English - Liberty

Liberty Linked Investment Platform (Pty) Limited – an Authorised Financial Services ProviderLiberty Centre, 1 Ameshoff Street, Braamfontein, Johannesburg, 2001PO Box 10499, Johannesburg, 2000Contact Centre number: 0860 456 789 / +27 (0)11 408 4871GATEWAY INVESTMENT RANGEFinancial Adviser InstructionCompleting this instruction will change your Financial Adviser and/or the level of financial advice fees you have agreed to pay them inrespect of your investment with Liberty Linked Investment Platform (Pty) Ltd, an authorised financial services provider and the administratorof this investment (“the Administrator”).SEND THE COMPLETED FORM TO LIBERTY INVESTMENTS BY: Fax: 086 683 9461/ +27 (0)11 408 2767 Email: opspcd@liberty.co.za Post: P O Box 10499Johannesburg, 2000About youTitleFull namesSurname/Name of legal entityIdentity/Passport/Registration no.Investment numberThe number the Administrator has assigned to thisinvestmentYour new adviser detailsComplete this if you have a new adviser.Title First name SurnamePractice/brokerage namePersonal ref.Liberty 13 digit adviser codePersonal codeContact numbers: Cell Work FaxEmail addressPostal addressPostal codeThe advice fees you payComplete this to change the level of advice fees.You have negotiated the following fees with your financial adviser. By making your selection below, you agree to pay the fees at theselected levels for this and all future transactions, until otherwise specified.Type of advice fee*Initial advice fee on my lump sum andadditional lump sum investments(0 – 5.7%)PercentageAmount on which percentage isappliedFrom date(inclusive)To date(inclusive)% The initial amount invested DD / MM / YYYY DD / MM / YYYYAdvice fees on my debit order(0 – 5.7%)%The regular amount invested eachmonth by debit orderDD / MM / YYYYDD / MM / YYYYOngoing advice fees(0 – 1.14% per annum)% The accumulated investment amount DD / MM / YYYY DD / MM / YYYYOngoing advice fees will be deducted monthly from your investment account. You can see the Administrator’s other ongoing charges in ourBenefits and Charges Schedule.* If these fees are payable to a VAT Vendor, VAT at a rate of 14% will be payable and this will form part of the selected percentage.Do you want to choose the unit trust we take the charges and fees from? Yes NoIf “No”, or if there is an insufficient balance in your chosen unit trust, we will deduct fees proportionately from the remaining unit trusts with sufficientbalances.Which unit trust should your charges and fees be paid from?Please note that in the event of any modification or variation of this standard form Liberty will regard this form as beinginvalid and of no force and effect. Do not sign blank or incomplete forms.LISP08 11/2013 – Page 1

Your agreement with your financial adviser1. I confirm that I have appointed the financial adviser above.Discretionary mandate declarationThis section is only applicable if the FSP above holds a “category II” license with the FSB board and is therefore an approved discretionaryFSP.2. I confirm that I have entered into a mandate with the above approved discretionary FSP (Practice/Brokerage). Yes No3. I agree and understand that in terms of the mandate, the FSP may give the Administrator instructions related to this investment directly,and I authorise the Administrator to accept all instructions submitted by the FSP on my behalf.Signed at this day of 20Signature of investor/natural or legal guardian(if a minor)Financial adviser declaration1. I provided financial advice to the investor and I am authorised to do so in terms of the Financial Advisory and Intermediary Services Act37 of 2002.2. I gave and explained all applicable documents that apply to this investment to the investor before they signed this InvestmentConfirmation form.3. I have explained all fees that relate to this investment to the investor. I understand and accept that the investor may write to theAdministrator to cancel my fees.4. I have identified all applicable parties to this transaction and verified their details under the requirements of Section21 of the Financial Intelligence Centre Act, No. 38 of 2001 ('The Act').Yes No5. I keep these parties' records as is required in terms of Section 22 of The Act. Yes No6. Where I identify all parties and keep all the records, I understand that I am the primary accountable institution under The Act.7. If I selected “No”, under 5 and 6 above, I understand that the Administrator will be responsible for the primary 'Know Your Client' requirements ofThe Act and that the application will be delayed until the Administrator receives these documents.Discretionary mandate declarationThis section is only applicable if the FSP above holds a “category II” licence with the FSB and is therefore an approved discretionary FSP.8. I confirm that I have entered in a mandate with the investor and I will adhere to the terms of this mandate at all times.Signed at this day of 20Signature of financial adviserYour agreement with the Administrator1. I confirm that all information provided in this form and all other documents signed by me in connection with this application, whether inmy handwriting or not, is correct.2. I am responsible for the accuracy and completeness of all answers, statements or other information provided by me or on my behalf.3. I have not received advice from the Administrator in respect of this application.4. I confirm that the Administrator may accept instructions from my financial adviser or any authorised third party who has been appointedand authorised by me in writing.5. I confirm that the Administrator may accept instructions in the prescribed format by facsimile or by other electronic means.6. I confirm that my appointed financial adviser will have access to my investment details through the secure section of the Administrator’swebsite.7. I have read and understood the Administrator Benefits and Charges Schedule.8. I have read, understood and agree to the latest Terms and Conditions.Signed at this day of 20Signature of investor/natural or legal guardian(if a minor)LISP11 06/2013 - Page 2