Please complete this form in BLOCK CAPITALS throughout.
This form is for plan owners who wish to make an additional payment into their PIMS plan.
Corporate and Trustee plan owners must complete Additional Payment Form – ref. PM03.
Company and Individual Trustee plan owners must complete Additional Payment Form – ref. PM04.
You can download these forms from our website www.rl360.com.
Once you have completed and signed the form, you should send it along with all requested additional information to:
firstname.lastname@example.org or alternatively post it to: New Business Team, RL360, International House, Cooil Road, Douglas,
Isle of Man, IM2 2SP, British Isles.
01 PLAN DETAILS
Plan owner 1 Plan owner 2
Country of residence
for tax purposes
If unavailable, provide a functional equivalent (eg National Insurance Number, Social Security Number, resident registration number)
Are you a Speciﬁed US Person?
Speciﬁed US Person means a US citizen or tax resident individual who has a US residential/correspondence address or who
either holds a US Passport, a US Green Card or who was born in the US and has not yet renounced their US citizenship. More
information on US FATCA can be found at: www.irs.gov/Businesses/Corporations/Foreign-Account-Tax-Compliance-Act-FATCA
If you choose Yes to being a Speciﬁed US Person, you will need to provide us with your US Taxpayer Identiﬁcation Number (TIN)
or US Social Security Number (SSN).
If you choose No but you have a US residential/correspondence address, hold a US Passport, a US Green Card or you were born
in the US, you will need to provide us with documentary evidence that you are in the process of or have renounced your US
Citizenship. RL360 can accept a certiﬁed copy of your DS-4083 form (also known as CLN – Certiﬁcate of Loss of Nationality)
and/or a certiﬁed copy of your passport for the country in which you have obtained new citizenship.
Do you want to update your contact/address details as part of this application?
If yes then please provide new details in Section 05 - Additional Information.
If you haven’t yet registered for online access to your plan but would like to, download our
agreement and registration forms from our website - www.rl360.com.