Third Party Payment Questionnaire - Hansard

1 Third Party Payment Questionnaire Page 2 of 16. Index Section Page number 1. Contract holder details 4. 2. Contract Details 4. 3. Source of Contribution Payments 4. 4. Source of Wealth 6. 5. Important Notes 12. 6. Data Protection 13. 7. Declaration 14. Page 3 of 16. Please note: Third Party payments may be acceptable in relationships between parent/guardian and child, husband and wife, employer and employee. Please also note that Hansard International Limited ( Hansard ) are unable to accept Third Party payments for contracts held in trusts. 1. Contract Holder Details Contract number Applicant 1. Applicant 2. 2. Contract Details Contribution amount Figures Currency Frequency of contribution Single Monthly Quarterly Half-yearly Yearly Payment method Standing Order/Telegraphic Transfer - If you would like Hansard to send the instruction to the bank, then Hansard requires the original.

2 UK Direct Debit - Please note that Hansard must receive the original before the direct debit instruction is sent to the bank. For use with regular contributions only. Credit card - For use with regular contributions only. Visa Debit - For use with regular contributions only. American Express - For use with USD and GBP regular contributions only. Other Payment must be made in favour of: Hansard International Limited. 3. Source of Contribution Payments Details of Third Party making the contributions (individual, corporation, insurance company). Name Residential/. registered address Date of birth D D M M Y Y Y Y. Page 4 of 16. 3. Source of Contribution Payments continued politically exposed Person Is any Party to this application, Yes No a politically exposed Person (PEP). or a close associate/family member of a PEP? All Isle of Man authorised life companies are required to identify any parties to the application who are politically exposed Persons ( PEP ) and request enhanced due diligence.

3 A PEP is a person who is or has been entrusted with prominent public functions. This includes immediate family members or any close associate. Enhanced Due Diligence (EDD) means, in addition to fulfilling the minimum verification requirements, the life company may be required to take extra steps to verify the identity, address, source of funds or source of wealth of a client. This may include requesting additional documentation which will support the identity, residency, source of funds or source of wealth of the applicant(s). Examples of PEPs include: a Head of State, a holder of a political or government post, a high level member of the Judiciary, a high ranking officer in the Military, an employee of a State owned Corporation or a board member of a Central bank. Further information can be obtained from If the answer is Yes , please provide further details below (including full name and PEP status).

4 Based on the information provided, we reserve the right to request further information or documentation. Source of Contributions Payment Details of the source of the contribution Payment from the Third Party (individual, corporation, insurance company). Name of account holder/contract holder Account number/ contract number IBAN. Sort Code BIC Details of the relationship between the contract holder and the Third Party payer Reason for the Third Party making the Payment (s)/Reason why the contract holder is not making the Payment (s). Hansard reserves the right not to accept payments made by Third parties. Page 5 of 16. 4. Source of Wealth This section must be completed in all instances by the Third Party payer. Failure to do so will result in a delay of your investment. In order for us to comply with our obligations under the Isle of Man Anti-Money Laundering regulations; we are required to understand how our applicants have acquired the monies they wish to invest with Hansard .

5 Please answer the following questions clearly and in full: a) What is the total value of all your assets? Currency Amount b) Please provide full details and description of the source of the contribution to be invested for example, investments, personal income, borrowing, personal savings, pension, other. Please note additional information may be required if insufficient information is provided. c) Please provide details of your annual earned income for example, employer's name, annual gross salary If the total contributions (including other Hansard International Limited contracts that you hold): are equal to or exceed GBP 250,000 for a single contribution contract, or currency equivalent; or are equal to or exceed GBP 50,000 per year for a regular contribution contract, or currency equivalent; or for all contracts that you hold with Hansard International Limited are equal to or exceed GBP 250,000, then supporting documentary evidence is required.

6 Please refer to our Source of Wealth table available on pages 10 and 11 for examples of suitable documentary evidence. The following question is mandatory and MUST be answered. What is the total value of your assets? Please provide a breakdown Third Party payer Property Currency Amount Investments Currency Amount Savings Currency Amount Other Currency Amount Please state Page 6 of 16. 4. Source of Wealth continued Please confirm the source of your contribution choosing the relevant section(s) below. If your investment comes from more than one source, then you should tick the relevant boxes, enter the percentage from each source, and then answer the relevant questions below. If it is unclear how the money was accumulated, we will request further information or supporting documentation. Source(s) Tick Box Third Party payer 1. Income and/or savings %.

7 2. Retirement income %. 3. Maturing investments/policy claims %. 4. Investment income/dividends %. 5. Sale of shares %. 6. Sale of property %. 7. Company sale %. 8. Inheritance %. 9. Loan %. 10. Gift %. 11. Competition/lottery/gambling win %. 12. Compensation Payment including matrimonial disputes, damage in negligence %. claims and/or breach of contract 13. Other source of income %. Total 1 0 0 %. Third Party payer 1. Income and/or savings Current annual salary Currency Amount Bonus Currency Amount What % of your income are you contributing? %. Name of employer/Company name Employer's address Nature of business I can confirm that I can afford to make the contribution as detailed on page 3. Page 7 of 16. 4. Source of Wealth continued Third Party payer 2. Retirement income Current annual income Currency Amount Name of final employer/Company name Final employer's address Source of income Date of retirement D D M M Y Y Y Y.

8 3. Maturing investments/policy claims Amount received Currency Amount Name of policy provider Length of time policy held Years Months (If the policy was held for less than 3 years, we may request further information) Date of maturity or surrender D D M M Y Y Y Y. 4. Investment income/dividends Amount received Currency Amount Name of policy provider Length of time policy held Years Months (If the policy was held for less than 3 years, we may request further information) Date of income received D D M M Y Y Y Y. 5. Sale of shares Name of company where shares were held Please provide company address Length of time held Years Months (If the shares were held for less than 3 years, we may request further information). Sale amount Currency Amount Date funds received D D M M Y Y Y Y. Page 8 of 16. 4. Source of Wealth continued Third Party payer 6. Sale of property Address of property sold Date property purchased D D M M Y Y Y Y.

9 Date property sold D D M M Y Y Y Y. Total sale amount Currency Amount 7. Company sale Legal name of company sold Address of company Nature of business Date of sale D D M M Y Y Y Y. Total sale amount Currency Amount Third Party payer's share %. 8. Inheritance Name of person who left inheritance Date of death D D M M Y Y Y Y. Third Party payer's relationship to the deceased Total amount received Currency Amount Date amount received D D M M Y Y Y Y. 9. Loan Name of loan provider Address of loan provider Reason for obtaining loan Amount received Currency Amount Date loan received D D M M Y Y Y Y. Page 9 of 16. 4. Source of Wealth continued Third Party payer 10. Gift Donor's name Donor's address Third Party payer's relationship to donor Reason for gift Total value of gift Currency Amount Date received D D M M Y Y Y Y. 11. Competition/lottery or gambling win Name of Payment organisation Description of win Date of win D D M M Y Y Y Y.

10 Total amount won Currency Amount 12. Compensation Payment /awards of Court Name of compensation payer Reason for Payment Total amount won Currency Amount Date Payment received D D M M Y Y Y Y. 13. Other source of income What type of income was it? Total amount received Currency Amount Date Payment received D D M M Y Y Y Y. Where did the income come from? Page 10 of 16. 4. Source of Wealth continued Source of Wealth table All documents must be on the relevant company letter headed paper, be dated and include the full name and address of the Third Party payer. The documents should be in English or accompanied by a translation. Documents such as bank statements and utility bills should be the most recent available or no more than 3 months old. Online bank statements will only be accepted as evidence where it clearly identifies the bank and the Third Party payer's full name and registered address.