Section 1: Section 2: Section 3:

Complete Form Complete Form Sign and

(Individual) (Employer) Send

Please complete this form if you resign, are retrenched or dismissed. You, as well as your employer representative, must initial any alterations to the form.

SUPPORTING DOCUMENTS AND CHECKLIST

Please attach a clear copy of your South African ID or passport (if a foreign national). If you have a South African SMART ID card, please attach a

clear copy of the front and back of the card.

Please attach a copy of your application form, if you are transferring to another approved retirement fund.

Please attach a copy of your bank statement which includes your personal details (document to be less than three months old please), if you are

cashing in a portion or your entire fund.

Please attach the required supporting documents, if there is a claim against the employee (refer to Section 2).

Ensure that you have filled in your income tax reference number in Section 1.

Ensure that you and your employer have signed the form in Section 3.

10X CONTACT DETAILS Cape Town Johannesburg

Please send this completed form, along with Suite 105, Sovereign Quay, Foyer A, Block D, Upper Grayston Office Park,
all supporting documents, to 10X Investments. 34 Somerset Road, Green Point, 152 Ann Crescent, Sandton,
CapeTown, 8005 Johannesburg, 2031
claimdocs@10x.co.za Tel: 0861 109 109 Tel: 011 685 1300

Depending on the reason for leaving the fund, you have a

I am leaving my employer because: (Tick one)
number of options available to you

Resignation

Dismissal
1. Y
 ou may remain invested in your current 10X Fund
Retrenchment (subject to a minimum of R30 000). Please complete A
below; or
E
 mployee is redundant in consequence of a general
reduction in staff 2. Y
 ou may choose to exit from your current 10X Fund.
E
 mployee is redundant in consequence of a reduction in Please complete B below.
personnel of a particular class
O
 ther reason for retrenchment (please specify)

10X Investments is a licensed Financial Services Provider #28250 and S13B Pension Funds Administrator #24/444.

10X Umbrella Funds / July 2017 Page 1 of 5

SECTION 1
personal details (Completed by you the member)

Title: _____________ Surname: ______________________________________________________________________________________________________________

First Name(s): ______________________________________________________________________________________________________________________________

SA ID or Passport Number (if foreign national): ____________________________________________________________________________________________________

IncomeTax Reference Number:_____________________________________________________________________________________________________________

Marital Status: Married Single Divorced: date of divorce _______________________ “Other”, please specify _________________________

Type of Marriage: In community of property Out of community of property

Physical Address: ___________________________________________________________________________________________________________________________

_________________________________________________________________________________________________ Postal Code: _____________________________

Postal Address: ____________________________________________________________________________________________________________________________

_________________________________________________________________________________________________ Postal Code: _____________________________

Telephone Number: ( _________ ) ________________________________________ Cell Phone Number: ( _________ ) __________________________________

Email Address: ____________________________________________________________________________________________________________________________

A Remain invested in my current fund (prior to retiring)

Please complete this section if you wish to remain invested in your current 10X Fund (subject to a minimum of R30 000).This section is only
applicable if you are leaving your current employment prior to retirement.

In future, if you need to access this money, then you may either:
• retire from the fund (a minimum age of 55 applies if you are invested in the Provident Fund);
• withdraw the full amount in cash (subject to the relevant tax table); or
• transfer to another retirement fund.
Investment fees:
The investment management fee will be fixed at 0.5% plus VAT per annum (this may be different to your current fee).
default Investment portfolio:
Your money will be invested according to the 10X Default Life Stage Strategy illustrated below.This means that your money will be invested
in the 10X High Equity portfolio while you are more than 5 years from retirement. As your time to retirement decreases below 5 years, your
exposure to shares that are more volatile will gradually decrease. However, you can opt-out of this Default Life Stage Strategy and choose
one of three portfolios: 10X High, Medium or Low Equity Portfolio.

Please enter your planned retirement age (55 years or older): ______________________________________________________________________________

EQUITY PROPERTY BONDS & CASH

72% 61% 50% 38% 25% 7%

5%

6%

8%
10X Life-stage Portfolios

10%
8%
5%

23% 32% 40% 55% 69% 89%

HIGH 60% MEDIUM 40% LOW DEFENSIVE

EQUITY EQUITY EQUITY EQUITY EQUITY
>5 YEARS 5 YEARS 4 YEARS 3 YEARS 2 YEARS 1 YEARS YEARS TO RETIREMENT

AVERAGE LONG-TERM
6.5% 5.5% 5,0% 4.0% 3.0% 1.5%
RETURN ABOVE CPI (% pa)

SOURCE: 10X Investments, Dimson, Staunton & Marsh. Based on back tested after-inflation returns since 1900.

10X Umbrella Funds / July 2017 Page 2 of 5

 A Remain invested in my current fund (Continued)

PLEASE NOTE Complete the table below only if you wish to opt out of the 10X Default Life Stage Strategy.This decision should be taken with a
long-term view based on your retirement plans. Ideally, you should make your decision only once, as frequent changes can impact negatively
on your return.
I hereby acknowledge that I understand the risks involved in selecting an alternative investment strategy
(and that I have consulted with a registered financial planner on any matters not clear to me).
I hereby elect that my retirement benefit in the 10X Fund be invested as follows:

10X Portfolio 10X High Equity 10X Medium Equity 10X Low Equity

Expected Long-Term Return CPI + 6.5% CPI + 5.0% CPI + 3.0%

1-Year Return Fluctuations High Medium Low

5-Year Return Fluctuations Medium Medium-Low Low

B Transfer to another fund and/or take a cash lump sum (Prior to retirement)

PLEASE NOTE Complete this section if you wish to transfer to another approved retirement fund or cash in some or all of the
money in your current 10X Fund.

The sub-section you need to complete depends on what you would like to do.You have the option to:
• Transfer the money to another (approved) retirement fund. Please complete B1 below. 10X has a low cost preservation fund and retirement
annuity fund into which you may transfer your money.
• Receive part of the money in cash and transfer the remainder to an (approved) retirement fund. Please note that the amount you receive in
cash may result in tax that will reduce the cash you receive. Please complete B1 and B2 below.
• Receive the full amount in cash. Please note that this may result in tax that will reduce the cash you receive. Electing this option may also
have a detrimental impact on your future retirement value. Please complete B2 below.

B1: Transfer to an approved fund

You may choose to transfer your benefit to another approved retirement fund.

Transfer to 10X Pension Preservation fund 10X Provident Preservation Fund 10X RA fund Another fund

Fund name

Administrator/insurer name

FSB registration number 12/8/

SARS approval number 18/20/4/

Name

Contact person E-mail

Telephone

B2: Take a cash lump sum

Benefit taken as cash: R________________________________________________or ______________________________________________________________%

Account Holder: _____________________________________________________ Bank Name: _________________________________________________________

Branch Name: _______________________________________________________ Branch Code: ________________________________________________________

Account Number: ____________________________________________________ AccountType: Cheque Saving Transmission

Please attach a copy of your bank statement to this form (refer to the checklist on front page for more details).

10X Umbrella Funds / July 2017 Page 3 of 5

SECTION 2
COMPLETED BY THE EMPLOYER

Title: _____________ Surname: ______________________________________________________________________________________________________________

Fund name: 10X Umbrella Pension 10X Umbrella Provident Fund

Employer name: ___________________________________________________________________________________________________________________________

Payroll number: ____________________________________________________________________________________________________________________________

MM / YYYY
Last contribution (to be) paid: _______________________________________________________________________________________________________________

DD / / MM YYYY
Last working day: __________________________________________________________________________________________________________________________

DD / MM / YYYY
Date of withdrawal:________________________________________________________________________________________________________________________

CLAIMS AGAINST BENEFIT (Please tick the relevant option)

A claim against the member’s benefit is subject to relevant legislation and approval by the Fund.

Housing loan Employee has a housing loan from the Fund. The Fund will confirm and pay the settlement amount.

Damages caused to the employer as a result of fraud, theft, dishonesty or misconduct.

Damages Document(s) included2 Written admission Court order Case No.____________________

Amount of damages to be paid R

Employer Bank details:

Account Holder: _____________________________________________________ Bank Name: _________________________________________________________

Branch Name: _______________________________________________________ Branch Code: ________________________________________________________

Account Number: ____________________________________________________ AccountType: Cheque Saving Transmission

Please attach a copy of the employer’s bank statement to this form (refer to the checklist on front page for more details).

Court order:

Maintenance payments or divorce order endorsed against the member’s fund credit.

Divorce order Please provide supporting documents: Final Divorce Decree and Settlement Agreement

Amount of the order R

Maintenance order Please provide supporting documents: Court Order

Amount of the order R

Recipient Bank details (for court order):

Account Holder: _____________________________________________________ Bank Name: _________________________________________________________

Branch Name: _______________________________________________________ Branch Code: ________________________________________________________

Account Number: ____________________________________________________ AccountType: Cheque Saving Transmission

Please attach copy of the recipient’s bank statement to this form (refer to the checklist on front page for more details).

Without a written admission or court order, the benefit may only be withheld for a limited period
2

10X Umbrella Funds / July 2017 Page 4 of 5

SECTION 3
To be signed by the employer and you (the member)

I, the undersigned:
1. Confirm that the above information is true and correct in every detail.
2. Am fully aware of the implications of the option(s) elected above and where I am not sure of those implications, I understand that
it is my duty to seek the advice of a registered financial services provider.
3. If applicable, hereby authorise the 10X Umbrella Pension Fund and/or the 10X Umbrella Provident Fund to make an electronic
transfer into the account(s) as stated above, upon receipt of the necessary tax clearance from the South African Revenue Service.
4. Agree that the payment in accordance with the payment instructions constitutes good and effectual settlement and represents full
and final discharge of the Fund’s liability to me.
5. Hereby indemnify the 10X Umbrella Pension Fund/10X Umbrella Provident Fund (as may be applicable), its officers and
10X Investments (Pty) Ltd against any claim, loss, liability or expenses that may arise from any incorrect banking details furnished
by me or that may arise from the implications of the options I have elected on the taxation of my benefit or of ensuring that I have
sufficient savings for retirement.

DD
___________ MM
/ ___________ YYYY
/ ___________ MEMBER SIGNATURE
DATE

_____________________________________
MEMBER FULL NAME

DD MM YYYY Employer representative’s SIGNATURE

___________ / ___________ / ___________
DATE

___________________________________________
EMPLOYER REPRESENTATIVE’S FULL NAME

10X Investments is a licensed Financial Services Provider #28250 and S13B Pension Funds Administrator #24/444.

10X Umbrella Funds / July 2017 Page 5 of 5