Retire - Fidelity Life KiwiSaver

Fidelity KiwiSaver Scheme Application Form

1 - YOUR DETAILS

Title:
Surname:
First names:
Date of birth:	Gender:
IRD Number:
Prescribed Investor Rate: 10.5% 17.5% 28% As outlined in the Investment Statement, your “prescribed investor rate” is the rate of tax we will apply to your investment.
Email:
Residential address:
Postal address: (if different from residential)

Telephone numbers:
	Home: Work: Mobile:

If you are an employee please fill in Sections 2 to 5
If you are contributing directly and you are not an employee, please fill in Sections 3 to 5

2 - EMPLOYER DETAILS (If you are an employee)

Employer
Employer name:
Employer IRD number:
Postal address:
Telephone number:
Payroll contact person:
Employee contribution rate:	2% 4% 8%

3 - INVESTMENT FUND OPTIONS (All investors)

Please give the percentage of your contribution to be invested in each Fund (maximum four Funds)

Capital Guaranteed Kiwi % Conservative Kiwi % Balanced Kiwi % Growth Kiwi %

Ethical Kiwi % Aggressive Kiwi % Options Kiwi %

4 - INVESTMENT DETAILS

5 - DECLARATION (All investors)

I declare that the above information is correct. The information and any information collected in the future can be used for statistical purposes as long as I am not identified, and for providing me with information about Fidelity Life and its services. I have rights of access to, and correction of the information held subject to the provisions of the Privacy Act 1993 and amending legislation.
I declare that I have received a copy of the Investment Statement, agree to be bound by the terms of the Trust Deed governing the Fidelity KiwiSaver Scheme, and apply for membership of the Fidelity KiwiSaver Scheme. This application is to be read in conjunction with the Investment Statement.
I consent to Fidelity Life providing information about my investments and my membership to either the adviser shown in this application form or to any other adviser allocated to service my business.
I agree that information held about me may be disclosed outside of the Fidelity Life group of companies to the Trustee of the Fidelity KiwiSaver Scheme, the Inland Revenue Department, to other companies for processing on the Manager’s behalf, where required by law, or with my consent.
I am normally present in New Zealand or I am an employee of the State services.
I am a New Zealand citizen or I am entitled to be in New Zealand indefinitely.
I direct the Trustee to invest contributions received by the Scheme, on my behalf, in the manner specified under section 4 of this application form.
I acknowledge that the direction I choose to invest contributions is my responsibility, and neither the Manager nor the Trustee is to be regarded as representing or implying that my investment choice is appropriate for my personal circumstances. I will seek my own financial advice in this respect.
I understand that the Fidelity KiwiSaver Scheme is for long term investment and the value of my investment may rise and fall from time to time.
I acknowledge and understand if I invest in the Options Kiwi Fund at anytime, that it is a high-risk investment which uses leverage and derivatives (options contract) that could enhance any returns or generate substantial losses.
I understand that deductions of contributions will be made from each payment of my gross salary or wages (at the rate of either 4% or 8% (or 2% from 1 April 2009), as applicable) if I am an employee.
Apart from the circumstances outlined in the attached investment statement, I understand that I will not have access to, or be able to withdraw from, my contributions/investment in the Fidelity KiwiSaver Scheme until I reach the age of entitlement to New Zealand Superannuation (currently 65) or have been a member of a KiwiSaver Scheme (or complying superannuation fund) for 5 years, whichever is the later.
If I am a member of another KiwiSaver Scheme, I understand and consent to the transfer of my interest in the other KiwiSaver scheme to the Fidelity KiwiSaver Scheme. I also understand that I will cease to be a member of the other KiwiSaver scheme.
If I have provided my email address in this application form, or if I provide it at any stage in the future, I consent to receive emails from Fidelity Life Assurance Limited and related companies, in respect of the Fidelity KiwiSaver Scheme and any further services.
I undertake to keep my Fidelity KiwiSaver member account password safe and to disclose it to no-one. I acknowledge that neither the Manager nor Trustee is liable for any loss following unauthorised access to my account where I have directly or indirectly disclosed my password to another person.

_____________________________________ Date: _________________
Signature of Applicant or legal guardian

Full name of legal guardian (if applicable):

Capacity of legal guardian (if not parent):

Identification Verification

Applicants full name:

Identification:

(To be completed in all cases except if the applicant is a Fidelity Life client. If Fidelity client quote any policy or client number)

Enclosed photo proof of identification or bank account proof of ID and proof of residential address in respect of the applicant. (Passport, birth certificate or driver's licence for ID and utility, rates, telephone, bank statement or other addressed to you at your residential address). Or Two non-photo proofs of identity from any of the following: (Full NZ Birth Certificate, Student or Employers issued ID card (with a photo), International Drivers Licence, your Utilities Bill, or your Bank or Credit card statement).

Name: Type of ID: ID No:

Proof of residential address - Type: Supplier:

On completion mail application and supporting documents to:

Freepost 207963
Fidelity KiwiSaver
PO Box 34 778,
Birkenhead,
Auckland 0746

Adviser company name: Costello Financial Services Ltd Adviser name: John Hyde
Adviser Code: 1356000

On "Submit" - your completed KiwiSaver Application will be emailed to you for printing, checking, signing and mailing. An Investment Statement will also be included as an attached pdf to the email for your future reference.