Horizon international pension plan (Hipp)Qualified recognised overseas pension scheme (Qrops)

A p p l i c At i o n f o r m :H i p p Q r o p S

H o r i z o n Q r o P Si n t e r n at i o n a l p e n s i o n p l a n s

H o r i z o n Q r o P Si n t e r n at i o n a l p e n s i o n p l a n s

A p p l i c At i o n f o r m :H i p p Q r o p S

Definition: the Horizon international pension plan (“Hipp” or “plan”) has been accepted by HMrC as a Qualified recognised overseas pension scheme

(“Qrops”) to which Gower pensions Management limited (“GpMl” or “trustee”) are trustee. it is a multi-member scheme governed by one master

trust deed to which GpMl are trustee. a “Member’s Fund” is established for each “Member” and is segregated from other Members’ assets.

note: the Horizon international pension plan normally only invests in standard asset Classes via an investment platform or insurance wrapper, as

defined in section 10, clause 6 of the Code of practice and Conditions (enclosed). should you require non-standard asset Classes then please refer to

your adviser or GpMl for further information.

introduction

this application Form should only be completed by the applicant and where applicable their Financial adviser. this form should be read in conjunction

with the current edition of our Code of practice and Conditions of the plan. See Section 10 of the Application.

please ensure you complete all sections. Failure to provide all relevant information and supporting documentation will result in a delay to the

application being processed. Further information may be required during the processing of this application.

to assist you in ensuring all relevant documentation is included when submitting your application to us please complete the following checklist.

cHeckliSt

please ensure that all relevant certified documentation is enclosed with this application.

Certified copy of applicants passport – see section 8 for guidance.

Certified copy of applicants address verification – see section 8 for guidance.

please ensure the following documentation is included when submitting your application

appropriately completed and signed discharge paperwork for each transfer.

Hmrc form ApSS263 – this form must be completed by the applicant for each pension transfer.

any relevant Hmrc cA1881-1890-1894-1895 forms.

2

2. detAilS of finAnciAl AdViSer

2.1 AdViSer detAilS

Full name

Firm

telephone

Facsimile

email

address

Will fees be payable to the adviser? (if yes, please complete section 2.2)

Yes no

2.2 AdViSer commiSSion/fee ArrAngement

initial commission/fee* %

annual commission/fee* %

additional information on commission/fee arrangements

note: Commission/fees will be paid from pension funds received into the scheme.

* initial and annual commission/fee can be either a percentage of your plan fund or

fixed sum (eg. £1,000)

3. propoSed trAnSfer

please indicate below the current estimated pension value to be

transferred to the plan.

(please note further details of existing pension plans will be required in section 5)

£

are monthly contributions to be made to the plan? Yes no

if yes, please indicate anticipated level of monthly contribution.

£

note: GpMl may seek verification of your source of wealth in accordance with the anti

money laundering procedures issued by the Guernsey Financial services Commission.

Has professional advice been provided? (if yes, please complete section 2.1)

Yes no

1. perSonAl detAilS

title

Forename/s

surname

previous name/s

Date of Birth

Gender Male Female

Marital status Married single

other (please specify)

Country of tax residency

Date left UK for tax purposes

occupation & Job title (if retired, please state retired, plus former occupations)

principal residential address

Home telephone

Facsimile

Mobile

email

the trustee’s principal form of correspondence will be via email to the

email address provided above. if email is not to be used please tick here.

Correspondence address (if different from residential address)

3

4. inVeStment mAnAgement StrAtegY

4.1 inVeStment StrAtegY Selection

the trustees require the appointment of a professional investment

manager. please indicate below your preferred option.

i. GpMl appoint a investment manager (note 1)

ii. You can nominate your own investment manager,

please complete section 4.4 (note 2)

note 1. A discretionary investment manager will charge an annual management

fee typically between 1% and 1.5% of fund value.

note 2. nominated investment manager is subject to trustee approval.

Where i have nominated an investment manager under this section

of this application i recognise my responsibility in any subsequent

appointment of this investment manager and therefore agree to hold

harmless and indemnify the trustees against any loss or liability that may

arise from this appointment.

4.2 riSk profile

risk profile undertaken with your financial adviser Yes no

Copy of risk profile provided with application Yes no

attitude to risk (please indicate the risk rating which best illustrates your risk profile)

low Medium High

1 2 3 4 5

notes on your risk profile

4.3 time HoriZon (Anticipated benefit date)

please outline when you anticipate commencing taking benefit from the

plan (please tick).

0 to 3 yrs 3 to 5 yrs 5 to 10 yrs 10 yrs +

indicated age at anticipated benefit date

notes

4.4 nominAted inVeStment mAnAger

please outline details of your nominated investment Manager

name

Company

telephone

email

address

please outline your requirements for the trustees to consider

Do you wish the trustees to accept investment instructions directly

from your nominated investment Manager without the trustees referral

to yourself?

Yes no

if “no” is selected your written approval/agreement on each investment

will be required.

4.5 inVeStment plAtform/Bond

is an investment platform or bond to be held within your plan?

Yes no

if yes, please provide details of your nominated platform or bond to be used

4

5. exiSting penSionS

6. feeS

additional information

HIPP - THe HorIzon InTernaTIonal PensIon Plan

initiAl fee

a one-off formation fee of £795.00 covering the set-up and asset transfer.

AnnuAl mAnAgement cHArge (Amc)

£795.00 annual Management Charge.

noteS:

please note that additional third party charges may be incurred

in administering the structure, in particular where the structure is

complex or unique to the Member’s requirements. For certain complex

arrangements or where unique to the Member’s requirements additional

Gower pensions Management limited (GpMl) charges may also be

applied. these charges will be discussed on a case by case basis and such

charges will normally be notified and agreed in advance.

Disbursements: Gower pensions Management limited as trustee reserve

the right to recover disbursements and out-of-pocket expenses, such as

third party charges, direct from the plan.

if your fund is transferred to another administrator, a termination fee of

£1,500.00 will apply.

all fees will be paid directly from your fund with the annual Management

Charge typically being paid annually in advance and is non refundable. the

calculation date for the annual Management Charge will be based on the

anniversary date of the trustee appointing the Member to the plan.

any retrocessions or commissions received from financial institutions

may be retained by GpMl (or any associated business within the Gower

Group). these can typically be up to 0.5% of funds under management.

please provide details below of any approved pensions you wish to

transfer to the plan. if possible please provide authorised Discharge Forms

for each pension.

penSion 1

provider

name of scheme

type of scheme

transfer value £

penSion 2

provider

name of scheme

type of scheme

transfer value £

penSion 3

provider

name of scheme

type of scheme

transfer value £

penSion 4

provider

name of scheme

type of scheme

transfer value £

5

7. BeneficiArY nominAtionS After memBer’S deAtH

Upon your death any remaining fund assets will be held for the benefit of

your estate. However if you would like to make alternative arrangements

GpMl will consider written requests from you regarding who you would

like to benefit and to what extent.

please confirm whether you would like to nominate beneficiaries.

Yes no

if yes, please nominate your chosen beneficiaries and their contact details

together with the percentage share of benefits you wish them to receive

from your fund in the event of your death within the relevant section below.

iMportant notes

1) if a designated beneficiary does not survive the other beneficiaries, their share

maybe distributed in proportion to the remaining beneficiaries share of benefits.

2) if no beneficiaries are nominated or if none of the beneficiaries survive the

Member, the total amount shall normally be paid to the Member’s estate.

3) should you wish to change beneficiaries or include further beneficiaries, please

provide details to the trustees via a letter of wishes.

8. client due diligence

as part of GpMl’s client due diligence procedures certified copies of the

client’s passport and a utility bill verifying their address are required.

please complete either the below instructions or a Client Verification Form

(copy available on website or on request).

8.1 certified copY pASSport

please provide an original certified copy of your passport. the copy

must be certified by a suitable Certifier (as detailed in 8.5) and suitable

Certification Wording for a passport (as detailed in 8.3) must be used.

8.2 AddreSS VerificAtion

please provide a utility bill to verify your address. this must be no more

than three months old and must be either an original utility bill or a

copy of an original certified by a suitable Certifier (as detailed in 8.5) and

suitable Certification Wording (as detailed in 8.4) must be used.

8.3 SuitABle certificAtion Wording for A pASSport

“i certify this to be a true Copy of the original document, which i have

seen, and that the photograph shown is a true likeness of the person

named therein.”

8.4 SuitABle certificAtion Wording for A utilitY Bill

“i certify this to be a true Copy of the original document, which i have seen.”

6

7.1 nominAted BeneficiArieS

BeneficiArY 1

Full name

address

relationship

share of benefits (%)

BeneficiArY 3

Full name

address

relationship

share of benefits (%)

BeneficiArY 2

Full name

address

relationship

share of benefits (%)

BeneficiArY 4

Full name

address

relationship

share of benefits (%)

9. plAn termS & declArAtion

9.1 ApplicAtion declArAtion

any reference to the singular will also have reference to the plural and

visa versa.

i confirm to you as the trustee of the plan, that i have been advised by you

to take independent financial, legal and taxation advice on the proposed

transfer to the plan and that i have made such enquiries and taken

such financial, legal, taxation and other advice as i consider necessary

concerning all possible implications concerning the proposed transfer and

your trusteeship of the plan. i acknowledge that you have not given me any

tax advice concerning the proposed transfer or the implications of the

proposed transfer on my circumstances or on the circumstances of any

other person likely to be affiliated with or benefiting from the plan.

in transferring out of my existing pension scheme/s, i understand and

accept that i may be giving up any guarantees, protected rights and

benefits associated with the scheme/s and i am satisfied that i have

obtained appropriate advice in respect of my proposed transfer/s.

i confirm that i do not require you to complete any tax returns or other

related information nor to establish a tax agent in respect of the proposed

transfer in any jurisdiction as i shall take full responsibility for making all and

any reports necessary in respect of any tax liabilities emanating from the

proposed transfer or its execution making use of the information you supply

to me on the affairs of the plan. i therefore indemnify you against any

and all claims arising in respect of any assessments for taxation matters

and associated penalties and damages in connection with the proposed

transfer to the plan where you have followed my requirements above.

Where i have nominated an investment manager under section 4.1 of this

application i recognise my responsibility in any subsequent appointment of

this investment manager and therefore agree to hold harmless and indemnify

the trustees against any loss or liability that may arise from this appointment.

all fees and charges relating to the advice have been disclosed to me

including any fees and charges for any underlying structures and investments.

i shall notify the trustee when any of my circumstances, or those of

persons for whom i act, materially change. if i fail to notify the trustee

of any material changes to my circumstances, or those of persons for

whom i act, i shall hold the trustee harmless with respect to any liability

that may arise as a result of my failure to notify the trustees accordingly,

for example the trustee failing to make all necessary reporting and

failing to take all other actions necessary to comply with the applicable

requirements of any relevant tax authorities.

i declare that the above particulars are true and correct to the best of my

knowledge and belief. i have carefully read this form prior to completion

and i am responsible for the accuracy of the information submitted.

i confirm that i have read and understood the Code of practice and

Conditions contained in section 10 of this application and agree to act in

accordance there with.

applicant signed

print applicant name

Date

9.2 finAnciAl AdViSer declArAtion

i, the adviser detailed in section 2.1, confirm that:

u i have provided appropriate advice regarding the suitability of the

applicants proposed transfer to the plan.

u i am suitably qualified to provide this advice and meet the license

and regulatory requirements of the jurisdiction in which the advice is

being provided.

u all fees and charges relating to my advice have been disclosed to the

applicant including any fees and charges for any underlying structures

and investments.

u Where a transfer is from a scheme with any form of guarantee,

protected rights or defined benefits i have undertaken an appropriate

analysis and the applicant has been advised of any guarantees,

protected rights or defined benefits that will be lost as part of the

proposed transfer to the plan.

signed

print adviser name

Firm

Date

7

8.5 SuitABle certifierS

u officials from regulated Financial Businesses in Guernsey.

u a Director or officer from financial institutions regulated in equivalent

jurisdictions to Guernsey.

u Qualified GpMl staff members.

u the embassy, consulate, or high commission of the country of issue of

documentary evidence of identity.

u a member of the judiciary, a senior civil servant, or a serving police or

customs officer from an equivalent Jurisdiction.

u a lawyer or notary public who is a member of a recognised

professional body.

u an actuary who is a member of a recognised professional body.

u an accountant who is a member of a recognised professional body.

u a member of the institute of Chartered secretaries and administrators.

the Certifier must sign and date their copy, printing his/her name and

position below their signature as well as their full contact details. Where

available a company stamp should also be applied.

10. code of prActice And conditionS

1. InTroDUCTIon

i. the Horizon international pension plan is a retirement annuity trust

scheme and is an approved Defined Contribution retirement Benefit

plan established by way of an irrevocable trust Deed. this has been

approved under the provisions of section 157e of the income tax

(Guernsey) law 1975, as amended. Guernsey income tax approved

reference 7r.011866/t/BH.

ii. the Horizon international pension plan has been accepted by Her

Majesty’s revenue and Customs (“HMrC”) as a Qualifying recognised

overseas pension scheme (“Qrops ”) which allows for inward transfers

from approved UK pension schemes. the HMrC Qrops reference is

Qrops 504174.

iii. the Hipp is a multi-member scheme governed by a master trust deed.

a “Member’s Fund” is established for each “Member” and is segregated

from other Members’ assets and held for the benefit of the designated

Member only.

iv. the Hipp will normally only invest in standard assets as detailed in

section 6 of this Code of practice and Conditions.

the plan is administered by Gower pensions Management limited

(“GpMl”), a Guernsey company which is regulated and licensed by the

Guernsey Financial services Commission, in accordance with the regulation

of Fiduciaries, administration Businesses and Company Directors, etc

(Bailiwick of Guernsey) law, 2000. GpMl act as trustee to the plan.

2. TrUsTees’ role

a. independent trustee

GpMl will be an independent trustee of the plan and neither

Members, nor their relatives, may be trustees of the plan.

b. plan Approval and code of practice

i. GpMl will act in a manner so as to maintain Guernsey income tax

approval of the plan.

ii. GpMl will act in accordance with the Code of practice as issued by the

Guernsey Director of income tax for the plan as relevant and as guided

by the Guernsey income tax (a copy of the current Code of practice is

enclosed in appendix 1. it should be noted that this is subject to change.).

c. QropS Status

i. GpMl will act in accordance with the conditions and undertakings

it has made to HMrC in their application (apss 251) for Qrops

acceptance. these undertakings include:

u in the event of a recognised transfer, at least 70% of the funds

transferred will be used to provide an income for life.

u the pension benefits payable to the Member are not payable

before the Member reaches normal minimum retirement age

unless the ill-health condition is met.

u the trustee will comply with the prescribed reporting requirements

by HrMC as relevant from time to time (see section 11 – reporting).

ii. GpMl will act in a manner so as to maintain Qrops status for the plan.

3. servICes

GpMl are the provider of administration services for the establishment

and running of retirement annuity trusts and pension solutions. the

following services are provided by GpMl:

i. the setting up of bespoke structures and/or establishment of

applicant’s membership to the plan and creation of a Member’s Fund.

ii. setting up administration records.

iii. receipt of contributions/transfer(s) into and payments/transfer(s) out

of the plan.

iv. preparation of documentation to appoint investment manager to

Member’s Fund.

v. arranging investments for the Member’s Fund.

vi. reporting.

vii. Creation and maintenance of banking facilities.

viii. settlement and payment of benefits.

ix. trustee to the plan.

x. such other services as may from time to time be necessary to efficiently

administer the plan and comply with any regulatory or requirements

to maintain appropriate approvals, exemptions and/or acceptances.

4. Plan MeMbersHIP & elIgIbIlITy

the plan is suitable for most UK expatriates and is open to anyone over

18 years of age and under the age of 77 years.

u the plan is not available to Jersey residents;

u the plan is not available to Us or Canadian nationals;

u the plan can be available to a UK resident if they have a clear

intention of leaving the UK.

Membership to the plan is subject to the GpMl’s approval, following

receipt of an appropriately supplied application form and supporting

documentation as prescribed by GpMl from time to time. this includes

evidence of identity, residential address, source of funds and also may

include evidence on health and/or marital status.

5. Plan ConTrIbUTIons anD Transfers In

transfers are accepted into the plan at the discretion of GpMl and will

generally include any transfers from UK registered pensions whether

occupational or personal.

prior to any transfer/contribution GpMl may require clarification that the

applicant and/or Member has received independent advice with regard to

the consequences of effecting the transfer/contribution and any benefits;

guarantees; or bonuses that may have been applicable in the previous

scheme which may be lost on transfer.

applicants who are already receiving benefits (lump sum or drawdown)

may transfer into the plan, although the type of benefit may impact on

the proportion of future benefits that are available. an annuity already

purchased from a life insurance company can not be transferred to the plan.

GpMl may decline an applicant or transfer or contribution, even if the

applicant is eligible for a Qrops. GpMl may view that the transfer

scheme is imposing conditions on the transfer assets that GpMl are

unable to meet or are administratively burdensome or onerous.

in-specie transfers may be accepted, but will be at the discretion of GpMl.

prior approval will normally be required, which may include providing

supporting literature and/or advice, before any transfer and additional

charges may be incurred.

source of Wealth / Funds – the Member confirms:

i. they will declare and possibly evidence, the source and origin of any

contribution(s) and transfer(s) to the plan to GpMl prior to their receipt;

ii. that the assets contributed or transferred to the plan do not represent

the proceeds of criminal activity;

iii. if no disclosure is forthcoming, the applicant and/or Member

understands that GpMl will decline such contribution or transfer

being settled within the plan.

8

10. code of prActice And conditionS (continued)

6. InvesTMenT CHoICe anD vIabIlITy

a. investment options:

investment options are wide ranging and may include the following

type of standard asset classes:

i. Cash deposits and/or fixed income securities; equities (on recognised

exchanges); collective investment unit trusts and funds; life polices.

b. restrictions on investments:

all investment transactions must be carried out on a commercial basis.

GpMl retains discretion on the type of asset held or investment made

within the plan. GpMl may either decline to hold an asset (particularly if

non-standard or of a high risk or limited liquidity) or make an investment

or stipulate a maximum portion of the asset or the investment to be

held within the Member’s Fund. GpMl may also seek to be indemnified

against the holding or purchase of an investment which has been

recommended by the Member or their appointed Financial adviser.

c. investment manager

GpMl does not provide investment advice, nor acts as investment

manager to the Member’s Funds.

GpMl will appoint an investment manager to manage the Member’s

assets within the Member’s Fund. the Member may choose to

nominate an investment manager / investment adviser. the

investment manager will need to satisfy GpMl that they are suitably

qualified and competent to act as investment manager.

d. Viability

prior to establishing a plan, GpMl recommends that the applicant

satisfies themselves that Contributions and transfers into the plan will

be of an appropriate size in order to be cost effective in relation to

the administration costs, intermediary costs, investment management

costs and any other adviser costs that may be applicable.

e. investment objective and performance

the investment objective must be to provide benefits throughout the

Member’s retirement. Consideration will need to be given to cash flow

requirements, particularly prior to the payment of benefits. this may

preclude holding certain illiquid assets or liquidating assets at certain

times when benefits are being taken or about to be taken.

7. benefITs

Benefits paid from the plan will be paid gross of any Guernsey tax.

However, a tax liability may arise in the Member’s country of residence

(note: if the Member has been UK tax resident within the last five full tax

years preceding benefit payment then UK taxes may apply in accordance

with HMrC regulations.).

it is the responsibility of the Member or their beneficiaries to disclose

payments of benefits to their relevant tax authority. Unless expressly

agreed, GpMl will not be involved in, or responsible for, the Member’s or

their beneficiaries tax affairs relating to the plan.

a. retirement Benefit

i. lump sum

a single lump sum payment, up to 30%* of the value of the Member’s

Fund, is available at normal retirement date, in accordance with

Guernsey income tax parameters. this payment is only available at the

commencement of benefit and prior to regular benefit payments*.

* or as the law as amended, governing the deed may permit.

ii. drawdown/Annuity

regular payments from the Member’s Fund, either monthly, quarterly,

bi-annually or annually for the duration of the Member’s life or until

the funds within the Member’s Fund are exhausted (which ever should

occur sooner). Drawdown/annuity quotations will typically utilise one

of the following sources:

u UK Government actuary’s Department (“GaD”) tables;

u annuity tables on the UK Financial services authority (“Fsa”) website;

u recognised insurance company quotation;

u alternative Government actuary tables according to currency and/

or residency of Member as may be applicable;

u actuary Quotation (Cost of obtaining an actuary quotation will be

borne by the Member’s Fund).

the drawdown/annuity quotation may allow for no increases or

for annual increases of a fixed rate of up to the prescribed limit as

advised or published by the Guernsey income tax. Drawdown/annuity

payments and their terms and conditions may be reviewed at intervals

of typically not less than three years, at GpMl’s discretion.

GpMl may implement an alternative drawdown arrangement and review

period, as agreed by the Guernsey income tax from time to time, to

comply with HMrC Qrops requirements.

b. notification

the Member should notify GpMl in writing at least 3 months before

their selected retirement date of their election to either:

i. commence benefit and the requested retirement benefits, or

ii. defer benefit, providing GpMl with the revised retirement date, which

normally will be prior to the Member’s 77th birthday*.

* or as the law as amended, governing the deed may permit.

c. disability / incapacity Benefits

should the Member become incapacitated (due to permanent and total

disability) prior to normal retirement date, then the Member may be

able to commence benefits as per one of the retirement benefit options

outlined above. the Member will need to provide GpMl with satisfactory

information and evidence of incapacity and/or GpMl may verify

incapacity with any suitable authority that it may deem appropriate.

d. death Benefits

on receipt of proof of the Member’s death, GpMl will distribute any

residual value of the Member’s Fund as follows:

u to one or more of the Member’s spouse and/or dependents, and/or;

u to the Member’s estate;

u By payment to a new plan for the provision of benefits to one or more

of the Member’s spouse and/or dependents, for their future benefit.

When considering a payment GpMl will be guided by the Member’s wishes

as per the application Form/Deed of adherence or superseded request

(letter of Wishes) received in writing, subject to GpMl’s discretion.

8. rIsk faCTors

the value of the benefits that a Member may receive when they retire

is not guaranteed. it will depend on a number of factors, for example

the performance of the Member’s chosen investments, the amount of

contributions or transfers, the age at which benefits are taken and future

annuity and drawdown rates. in particular:

i. some investments carry a higher level of risk than others and the value

of the Member’s Fund could be lower than the total amount invested.

ii. investments into stock markets and/or exchanges and investments

linked to these fluctuate in value, as does any income derived from

them. past performance is not a reliable indicator of future returns.

9

10. code of prActice And conditionS (continued)

iii. inflation could reduce purchasing power of the Member’s Fund.

iv. the basis and amount of tax benefits could change in the future.

v. Governments and/or the laws and/or the policies of Guernsey, the

UK and/or another relevant jurisdiction relating to pensions and

retirement benefit could change in the future. this may affect the

benefits that a Member may take from the plan at retirement age.

9. CUrrenCy

Base currency for all Members’ Funds will normally be in sterling.

investments within the Member’s Fund may be invested in other currencies;

however the Member must realise that this may create a currency exposure,

where fluctuations with the rates of exchange may go down as well as up.

10. TerMInaTIon

this agreement will be terminated by either:

i. the last payment of the provision of benefits (retirement Benefit;

Death Benefit etc.) which have run their course and no residual value

relating to the Member is held within the plan or;

ii. the transfer out of funds to another corresponding scheme. a Member

may only transfer their Member’s Fund to a suitably approved/

accepted scheme, on no less terms than the Qrops, and this is

subject to GpMl’s discretion.

11. rePorTIng

a. trustee reporting

GpMl will report to the Guernsey income tax and to HMrC as per the

current obligations, and/or as requested from time to time as relevant.

Following a UK pension transfer, GpMl have undertaken to report to

HMrC any payment or deemed payment where the:

u Member is resident in the UK when the payment is made (or

treated as made), or

u payment is made (or treated as made) within the first ten years

after the date of receipt into the plan.

u Member has been UK tax resident within the last five full tax years.

b. member reporting

GpMl will provide annual statement relating to the Member’s Fund

including details of contributions and transfers received and/or

payments made. any other frequency or reporting will be by individual

arrangement agreed on establishment or as amended from time to

time. a cost may be incurred for additional or ad-hoc reporting.

12. CHarges

the charges of the plan are set out in the application Form, a copy of

which the applicant(s) acknowledges has been supplied to them. the

Member acknowledges that GpMl is able to recoup any third party

expenses incurred in administering the Member’s Fund, as billed directly,

from the Member’s Fund.

GpMl reserves the right to share its fee with any third party, including the

introducers of new business, at its sole discretion.

13. aDvICe

GpMl does not offer advice whether financial, legal or tax and nothing

provided to the applicant and/or Member whether verbally or in writing

whatsoever should be construed as financial, legal or tax advice.

applicants are recommended to obtain appropriate advice (tax, legal and

financial) prior to proceeding with a plan. the applicant and/or Member

hold GpMl harmless against any advice sought and the consequences of

them not seeking advice. GpMl rely on the applicant’s adviser to guide

them on the suitability of the retirement solution for them both on

establishment and in the future.

14. ConfIDenTIalITy anD DaTa ProTeCTIon

all information provided to GpMl will be treated as strictly private and

confidential.

For the purposes of the Data protection (Bailiwick of Guernsey) law, 2001,

the data controller in relation to any personal data supplied is GpMl.

information from an applicant and/or the Member may be processed, for the

purposes of administration by GpMl, by third parties who are appointed to

provide services to GpMl and by the applicant and/or Member’s professional

adviser. such processing may involve the transfer of data out of Guernsey.

the Member consents for GpMl (or any of its delegated third parties)

to share data relating to the Member, Member’s Fund and the plan, with

any appointed professional adviser by the Member as per the application

Form or by notice from the Member from time to time.

15. governIng law

this document shall be construed in accordance with the laws of the

island of Guernsey and the parties submit to the exclusive jurisdiction of

the island of Guernsey courts.

if there is a conflict or inconsistency between the application Form, this Code

of practice and Conditions, and the trust Deed, the trust Deed will prevail.

16. oTHer InforMaTIon

GpMl have the right to make any amendment to these Code of practices

and Conditions in order to comply with a change of applicable law or

regulation and best practice.

please note that all information in this document regarding contribution

or transfers to the plan, benefits payments or transfers made from the

plan, the Member’s tax position and otherwise is subject to any change in

the laws of Guernsey, the UK and other relevant jurisdiction from time to

time. any such change in the laws may have retrospective effect.

this document is based on GpMl’s current understanding and

interpretation, as at March 2012.

Gower pensions Management limited is licensed by the Guernsey

Financial services Commission. its company registration number is 46231

and its registered office is at suite 2, Weighbridge House, le pollet,

st. peter port, Guernsey, GY1 1Wl.

10

ref: Qrops-Horizon-Cop-V3-22032012

For more information please contact:

Gower pensions Management limitedpo Box 129, suite 2, Weighbridge Housele pollet, st peter port, Guernsey GY1 4eH

telephone +44 (0)1481 700200Fax +44 (0)1481 740550email info@thehorizonplan.comwww.gowerpensions.com

Company registration number 46231

Gower pensions Management limited is licensed by the Guernsey Financial services Commission

ref: p003-Qrops-Hipp-app-V3-22032012

Qualifying Recognised Overseas Pension Schemes– Member information

APSS263 Page1 HMRC03/12

About this formUsethisformtogiveyourschemeadministratortheinformationtheyneedtotransfersumsorassetsheldwithinaregisteredpensionschemetoaQualifyingRecognisedOverseasPensionScheme(QROPS).TheschemeadministratorwillneedthisinformationbeforeproceedingwithyourtransferrequestandHMRevenue&Customsmayasktoseethis.

PleasereadtheAPSS263Notes,theywillhelpyoufillinthisform.

Tax charges

TherearecircumstancesinwhichyoumayhavetopayUKtaxonthistransferorlaterpaymentoutoftheoverseasschemeevenifyouarenotresidentintheUK.

Tofindoutwhatyoucanexpectfromusandwhatweexpectfromyougotowww.hmrc.gov.uk/charter andhavealookatYour Charter.

About you

1 Your full name

Title

Surname

First name(s)

2 National Insurance number

If you have contacted Jobcentre Plus and are not entitled to a National Insurance number, please give the reason why

3 Your date of birth DD MM YYY

4 Your principal residential addressThis must not be a PO Box number or c/o the

scheme manager

Country

5 If the address given in the previous question is not in the UK, please give your last principal address in the UK

Postcode

Country

If you don’t have a previous UK address, please tick this box

6 Your contact phone number

Page2

Acknowledgement

11 I am aware that:

In some circumstances a transfer of funds might not be a recognised transfer and may be treated as an unauthorised payment giving rise to a liability to pay tax in the UK.

In some circumstances a future payment made or treated as made by a QROPS may be treated as an unauthorised payment giving rise to a liability to pay tax in the UK.

To the best of my knowledge and belief the information given in this form is correct and complete

Signature

Date DD MM YYYY

About the QROPS receiving the transfer

7 HMRC reference numberThis is the QROPS reference number, allocated to the

scheme by HMRC, when the notification that it met

the requirements to be a recognised overseas pension

scheme was acknowledged

QROPS

8 Name of QROPS

9 Address of QROPS

Country

10 Country in which QROPS is established and regulated

Gower Pensions Management Limited

PO Box 129, Suite 2

Weighbridge House

St. Peter Port

Guernsey, GY1 3EH

Guernsey