Savings Annuity

Savings Annuity TFSA 1. ApplicATion (new plan) inSTrucTionS – Client No: ___________ 2. conTrAcTholder’S perSonAl inFormATion Gender: Last Name First Name Occupation M F Address (No., Street, Apartment) City Province Country Postal Code Home Tel. Work Tel. Ext. Social Insurance No. Language preference: Date of Birth (YYYY/MM/DD) E-mail address French English 3. BeneFiciArY deSiGnATion > Required for applications only Estate Name of beneficiary or Designation Relation to contractholder Date of Birth (YYYY/MM/DD) Revocable Irrevocable caution If you live in Quebec and the beneficiary you have named is the person to whom you are married or civilly united, this designation is considered irrevocable unless you indicate that you wish for the designation to be revoCAbLe. Designating an irrevocable beneficiary can have significant consequences. To replace a beneficiary designated as irrevocable, or carry out certain transactions, you must obtain the beneficiary’s consent. If the irrevocable beneficiary is a minor, the consent of the beneficiary’s legal guardian is required in addition to any other legal formalities. 4. Source oF FundS Preauthorized payment (savings annuity only) (Complete the preauthorized payment authorization form) $ Amount Cash deposit by cheque 1 Amount already held with Insurer 1 Transfer from another institution (Attach copy of statement if possible) $ Amount Date of cheque (YYYY/MM/DD) $ Amount Account No. Client No. $ Amount Maturity date of investment (YYYY/MM/DD) Name of financial institution or employer Address of institution No., Street City Province 1) You may not combine a cash deposit or amount already held with the Insurer with a transfer from another institution. Country Postal Code La Capitale Insurance and Financial Services Inc. "The Insurer" TFSA T087 (11-2008) 1 SAvinGS AnnuiTY 5. inveSTmenT inSTrucTionS > See rates statement to learn more about available products. products Amount of $____________ % $ Term redeemable (R) non-redeemable (NR) R NR Compound (C) interest Simple (S) Frequency 1 (A, S, Q, M) Payment 2 (DIA, DD) Traditional Gic equity index Gic R R R R R – – – – – – – – – – – – – – – index Accounts – – – – – R R R R R – – – – – – – – – – – – – – – other 1) Annual, Semi-annual, Quarterly, Monthly 2) DIA = Daily interest account, DD = Direct Deposit (attach a cheque specimen) La Capitale Insurance and Financial Services Inc. "The Insurer" TFSA T087 (11-2008) 2 6. cAuTion Amounts invested in these accounts are not guaranteed, except in the event of the death of the contractholder. Any returns generated by these accounts are tied to the performance of a market index or underlying fund, less any applicable management fees. The value of the market index or underlying fund fluctuates depending on the market value of the securities that make up the index or fund. The value of these accounts may, depending on the performance of the market index or underlying fund, increase or decrease on a daily basis and even fall lower than the initial capital invested if the rate of return, after deduction of management fees, is negative. Should the market index or underlying fund be unavailable or cease to be used by the insurer for any reason whatsoever, the insurer reserves the right to replace it with another market index or underlying fund it deems equivalent or to determine the applicable rate of return. Transaction date: The recorded transaction date of a purchase or redemption shall correspond to the business day following which complete, duly signed instructions, accompanied by any required sums, are received at the insurer’s Head Office. Any instructions received at Head Office later than 4:00 p.m. shall be considered to have been received on the following business day. redemption and Transfer Fees: This investment may be redeemed or transferred at any time, subject to applicable redemption and transfer fees. 7. rATe GuArAnTee In the case of a cash deposit made by cheque, the interest rate will be determined on the date the cheque is received based on the higher of the rates specified by the Insurer that is in force on the date the quotation is calculated and the rate in force on the date the cheque is received if these two dates are less than 12 days apart. Otherwise, the rate specified by the Insurer on the date the cheque is received will apply. In the case of a transfer from another financial institution, the interest rate is guaranteed for a period of 60 days from the date this application is signed, provided the cheque is received and cashable before the end of this period. 8. conTrAcTholder’S declArATion I have verified the information contained in this application and certify it to be true and complete. I acknowledge that I have read and understood the caution provided above. In the case of an application, I am applying for a TFSA Savings Annuity contract based on this information and I acknowledge that I am responsible for any taxes payable for amounts exceeding my TFSA contribution room. In the case of an application, I agree that the insurer shall file an election with the Minister of National Revenue to register this contract as a Tax-Free Savings Account under the provisions of tax legislation. Signed at on this day of 20 . Signature of Witness Signature of Contractholder Name of Financial Security Advisor (PLEASE PRINT) Signature of Financial Security Advisor Number La Capitale Insurance and Financial Services Inc. "The Insurer" TFSA T087 (11-2008) 3 9. preAuThorized pAYmenT AuThorizATion > Savings annuity only Payer’s contact information: Gender: Last Name Address (No., Street, Apartment) Home Tel. Date of Birth (YYYY/MM/DD) First Name City Work Tel. E-mail address Ext. Province Social Insurance No. Country Postal Code M F Language preference: French English Frequency of payments: Every two weeks (14 days) starting on or Once a month, the of each month. I, the undersigned, hereby authorize La Capitale Financial Management Inc. to draw cheques for the amount required from the bank account indicated on the enclosed cheque specimen. This authorization shall also be valid for any other product or service offered by La Capitale Insurance and Financial Services Inc., or an affiliated company, for which I may request to pay premiums by the same method of payment. I authorize the financial institution shown on said cheque to process each preauthorized payment as if it had been signed by myself, to debit my account in the amount of such payment, and to credit such payment to La Capitale Financial Management Inc. I understand that I may cancel this authorization at any time by giving written notice to La Capitale Financial Management Inc., at: 625 Saint-Amable St. P.O. Box 1950 Quebec QC G1K 9J8, 418 528-2211, 1 800 463-4433 or by fax at: 418 643-5051. Signature of the account holder(s) Signature of the account holder(s) Date Date important: Enclose a cheque specimen marked "Void". note: Please advise La Capitale Financial Management Inc. of any change of address or banking information. If your account has insufficient funds to honour a bank payment on the scheduled payment date, our financial institution will attempt to collect the amount automatically within the next three working days. The client must pay any fees charged for this service by the financial institution. Should the lack of funds persist, the privilege of preauthorized bank payment will be withdrawn. Any preauthorized payment that is not honoured will incur a charge determined by La Capitale Financial Management Inc. Please allow approximately two (2) weeks for any account changes or other modifications to be processed by your financial institution. HeAD oFFICe USe oNLY La Capitale Insurance and Financial Services Inc. "The Insurer" TFSA T087 (11-2008) 4