Policy Number SEPA DIRECT DEBIT MANDATE - …

1 DIRECT DEBIT MANDATE Policy Number SEPA DIRECT DEBIT MANDATE . SEPA DIRECT DEBIT MANDATE Unique MANDATE Reference (UMR) To be completed by Aviva Life & Pensions UK Limited By signing this MANDATE form, you authorise (A) Aviva Life & Pensions UK Limited to send instructions to your bank to DEBIT your account and (B) your bank to DEBIT your account in accordance with the instructions from Aviva Life & Pensions UK Limited. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that can be obtained from your bank. Please complete all fields marked*.

2 Name(s) of Account holder(s) *. Address* Town/City* County* Country* Account Number IBAN*. Bank identifier code BIC*. Creditor's name Aviva Life & Pensions UK Limited Creditor identifier I E 7 4 Z Z Z 9 9 2 9 5 0. Creditor branch address One Park Place, Hatch Street, Dublin 2, Ireland. This MANDATE is in respect of a recurring payment. x x Signature* Signature*. Date D D M M Y Y Y Y Location Please return this MANDATE to Aviva Life & Pensions UK Limited trading as Aviva Life & Pensions Ireland, One Park Place, Hatch Street, Dublin 2. Please note: Banks may refuse to accept instructions to pay DIRECT Debits from some types of accounts, usually savings or deposit accounts. If in doubt check with your bank. Aviva Life & Pensions UK Limited may combine the DIRECT Debits for this MANDATE with those from any other MANDATE (s) which you have signed in their favour and which may be payable to them within the same calendar month.

3 Payment amounts may vary from time to time. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is authorised by the Prudential Regulation Authority in the UK. and is regulated by the Central Bank of Ireland for conduct of business rules. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is also regulated in the UK: by the Prudential Regulation Authority for prudential rules and, to a limited extent, by the Financial Conduct Authority for applicable UK conduct rules. Registered Branch Office in Ireland (No 906464) at One Park Place, Hatch Street, Dublin 2. Tel (01) 898 7000 Web Registered in England (3253947) at 2 Rougier Street, York, YO90 1UU.