Adviser Remuneration Form This form is used when you want to authorise remuneration for your adviser, either on an ongoing basis, or as a once-off fee. The fee will be deducted from your Emplus account and paid to your financial adviser where the advice incorporates your Emplus account. This form can be used by all members of a division of Emplus Super. 1. YOUR DETAILS Full Name: Address: Date Of Birth: Member Number: Mobile Number: Email Address: 2. ONCE-OFF FEE Amount to be paid (exclusive of GST) $ OR % Deducted from the member’s account balance upon lodgement of this form AND 3. ONGOING FEES Amount to be paid (exclusive of GST) $ pa OR % pa Deducted from the member’s account at the last day of the month, commencing from / / AND Amount to be paid on all amounts switched between investment options (exclusive of GST) % of the amount switched Deducted from the member’s account balance upon each and every investment switch 4. ADVISER DECLARATION I, the Adviser whose details and signature are provided below, confirm that the nominated Fees are in relation to services to be provided to the Member specified in Section 1, and that these services incorporate advice in relation to their Emplus account. Adviser Name: Business Name: Phone Number: Adviser Authorised Representative Number: Adviser AFSL Number (if applicable): Signature: Date: / / 5. MEMBER’S DECLARATION I, the Emplus member whose details are provided above, and whose signature appears below, declare: • This Adviser Remuneration Form replaces any previous Adviser Remuneration arrangement; • I understand the Once-off Fee and Ongoing Fee are negotiable between my authorised adviser and myself and that any fees agreed to by me are in addition to the base fees stipulated in the PDS; • I have read and understood the PDS and Additional Information Booklet; and • I authorise the Trustee of Emplus to deduct the amount specified in Section 2 and 3 from my account in Emplus, and to pay the full amount to the Adviser specified in Section 4. Signature: Date: / / We are committed to respecting the privacy of the personal information you give us. Our formal Privacy Statement sets out how we do this. If you would like a copy of Emplus Super’s Privacy Statement, please let us know. We have published our Privacy Statement on our website at www.Emplus.com.au P PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E [email protected] | W www.emplus.com.au Emplus ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 1 of 1