"insured" means that the benefits (other than the death benefits) of the trust RAC are insured with a life assurance company;

"self administered trust RAC" means a trust RAC where some or all of the benefits (other than the death benefits) are not insured with a life assurance company.

Full name of registered administrator:

Principal business address:

Email address for queries:

Registered office address (if body corporate):

Telephone no:

Signed by (Note 1):

Print name of signatory:

Notes on Completion of Form

General

1 All sections of the form must be competed in full. "None" or "Not applicable" should be entered where appropriate, but blank spaces or "To be advised" or similar responses may result in the form being rejected as incomplete.

2 The form is also available in electronic format from the website www.pensionsauthority.ie.

3 This form should be submitted to: The Pensions Authority, Verschoyle House, 28/30 Lower Mount Street, Dublin 2 or electronically, subject to such requirements as the said Authority may stipulate.

Note 1: The form should be signed by the person completing it, who will normally be a member of the staff of the registered administrator.