White copy to IA Clarington Investments Inc. Blue copy to dealer. Carbon white copy to client. GIF TFSA Contract | December 2017 2
1. CONTRACT INFORMATION
MANDATORY
❑
New contract ❑ Existing contract # ❑ Transfer from existing IAC contract #
2. FINANCIAL ADVISOR INFORMATION
MANDATORY
Financial advisor’s full name Advisor code/number Telephone number Fax number
Dealer name Dealer code/number Advisor email address
3. TFSA HOLDER/ANNUITANT INFORMATION
MANDATORY Language preference: ❑ English ❑ French
❑ Mr. ❑ Mrs. ❑ Ms. ❑ Miss ❑ Dr.
Last name First name Initial(s)
Principal occupation (Be specific. Generic terms such as "manager" or " consultant" are not sufficient.)
Address City Province Postal code
Residence phone number Business phone number Ext.
Note: In order to contribute to a TFSA the holder must be a Canadian resident and is the age of majority or older in their Province of Residence.
4. BENEFICIARY DESIGNATION
OPTIONAL This section is only for contracts held in client’s name
Notwithstanding any other beneficiary designation, for a contract held in client name and if the application acts as mandatory, trustee, or tutor or guardian, the beneficiary of the contract is the
legal heir. For a registered or intermediary TFSA contract, the beneficiary of the contract is automatically the trustee of the registered nominee or intermediary contract for the benefit of the TFSA
holder of the registered nominee or intermediary contract. For a nominee or intermediary TFSA contract, any death benefit will be paid to the nominee or intermediary in trust for the beneficiary
of the estate.
The holder reserves the right to revoke the beneficiary, unless the beneficiary designated is irrevocable. Written consent of irrevocable beneficiary is required for certain plan transactions.
Quebec residents: If you name your spouse or civil union spouse as a beneficiary, the designation is considered irrevocable unless you check the box indicating that it is revocable.
Note: The beneficiary shares allocation will be split equally if not indicated.
Primary beneficiary’s full name Date of birth (DD/MM/YYYY) Social insurance number Relationship to TFSA holder Shares % Designation
%
❑
Revocable
❑
Irrevocable
%
❑
Revocable
❑
Irrevocable
Irrevocable beneficiary authorization – MANDATORY if "Irrevocable" designation is indicated
Note: future beneficiary designation can not be changed by the policyholder without the irrevocable beneficiary's consent
X
Signature of irrevocable beneficiary Date (DD/MM/YYYY)
Check here ❑ if you have attached a separate sheet with additional primary beneficiary designations.
Contingent beneficiary – applicable if only ONE primary beneficiary is designated.
Contingent beneficiary’s full name Date of birth (DD/MM/YYYY) Social insurance number Relationship to TFSA holder
Check here
❑ if you have attached a separate sheet with additional contingent beneficiary designations.
5. INVESTMENT INSTRUCTIONS
MANDATORY for purchases and transfers (i.e. T2033).
❑ Transfer from another institution (Attach a copy of the transfer form)
❑ One time PAC (Pre-authorized Contribution)
(Withdraw directly from a bank account)
VOID CHEQUE REQUIRED
Amount: $
❑Upon receipt of this application in good order.
❑Specify date
(DD/MM/YYYY)
One-time purchase: If no date is provided, IAC will process the one time
purchase on the next available trade date after reception of the request
in good order.
FundSERV
wire order number
Fund code Investment amount
Amount ❑ $ or ❑ %
Front End Sales
charge 0–5%
Default is 0%
if left blank.
%
%
%
%
%
Check here ❑if you have attached a separate sheet with additional investment instruction.
Total: 100%
IA Clarington Segregated Fund Individual Variable Annuity Contract
for a Tax-Free Savings Account (TFSA)
Issued by Industrial Alliance Insurance
and Financial Services Inc.
Administered by IA Clarington Investments Inc.
Date of birth (DD/MM/YYYY)
Social insurance number/ Business ID number
MANDATORY
click to sign
signature
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