Request for a Tax Deduction Directive Retirement Annuity …

1 Request for a Tax Deduction DirectiveRetirement Annuity FundsFORM CFORM CVersion: Page of Page: 01/06 Application AddressPostal AddressFOR OFFICE USE15 Postal CodePostal CodeParticulars of FundContact personRegistered Name of fundE-mail address Tel of fund: Retirement annuityTaxpayer DetailsSpecify otherAnnual incomeIf the taxpayer/member is not registered for income tax, select one of the following reasons:UnemployedOtherEmployee numberIs the taxpayer a non-resident?YesNoTaxpayer reference of Assessment ended on (CCYYMMDD) Name(s)InitialsSurnameIdentity numberDate of Birth (CCYYMMDD)Passport Country / Country of Origin ( South Africa = ZAF)Passport/ Permit ,Policy numberFSB Registration the certificate of residency (citizenship certificate where DTA is not applicable) attached?

2 Particulars of Gross Lump Sum DueReason for Directive :Date of accrual (CCYYMMDD)Date of death of member (if applicable) (CCYYMMDD)Gross amount of lump sum payment (Including the amount deemed to accrue in terms of par 2B of the Second Schedule)Total value of full annuityAmount distributed to non-member spouse in respect of divorce order (if date of accrual is before 1 March 2012)Commencement date of policy (CCYYMMDD)Date of divorce order (CCYYMMDD)Transfer by non-member spouse previously taxedParticulars of Fund (continued)Postal AddressPostal CodeOn death of member prior to Retirement from the fund before 1 October 2007: What amount would the taxpayer have derived in respect of the commutation of one-third of the Annuity if he had Retired the day preceding his death?

3 On death of member prior to Retirement from the fund before 1 October 2007: State total contributions by member to the fund, accumulated at 7% compound interest to the date of member contributions to the fund have exceeded such amounts as allowed for Deduction against income, state total amount of excess contributions. ,R,,R,,R,Specify otherIndicate whether this fund is:An approved fundOtherRetirement Retirement due to ill healthDeath prior to RetirementTransfer prior to RetirementDiscontinued ContributionsFuture Surplus Divorce - Non-Member SpouseDivorce TransferEmigration WithdrawalDivorce - Member SpouseWithdrawal due to Visa ExpiryIf 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),R,,R,,R,,R,,R,Was there a partial withdrawal amount taken from this benefit in the previous Fund?

4 YesNoDate of partial withdrawal (CCYYMMDD)Amount of partial withdrawalIf yes, state the particulars below: Directive number If the amount is from a Provident Fund, indicate total provident fund contributions by member up to 1 March 2016. , If the amount is from a Provident Fund, indicate total provident fund contributions after 1 March 2016. ,FORM CVersion: Page of Page: 02/06 RRR,,,Particulars of purchase of pension/annuityDid the fund purchase an Annuity ?If yes, state the particulars per Annuity purchase:YesNoName of the registered long-term insurer where the Annuity was purchased: Annuity policy numberEmail address of insurerTel ,FSB Registered Insurer utilised to purchase an annuity10/0/1/1 Death prior to Retirement , the following fields are also mandatory for this purchase:Taxpayer reference (s)SurnameIdentityNumberDate of Birth (CCYYMMDD)Passport / Permit the fund transfer the benefit to another fund before Retirement ?

5 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: Retirement fundParticulars of transferState if the transfer / purchase of the annuities is subject to special conditions. If yes, confirm the applicable provision in the fund rules:R,00 Date of partial withdrawal (CCYYMMDD)Amount of partial withdrawalDirective number Particulars of Gross Lump Sum Due (continued)FORM CVersion: Page of Page: 03/06,RParticulars of purchase of pension/ Annuity (continued)Name of the registered long-term insurer where the Annuity was purchased: Annuity policy numberEmail address of insurerTel ,FSB Registered Insurer utilised to purchase an annuity10/0/1/1 Death prior to Retirement , the following fields are also mandatory for this purchase.

6 Taxpayer reference (s)SurnameIdentityNumberDate of Birth (CCYYMMDD)Passport / Permit prior to Retirement , the following fields are also mandatory for this purchase:Taxpayer reference (s)SurnameIdentityNumberDate of Birth (CCYYMMDD)Passport / Permit policy numberEmail address of insurer Tel ,FSB Registered Insurer utilised to purchase an Annuity 10/0/1/1 Name of the registered long-term insurer where the Annuity was purchased:FORM CVersion: Page of Page: 04/06 Particulars of purchase of pension/ Annuity (continued)Is the fund paying the Annuity ?If yes, state the amount remaining in the fund to pay the annuityYesNoR,Death prior to Retirement , the following fields are also mandatory for this purchase:Taxpayer reference (s)SurnameIdentityNumberDate of Birth (CCYYMMDD) Passport / Permit 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)Date From (CCYYMMDD)Date To (CCYYMMDD)Completed years=R,Date of transfer from first approved fund (CCYYMMDD)YesNoDid the previous Fund indicate the benefit was from a Public Sector Fund?

7 YesNoEmigration withdrawalWas an application for emigration recognised by the Reserve Bank?Is proof of a valid Tax Clearance certificate attached? Please note: if the answer to any of the above questions is Yes , copies of the said documentation must be submitted as supporting documents to verify the validity of this the certificate of residence of the new country of residence attached?Please state date of emigration. (CCYYMMDD) Annuity policy numberEmail address of insurer Tel ,FSB Registered Insurer utilised to purchase an Annuity 10/0/1/1 Name of the registered long-term insurer where the Annuity was purchased:Was the benefit received directly from a Public Sector Fund? FORM CVersion: Page of Page: 05/06 Expiry of Working VisaWas the visa issued in terms of paragraph (b) or (i) of the definition of visa in section 1 of the Immigration Act, no.

8 13 of 2002?Did the visa expire?Did the member exit South Africa?I declare that the information furnished is true and correct in every (CCYYMMDD)For enquiries go to or call 0800 00 note: if the answer to any of the above questions is Yes , copies of the said documentation must be submitted as supporting documents to verify the validity of this CVersion: Page of Page: 06/06