FICA:

THIRD PARTY AFFIDAVIT IN

VERIFICATION OF
RESIDENTIAL ADDRESS
Please print in block letters using black or blue ink.

I, (insert full name and surname of deponent)

with identity number , do hereby make oath and state that:

1. I am an adult male/female* and confirm that the information contained in this affidavit is true and correct.

2. I reside at/own* the property located at (insert physical address).

3. I confirm that (insert name of prospective client)

resides /carries on business* at the abovementioned physical address due to

(state the relationship or reason(s) for the client residing/carrying on business at the given address).

4. In verification of my association to the aforementioned address, I attached herewith a copy of (insert

name) of prescribed and acceptable FICA verification document) which reflects my name and the said address.

Signature of deponent

I certify that the deponent acknowledged to me that he/she* knows and understands the content of this declaration, and took the oath in the manner prescribed
by regulation.

Thus signed and sworn to before me at on this day of 20

Signature of Commissioner of Oaths

COMMISSIONER OF
OATHS STAMP

* Delete where applicable

Old Mutual is a Licensed Financial Services Provider

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Old Mutual South Africa Limited AML FICA: 3rd Party Affidavit in Verification of Address omms 11.2015 L7864