Kharafi National Retirement Savings Plan (the Plan)

End of Service Termination Form

PLEASE ENSURE THIS FORM IS COMPLETED IN BLOCK CAPITALS
Leaving Reason:
Resignation

Termination/Dismissal

Redundancy

Retirement

Other______________

The following information is necessary before RBC cees Trustee Guernsey Limited (the Trustee) can release your benefits
from the Plan:

EMPLOYEE NAME:
Employee
Permanent Primary
Address:

Employee ID
No:
Employee
Contact Details
(Email and/or
Phone):

DATE OF BIRTH:
(DD/MM/YYYY)

Work Location
(KN Area of
operation):

Nationality:

Employment
Start Date:
(DD/MM/YYYY)

Kuwait
UAE
Lebanon
Egypt
Other: ____________

Last Working Date:

(DD/MM/YYYY)
Options at End of Service:
On leaving the service of my employer (Kharafi National), I request the Trustee to consider the following action in respect of
my Plan benefits:
1.

Sell my assets at this time and transfer the vested portion of funds as a lump sum payment to my bank details below:

2.
Retain assets within the Plan. If assets remain in the Plan 1 year after my last working date with Kharafi National, I understand
and confirm that the vested portion of the assets will be used to settle the annual participant administration fee for the Plan until I either
request payment of my remaining assets or the assets are exhausted:
3.
Transfer to the retirement plan of my new employer, I accept the transfer out fee in accordance with the current fee agreement
between RBC and Kharafi National of which I can view an extract on RBC cees online. Please see note 2 of the Notes for the Employee.

RBC Corporate Employee & Executive Services ("RBC cees") comprises a number of companies which are all
subsidiaries of RBC. RBC cees International Limited ("the Company") is regulated by the Jersey Financial Services
Commission in the conduct of trust company business. RBC cees terms and conditions are updated from time to
time and can be found at http://www.rbccees.com/cees-legal.html. Registered office of the Company: 19 21
Broad Street, St Helier, Jersey, Channel Islands, JE1 3PB, registered company number 77856. Registered
trademark of Royal Bank of Canada. Trademark of Royal Bank of Canada. Used under licence.
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Kharafi National Retirement Savings Plan (the Plan)

Bank Account Details:

Please tick the box if you have submitted your bank details on RBC cees Online.
If you have not completed your bank details online then please complete the table below ensuring all fields are populated

Bank Name:

Full Bank Address:

SWIFT Code: (contact your bank for the swift code)

NB: If you cannot provide SWIFT bank details, we may require further
documentation from you

Your name on Bank Account: (the account must be in your

name. No payment will be made to accounts in any other
name, including other family members):
Bank Account Number:
Account IBAN Number: (contact your bank for the IBAN code.
IBAN is compulsory for Kuwait, Lebanon, UAE, Bahrain and
Qatar)
Please ensure you check with your bank and provide an IBAN and SWIFT code where possible. Failure to supply all required
information will result in charges and a delay in withdrawal proceeds reaching your personal bank account.
Indemnity:
By signing this Leaver Form I confirm that I am tax resident in .and am domiciled
in.. .., and that I will ensure that any taxation that falls due upon receipt of this lump sum payment, will be paid
directly by myself to the relevant tax authorities.
I accept that I am responsible for consulting with my own professional advisers (including my own tax adviser) concerning the tax, legal,
regulatory, currency and other consequences to me of and incidental to the lump sum payment and that I have not relied on RBC
Corporate Employee and Executive Services (RBC cees) or any of your directors, officers, employees, agents, delegates, advisers or
affiliates for any such advice. I also undertake to you, your successors and assigns to do all such things as might be reasonably
necessary to comply with any applicable fiscal obligations to which I am subject with respect to the lump sum payment including, in
particular, to discharge any tax, duty, levy or other fiscal payment imposed on me by any applicable fiscal obligation with respect to the
lump sum payment.
Foreign Account Tax Compliance Act (FATCA):
Please refer to note 9 of the Notes for the Employee for further information in relation to FATCA
Please tick the box to confirm you have completed and returned a signed copy of the attached FATCA Self Certification form*

RBC Corporate Employee & Executive Services ("RBC cees") comprises a number of companies which are all
subsidiaries of RBC. RBC cees International Limited ("the Company") is regulated by the Jersey Financial Services
Commission in the conduct of trust company business. RBC cees terms and conditions are updated from time to
time and can be found at http://www.rbccees.com/cees-legal.html. Registered office of the Company: 19 21
Broad Street, St Helier, Jersey, Channel Islands, JE1 3PB, registered company number 77856. Registered
trademark of Royal Bank of Canada. Trademark of Royal Bank of Canada. Used under licence.
ISO Approved, version 1 October 2014

DWI 503 Att.9 Rev.3 09 Mar. 2015

Page 2 of 5

Kharafi National Retirement Savings Plan (the Plan)

Employee Authorisation
I hereby request the Trustee and RBC cees Guernsey Limited (the Administrator) to distribute the value of my account in accordance
with the above and confirm that the information I have provided is correct.
I also confirm that I am satisfied and agree for Kharafi National to receive any information regarding my member account in the Plan,
from the Administrator, at any time for maintenance of their records.
I have read and understood the notes below.
Employee Signature

Date (DD/MM/YYYY)

Employer Confirmation
I hereby confirm that the above information is correct.
Authorised Company Signature

Date (DD/MM/YYYY)
Please return this form to your HR Representative.

Notes for the Employee

1.
You may wish to consult an independent financial advisor at your own cost regarding the potential tax implications of receipt of this payment,
which arises from an International Retirement Plan. RBC cees take no responsibility for any tax liability arising on your behalf as a result of this
distribution.
2.
If you wish to transfer your benefits from the Plan to your new employers plan, you will need to ensure that your new employers plan will accept
transfers from another plan. In order to complete the transfer we will need to liaise with you and your new employer so please ensure you provide
contact details including an email address (if possible) in order that we can contact you.
3.
All payments will be made by electronic wire transfer in US Dollars, Euro, Canadian Dollars or Pounds Sterling or your receiving bank will convert
the US Dollars, Euro, Canadian Dollars or Pounds Sterling to your account currency as required upon receipt.
4.
In general, proceeds should be received in your bank account within 30 working days (provided all contributions have been received) following
receipt of this form and its approval by the Trustee of the Plan. Forms are processed once a month and payments can only be made after your
date of leaving Kharafi National. Therefore your request will be processed in the later month of (1) the month in which you leave service of Kharafi
National and (2) the month in which you submit this form, dependent on whether contribution deductions have been taken in the month before or
st
the month of leaving Kharafi National. For example, if you leave service on 31 March and had contribution deductions taken from your March
salary, your form will be processed first week of May and the payment sent in June. If there were no contribution deductions in March and your
form was submitted prior to the beginning of March, your form would be processed first week of March and the payment sent in April. Please note
that RBC cannot accept responsibility for delays caused by the fund managers in selling units or by the intermediary or receiving bank in applying
the funds to your account.
5.
RBC will apply a $50 bank charge prior to releasing the funds to you, any further deductions from your payment in respect of bank charges
applied by your receiving bank or intermediaries is outside the control of RBC.
6.
Employees are entitled to receive 100% of contributions made by them.
7.
Employees will receive only the vested percentage of contributions made by Kharafi National, as follows:

8.
9

Vesting based on the number of months of

participants contributions to their Employee
Account
Vesting Amount
0 - 35
0%
36 - 47
25%
48 - 59
40%
60 - 71
60%
72 - 83
80%
* Correct as at 10 October 2014
84 +
100%
RBC reserves the right to request a certified copy of the employees passport and any other due diligence information if required for compliance
purposes.
As you may be aware FATCA, came into effect under both US and UK laws on 1 July 2014 and requires the Trustee of the Plan to file reports to
the US and UK tax authorities relating to your distribution. In this regard please find attached a Self Certification form which you are required to
complete and return along with your leaver form. The form is also available to download through your login at RBC Cees Online, under the
section Useful Information. Failure to complete the form may result in your details being reported to the relevant authorities regardless of
whether you are classed as having US connection or are UK resident. If you have no connection your should complete the form anyway in order
to rule you out of reporting.

RBC Corporate Employee & Executive Services ("RBC cees") comprises a number of companies which are all
subsidiaries of RBC. RBC cees International Limited ("the Company") is regulated by the Jersey Financial Services
Commission in the conduct of trust company business. RBC cees terms and conditions are updated from time to
time and can be found at http://www.rbccees.com/cees-legal.html. Registered office of the Company: 19 21
Broad Street, St Helier, Jersey, Channel Islands, JE1 3PB, registered company number 77856. Registered
trademark of Royal Bank of Canada. Trademark of Royal Bank of Canada. Used under licence.
ISO Approved, version 1 October 2014

DWI 503 Att.9 Rev.3 09 Mar. 2015

Page 3 of 5

Tax Information Exchange Self Certification Form (SCF)

(Please complete in block capital letters)

This information is required to enable Royal Bank of Canada to comply with its obligations under the US Foreign Account Tax Compliance
Act (FATCA) and Inter-Governmental Agreements (IGA) entered into between Jersey/Guernsey and the US/UK together with any future
tax information exchange agreements which may be entered into between Jersey/Guernsey and other jurisdictions in future.
Reporting, if required under the relevant agreement, will be made to the relevant tax authority via our local authorities or in such manner
as set out in the relevant IGA.
Section A
Please state all countries of which you are resident for tax purposes, and provide your Tax Identification Number (TIN) (or your Social
Security Number if it is different to your Tax Identification Number. For UK purposes, your Social Security Number is your National
Insurance Number) where available.
I certify that I am a resident in the following countries for tax purposes (list all):
Country:

Tax ID:

Country:

Tax ID:

Country:

Tax ID:

Country:

Tax ID:

Section B
If you are UK Person for UK tax purposes but not domiciled, please provide the following information:
I wish to be reported for UK FATCA under the Alternative Reporting Regime
If you do wish to be reported for UK FATCA under the Alternative Reporting Regime, please provide written and signed confirmation of the
following by 28 February following the end of the Relevant Tax Year:
That your UK tax return for the Relevant Tax Year:
a) Contains a claim or statement that you are not domiciled anywhere in the UK; and
b) Includes a claim to be taxed under the remittance basis under Part 14 Chapter A1 Income Tax Act 2007 and, if appropriate, the tax
chargeable under section 809H Income Tax Act 2007 has been paid, or any such equivalent sections in any successor legislation; and
c) To the best of your knowledge, the domicile status and claim to be taxed on the remittance basis is not being formally disputed by the
UK Competent Authority.

Tax Information Exchange Self Certification Form (SCF)

DWI 503 Att.9 Rev.3 09 Mar. 2015

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Page 4 of 5

Section C
Are you a US citizen*? Yes No
If you are a US citizen then please provide your US TIN number
(if not already provided overleaf)
Section D
By signing below, you confirm that:
The information you have given us above is true and accurate and complete to the best of your knowledge. You will inform us promptly of any
change in circumstances.
Please note that Royal Bank of Canada will not accept responsibility for the consequences of any failure on your behalf to provide notification
of a change of circumstances on a timely basis.
Name

Date of Birth

Signed

Date (dd/mm/yy)

*Notes
The IRS defines a United States Person or US Person for US tax purposes as:
A citizen or resident of the United States
A domestic (US) partnership or corporation
An estate other than a foreign (non-US) estate
A trust if a court within the US is able to exercise primary supervision over the administration of the trust; and one or more US persons
have the authority to control all substantial decisions of the trust.
n Any other person that is not a foreign (non-US) person
n
n
n
n

(Source: http://www.irs.gov/Individuals/International-Taxpayers/Classification-of-Taxpayers-for-U.S.-Tax-Purposes)

The information provided by you in this form will be held and may be used by one or more of the RBC companies that collectively form the RBC Wealth
Management network of offices in the British Isles (the BI subsidiaries). The use of any personal information will be governed by the applicable terms and
conditions of the RBC company (ies) with which you have applied to establish or have established a business relationship.
This document is issued by Royal Bank of Canada (Channel Islands) Limited (the Bank) on behalf of the BI subsidiaries. Details of the names, addresses
and regulatory status of the principal BI subsidiaries, together with their applicable terms and conditions, may be obtained at the following address: www.
rbcwminternational.com.
The Bank is regulated by the Guernsey Financial Services Commission in the conduct of deposit taking and investment business and to act as a custodian/
trustee of collective investment schemes in Guernsey and is also regulated by the Jersey Financial Services Commission in the conduct of deposit taking,
fund services and investment business in Jersey. The Banks General Terms and Conditions are updated from time to time and can be found at
www.rbcwminternational.com/terms-and-conditions-British-Isles.html. Registered Office: PO Box 48, Canada Court, St Peter Port, Guernsey, Channel Islands,
GY1 3BQ, registered company number 3295.
/

TM

Trademark(s) of Royal Bank of Canada. Used under licence.

Tax Information Exchange Self Certification Form (SCF)

DWI 503 Att.9 Rev.3 09 Mar. 2015

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CA/Dec 15/1721 110933 (06/14)

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