1 of 3

AUTOMATIC WITHDRAWAL/ INCOME PAYMENT INSTRUCTIONFor the Individual Savings Account (ISA) and Collective Investment Account (CIA)

Client reference number u if known

Names of joint investors u if applicable

Names of first investor

1 YOUR DETAILS

2 YOUR ACCOUNT DETAILS u please complete a separate form for each account

WITH THIS FORM YOU CAN:

• set up a new automatic withdrawal or income payment instruction

• amend an existing automatic withdrawal or income payment instruction.

It cannot be used for any other Old Mutual Wealth products.

1.

2.

3.

4.

Tick below to indicate whom we should contact if we have any queries about your instruction:

My/Our financial adviser OR Me/Us using the details above

• It is important that you are aware that the Old Mutual ISA is not a `Flexible ISA’, meaning that any money withdrawn from it cannot be reinvested in the ISA without counting as a new subscription.

• Non UK tax – if you are subject to tax in any country outside the UK, please contact your tax specialist to understand whether you will be liable for tax in that country.

• Payments will be made direct to the bank using BACS (Bankers’ Automated Clearing System) on the 28th of each month you specify in your instructions.

• If we receive your instructions after the 15th of the month we cannot guarantee that they will take effect for that month.

• The minimum payment amount is £25.

• If we need any additional information to enable us to carry out your request, we will let you know as soon as we can.

NOTE

E-mail addressTelephone number

Please tick/complete this form, as applicable, using BLOCK CAPITALS and blue or black ink.

Account number ISA CIA(tick one)

2 of 3PDF12019/220-0066/January 2020 (ISA/CIA Withdrawal/Income Form)

OR:

OR:

1. Income Payment Option u�this means distribution payments from any income funds in your account will be paid into your bank account on the months you request in part C (provided the total received is at least £25).

£

B – FUNDS TO BE SOLD

For Option 1 above – this part does not apply, go to PART CFor Options 2 and 3 above – Managed Portfolio Service (MPS) investors - If you invest using the MPS, we will meet your withdrawals by selling units proportionally

across all funds in your account. – Other investors - we will meet your withdrawals by selling units proportionally across all funds in your account. However, you can

instead choose to sell proportionally from specific funds by selecting an alternative fund choice below or you can write `largest fund’ if preferred.

• This must be your own bank account; we CANNOT make withdrawal payments to third parties.• We may need to see proof of bank account ownership. We will let you know if this is the case as soon as we can.• Some banks or building societies cannot accept direct credits.

Branch address (must be in the UK)

Name of bank/building society

Postcode

Sort code Building society referencenumber (if applicable)– –

D – BANK DETAILS FOR YOUR PAYMENTS

3 YOUR INSTRUCTION

A – CHOOSE ONE OF THE FOLLOWING OPTIONS

• Any instructions you give in this section will apply to your entire account, and will override any existing instructions.• There may be tax implications if you make withdrawals from your account; please refer to your financial adviser for advice.NOTE

Yes

Jan Feb Mar Apr May Jun

Jul Aug Sep Oct Nov Dec

When would you like payments to start?

C – FREQUENCY

2 8 u if left blank it will be the next available of the months you selected

Do you want to receive payments every month? No – tick below the months in which you would like to receive payments:

2. Automatic Withdrawals of a specific amount of money

3. Automatic Withdrawals of a percentage of your account value

State how much you want to receive EACH PAYMENT (minimum £25)

increase annually by 5% increase annually by the Retail Prices Index % increase

u leave blank if automatic increase is not required

% paState how much you want to receive EACH YEAR*

* This is an annual percentage; when the payment is due, we will calculate the percentage based on the value of your account at that time. We then divide that amount by the number of payments you specify in Part C, to calculate the amount to be paid at that time, which must equate to at least £25.

Bank accountnumber

Name of bank account holder(s)

Fund Name

3 of 3

This declaration is made by each account holder or authorised signatory

a) I authorise and request Old Mutual Wealth to carry out the instructions detailed in this form.

b) I understand that these changes will take effect in accordance with the account Terms and Conditions.

c) I confirm that I am entitled to give instructions on the account stated on page 1.

d) I declare that this form has been completed correctly to the best of my knowledge and belief.

u please continue on a separate sheet if necessary

www.oldmutualwealth.co.uk

Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years.

Old Mutual Wealth is the trading name of Old Mutual Wealth Limited which provides an Individual Savings Account (ISA) and Collective Investment Account (CIA) and Old Mutual Wealth Life & Pensions Limited which provides a Collective Retirement Account (CRA) and Collective Investment Bond (CIB).

Old Mutual Wealth Limited and Old Mutual Wealth Life & Pensions Limited are registered in England and Wales under numbers 1680071 and 4163431 respectively. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority. Old Mutual Wealth Life & Pensions Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Their Financial Services register numbers are 165359 and 207977 respectively. VAT number 386 1301 59.

PDF12019/220-0066/January 2020 (ISA/CIA Withdrawal/Income Form)

Send the completed form as follows:

• By post: to Old Mutual Wealth, Old Mutual House, Portland Terrace, Southampton SO14 7AY• By email: send a scanned copy of the form to ask@omwealth.com Note: We cannot accept photographs of instructions.• By PROMPT: our tool for financial advisers to upload documents direct to us; advisers can contact us for details.

4 DECLARATION AND AUTHORITY

1. Signature

Print full name Capacity u eg investor, trustee, signatory, attorney

2. Signature

3. Signature

4. Signature

Print full name

Print full name

Print full name

Capacity u eg investor, trustee, signatory, attorney

Capacity u eg investor, trustee, signatory, attorney

Capacity u eg investor, trustee, signatory, attorney

Where there is more than one account holder, or more than one person is required to authorise changes, each one must sign.

NOTE

Date u (ddmmyyyy)

Date u (ddmmyyyy)

Date u (ddmmyyyy)

Date u (ddmmyyyy)