssesorReasonPend for Deactivation after assessmentYNYNDo not Impose additional tax for RenditionUnit (if applicable)

4 Street / Farm NameSuburb /DistrictCity / TownPostal Code2433102421 Country Code2 Shareholders Details (Details of three main shareholders, and if more than three shareholders, the details of the remaining shareholders holding more than 5% must be furnished in Schedule)Company NameBus Tel No. Bus Tel No. 2 Cell Address535327ID Reference NumberPercentage Interest%+Page 3 of Information Audit report qualificationYNIs the company dormant?YNIf dormant , does the company have assets and / or reserves?YNIs the company a South African resident as a result of effective management in South Africa?YNDoes the company receive Income from a controlled foreign entity?YNIs the Return in respect of branch of foreign company?

5 YNProvince where main activity is carried onAssessment Information Individual Policyholder Fund (IPF) Income Statement InformationPremiumsInvestment and other incomeRRRealised gains on Investment assetsRealised losses on Investment assetsRRClaimsR47014702470347044705 Balance Sheet InformationIncome Statement Information continuedSelling and administration of policies expensesOther expenses allocated to the fundRRUnrealised gains on investment assetsUnrealised losses on investment assetsRRExpenses and allowances directly attributable to incomeR47064707470847094710 Expenses and allowances directly attributable to non- Income amounts R4711 Balance Sheet Information continuedOther InformationInterest as defined in section 24J Rental Income after deduction of directly

6 Attributable expenses RRTaxable foreign dividends Exempt foreign dividends RRLeased assetsR50175018501950205021 Leased liabilitiesRealised profit disposal of shares other than section 9 CRRR ealised profit on disposal of other assetsExempt Income : DividendsRRValue of script dividends receivedR50225001500250045015 Life FundLong-term liabilitiesRRCurrent liabilitiesProvisions - actualRRProvisions - deferredR48014802480748174809 Strategic shareholdingsNon strategic shareholdingsRRFixed interest stockOther interest bearing assetsRRPropertiesR48104811481248134814 Directly held foreign assetsIndrectly held foreign assetsRROther investment bearing assetsR481548154816 Fixed assetsRCurrent assetsR48044806 Financial arrangements.

7 Derivatives and/or similar instrumentsR4818 Other assetsR4805 Page 4 of of transfersMarket value of gross assetsActuarial liabilitiesRRExcess of assets over liabilitiesTransfer from Corporate fundRRTransfer to Corporate fundR49014902490349054906 Return transfer to Corporate fund [provision to section 29A(11)(d)]Balance of transfers (end of year) in respect of previous shortfalls49074909 RRAssessment Information Individual Policyholder Fund (IPF) continuedExempt Income : OtherR5005 Section 31 adjustmentRForeign source Income : Non taxable (excluding foreign dividends)Foreign source Income : Taxable (excluding foreign dividends)RRFuture expenditure allowanceR5006500750085009 Other Information continuedReinsurance commission received: ForeignRReinsurance commission received: LocalRReinsurance commission/premium paid: ForeignR50125013 Reinsurance commission/premium paid.

8 LocalR50145016 Aggregate tax credit brought forwardRCurrent year creditR44464447 Total credit forfeitR4450 Foreign Tax CreditTotal foreign tax creditRSource codeTaxable IncomeTaxable Income / (loss) (after transfers) (before assessed brought forward)RAssessed loss brought forwardRTaxable Income this year (form 7, line 15)RSource codeSource codeAggregate capital gains Local RRCapital GainsAggregate capital gains Foreign42604268 Aggregate capital loss Local R4261 RAggregate capital loss Foreign4269 Foreign IncomeTotal taxable foreign Income Profit (excluding capital gain )R4220 Total taxable foreign Income Loss (excluding capital gain )R4221 Credits AvailableForeign tax credits (attach receipts)R4106 Page 5 of capital Gains and Losses IPFP roceedsBase CostRollover Base CostMain Asset Type Source CodeExclusions/Adjustments (Not Annual Exclusions) capital gain / LossMain Asset Type Source Code Please refer to the guide with regards to the main asset type source code list.

9 Even numbered codes refer to gains and uneven numbered codes refer to losses. Please note the inclusion rate will be applied by GainAggregate LossCapital Gains/LossesIndicate whether a valuation certificate as required in terms of the Eighth Schedule to the Income Tax Act ( capital Gains) is attachedYNForeign capital Gains and Losses (IPF)ProceedsBase CostRollover Base CostMain Asset Type Source CodeExclusions/Adjustments (Not Annual Exclusions) capital gain / LossMain Asset Type Source Code Please refer to the guide with regards to the main asset type source code list. Even numbered codes refer to gains and uneven numbered codes refer to losses. Please note the inclusion rate will be applied by SARS.

10 ++Page 6 of Information Untaxed Policyholder Fund (UPF)Balance Sheet InformationLife FundLong-term liabilitiesRRIncome Statement InformationPremiumsInvestment and other incomeRRRealised gains on Investment assetsUnrealised gains on investment assetsRRCurrent liabilitiesProvisions - actualRRRealised losses on Investment assetsRProvisions - deferredR5101510251035108510452015202520 752085217 ClaimsRRSelling and administration of policies expensesExpenses and allowances directly attributable to incomeRRExpenses and allowances directly attributable to non- Income amounts (from 4, line3) R51095105510651105111 Unrealised losses on investment assetsStrategic shareholdingsNon strategic shareholdingsRRFixed interest stockOther interest bearing assetsRRPropertiesR52095210521152125213 Directly held foreign assetsIndrectly held foreign assetsRROther investment assetsFixed assetsRRCurrent assetsR52145215521652045206 Other expenses allocated to the fundR5107 Balance Sheet Information continuedFinancial arrangements.