Request for a Tax Deduction Directive Pension and ...

1 Request for a Tax Deduction DirectivePension and provident Funds on retirement /Death before RetirementFORM A&DTaxpayer DetailsApplication AddressPostal AddressSpecify otherAnnual incomeIf the taxpayer/member is not registered for income tax, select one of the following reasons:UnemployedOtherEmployee numberFOR OFFICE USE15 Postal CodeIs the taxpayer a non-resident?YesNoPostal CodeTaxpayer reference of Assessment ended on (CCYYMMDD)Name(s)InitialsSurnameIdentity numberDate of Birth (CCYYMMDD)Passport Country / Country of Origin ( South Africa = ZAF)Passport/ Permit no.,Contact PersonE-mail address Tel numberFund Approval no.(Applicable to Public Sector Funds)18204 Particulars of FundPAYE Reference Registration the certificate of residency (citizenship certificate only where DTA is not applicable) attached?Registered Name of Fund12//800/RFORM A&DVersion: Page of Page: 01/07 Particulars of fund (continued)Postal AddressParticipating Employer NameType of fund :Specify otherParticulars of Gross Lump Sum DueReason for Directive :Date of accrual (CCYYMMDD)Date on which the member became a member of the fund (CCYYMMDD)Transfer by non-member spouse previously taxedFormer AIPF member s contributions transferred to the fundGross amount of total benefitGross amount of lump sum payment (Including the amount deemed to accrue in respect of par 2B of the Second Schedule)Amount attributed to a non-member s spouse in respect of divorce orderWhere member contributions to the fund have exceeded such amounts as allowed for Deduction against income, state total amount of excess contributions.

2 If YES , state the period of employment taken into account in terms of the rules of the fund :If NO , state the period of membership of this fund during which contributions were made:In case of a provident fund , total contributions to the fund after 1 March 2016 (excluding interest and profit)Date From (CCYYMMDD)Date To (CCYYMMDD)Completed years=Date From (CCYYMMDD)Date To (CCYYMMDD)Completed yearsWas a period consisting of a number of completed years used to determine the quantum of the benefit in terms of a formula prescribed in terms of the rules of the fund ?In case of a provident fund , total contributions by member to the fund up to 1 March 2016 (excluding interest and profit) provident PreservationPensionProvidentPension PreservationProvident fund Deemed RetirementIf a policy of insurance is ceded to the member, state the surrender value as at date of cession (for the purpose of paragraph 4(2)bis of the Second Schedule)Postal CodeOtherAn approved fundA public sector fundIndicate whether this fund is:RetirementRetirement due to ill-healthDeath before RetirementTransfer on retirement [Par 2(1)(c)]R,R,R,R,R,R,R,R,R,YesNoFORM A&DVersion: Page of Page: 02/07=Did the fund purchase a Pension / annuity?

3 If YES , state the particulars per Pension / annuity purchase:YesNoName of the registered long-term insurer where the Pension /annuity was purchasedPension / annuity Policy numberE-mail address of insurerTel Registered Insurer utilised to purchase a Pension / annuity Pension /Annuity Purchase DetailsDeath prior to retirement , the following fields are also mandatory for this purchase:Taxpayer reference (s)SurnameIdentity NumberDate of Birth (CCYYMMDD)Passport / Permit of Transfer on RetirementDid the fund transfer the retirement benefit to another fund before retirement ?FSB Registration no. of transferee fundThe amount transferred to the transferee fundYesNo12///8000000E-mail address of transferee fundTel no. of transferee fundCell no. of transferee fund Name of transferee fundTransferee fund type:00 Particulars of Gross Lump Sum Due (continued) retirement Annuity FundWas there a partial withdrawal taken from this benefit in the previous or current fund prior to this payment?

4 Date of partial withdrawal (CCYYMMDD)Amount of partial withdrawalIf YES , state the particulars below: Directive numberYesNoR,Date of partial withdrawal (CCYYMMDD)Amount of partial withdrawalDirective numberR,R,R,FORM A&DVersion: Page of Page: 03/07 Pension /Annuity Purchase Details (continued)Name of the registered long-term insurer where the Pension / annuity was purchasedPension / annuity Policy numberAmount utilised to purchase a Pension / annuity Death prior to retirement , the following fields are also mandatory for this purchase:Taxpayer reference (s)SurnameIdentity NumberDate of Birth (CCYYMMDD)Passport / Permit address of insurerTel Registered Insurer ,10/10/1/Name of the registered long-term insurer where the Pension / annuity was purchasedPension / annuity Policy numberAmount utilised to purchase a Pension / annuity Death prior to retirement , the following fields are also mandatory for this purchase:Taxpayer reference (s)SurnameIdentity NumberDate of Birth (CCYYMMDD)Passport / Permit address of insurerTel Registered Insurer ,10/10/1/FORM A&DVersion: Page of Page: 04/07 Pension /Annuity Purchase Details (continued)State if the transfer / purchase of the annuities is subject to special conditions.

5 Confirm the applicable provision in the fund the fund paying the annuity?If yes, state the amount remaining in the fund to pay the annuityNon Resident Service Rendered inside the Republic [Section 9(2)(i)]Were any services rendered inside / outside the Republic during the period of membership of the fund ?Total number of months services were rendered while contributing to fundTotal number of months services were rendered inside the Republic while contributing to fundTotal number of months services were rendered outside the Republic while contributing to fundPeriod of Employment in Public Sector fund (excluding AIPF) The original amount attributed to the above period of membership in the public sector fund (full benefit)Date the amount was transferred from public sector fund (CCYYMMDD)R,Date of transfer from first approved fund (CCYYMMDD) Was the benefit received directly from a Public Sector fund ? Did the previous fund indicate the benefit was from a Public Sector fund ?

6 YesNoName of the registered long-term insurer where the Pension / annuity was purchasedPension / annuity Policy numberAmount utilised to purchase a Pension / annuity Death prior to retirement , the following fields are also mandatory for this purchase:Taxpayer reference (s)SurnameIdentity NumberDate of Birth (CCYYMMDD)Passport / Permit address of insurerTel Registered Insurer ,10/10/1/YesNoR,YesNoDate From (CCYYMMDD)Date To (CCYYMMDD)Completed years=YesNoFORM A&DVersion: Page of Page: 05/07 Details of Salary Earned (only applicable for date of accruals prior to 1 October 2007)Highest average salary earned by the taxpayer during any 5 consecutive years in the service of the employer during his membership of the fund :Date From (CCYYMMDD)Date To (CCYYMMDD)SalaryDate From (CCYYMMDD)Date To (CCYYMMDD)SalaryDate From (CCYYMMDD)Date To (CCYYMMDD)SalaryDate From (CCYYMMDD)Date To (CCYYMMDD)SalaryTotalAverage for 5 years or lesser period if employee employed for lesser periodOn death: The member s salary during 12 months immediately preceding deathDate From (CCYYMMDD)Date To (CCYYMMDD)SalaryNote: Salary includes any amount received or receivable annually under a contract of service including cost of living allowances, commission, shares of profits, etc.

7 , but not occasional bonuses or fees which were dependent on the whim of directors or of Employer (only applicable for date of accruals prior to 1 October 2007)Tel ref of EmployerInitialsSurnameContact PersonResidential AddressFORM A&DVersion: Page of Page: 06/07R,R,R,R,R,R,R,R,7 Postal CodePostal AddressI declare that the information furnished is true and correct in every (CCYYMMDD)For enquiries go to or call 0800 00 7277 DeclarationParticulars of Employer (only applicable for date of accruals prior to 1 October 2007) (continued)FORM A&DVersion: Page of Page: 07/07 Postal Co