Please complete this form in BLOCK LETTERS and return it to your financial advisors or send it to us at the below address: 2701, 27/F., Berkshire House, 25 Westlands Road, Island East, Hong Kong.
Plan Number 計劃號碼
請以正楷填寫整份文件，並寄送至香港港島東華蘭路 25 號栢克大廈 27 樓 2701 室。 Please select the appropriate service that you would like to apply 請勾選閣下欲申請項目：
1) Reinstatement of the Plan and Instruction on Future Contribution Details 計劃復效與未來供款指示
Please reinstate my/our captioned Plan and I /we would like to re-start making contributions by following chosen payment method: 請將本人／吾等之計劃復效。本人／吾等將以如下選擇的付款方式重新開始供款：
☐ the existing payment method; or 依照原供款方式；或 ☐ change to following payment method 改用以下供款方式：
① Credit Card 1&2 信用卡1&2 ① JPY Direct Debit Authorization 1&2日圓直接付款1&2 ① Telegraphic Transfer 3 (T/T)電匯3 ① Bank Standing Instruction 2常行指示2 ① Online Payment in HKD 1&4 港幣網上付款1&4
① Physical Card Collection in HKD in Hong Kong 1&5 港幣到港刷卡1&5 ① Others 其他 _________________________________
Notes / 注 意：
1. Please be reminded that the Plan is unable to reinstate once it has been terminated. 若計劃已被解約，則無法接受復效申請。
2. The Plan can only be reinstated once the outstanding contributions within the Initial Contribution Period have been cleared.
若閣下的計劃首初期供款尚未繳齊，則所有欠款需繳清後方可復效。
3. The payment currency needs to be identical with the Plan contribution currency during Initial Contribution Period (“ICP”). Af ter ICP, should you wish
to change the contribution currency, please complete “Alteration of Plan Contribution Form” and submi t it with this application. 在首初供款期內的供款幣別必須與計劃供款幣別相同。於首初供款期之後，如欲更改供款幣別，請填寫「更改計劃供款事項申請表」，並連同本申請書一併提交。
2) Instruction on Repayment of Contribution 補繳計劃欠款指示
I/we would like to settle the outstanding contributions for the captioned Plan (if any) by the following payment method: 請依下列所選之供款方式扣取本人／吾等之計劃欠款（如有）：
☐ 1. By taking Contribution Holiday and waiving the outstanding contributions (if applicable)
設定「供款假期亅並免除有關欠款（如適用）
(The maximum is 24 months and it is only applicable to “Int elligence / Intelligence Pro ” Plan which has completed the contribution s within the Initial Contribution Period) (供款假期最長為24個月，並僅適用於已繳清所有首初供款期內所有供款之「智富／智富Pro 」計劃)
☐ 2. By ① Telegraphic Transfer 3 電匯3 / ① Online Payment in HKD
1&4
港幣網上付款1&4
① Physical Card Collection in HKD in Hong Kong 1&5 港幣到港刷卡1&5
I/We have/will remitted the amount of ________(currency )________________ (amount) to settle the
outstanding contributions. 本人／吾等已／將透過以上勾選方式，匯款________(幣別)________________ (金額) 以補繳先前欠款。 ☐ 3. By ① JPY Direct Debit Authorization 1&2 日圓直接付款1&2 ／ ① Others 其他 __________________________
Please collect_______(currency)________________(amount) to settle ☐ all the / ☐ ______ installments of outstanding contributions at once by using the chosen payment method.
請用以上所選擇方式一次過扣款繳付 ☐ 全部 ／ ☐ ______期欠款: ________(幣別)________________ (金額)。
(Please ensure that there are enough funds in the designated payment account to clear the outstanding contributions) （請留意指定之銀行賬戶餘額是否足夠補繳欠款）
☐ 4. Others, please specify 其他，請說明：
◆ Remarks / 附註：
1. Where contributions are paid by JPY Direct Debit Authorization/Credit Card/Online Payment in HKD/Physical Card Collection in HKD in Hong Kong, there will be an additional handling charge between 0.5% to
2.67% (depends on the type of payment method) of each contribution paid.當使用日圓直接付款／信用卡／港幣網上付款／港幣到港刷卡為付款方式，每筆扣款皆會有額外0.5%~2.67%的相關處理費用產生（依所選付款方式而定)。
2. If you change the payment method to Credit Card/Bank Standing Instruction / JPY Direct Debit Authorization, please submit the relevant authorization form with this application. Future regular contributions will be collected on the next appropriate date or around due date or the relevant collection date after the bank authorization has been set up.
如閣下改使用信用卡／常行指示／日圓直接付款做為付款方式，請填妥相關新的授權表格，連同此申請書一併提交。
icp申请3. If you have chosen T/T as the payment method, please contact Metis Global Limited / Metis Global (Cook Islands) Limited* (“Metis”) to obtain the “Bank Details on Telegraphic Transfer” for remitting reference. Please also provide the wire transfer receipt (the name and bank ac count number must be visible) to Metis with this application for further processing. 如選擇電匯做為付款方式，請向安智環球服務有限公司／安智環球服務(庫克島)有限公司* (「安智」)索取「銀行付款帳戶明細」，並請於完成匯款後，將匯款收據（需可看到匯款人姓名與銀行賬號）連同此申請書一併提供予安智。
4. If you have chosen Online Payment in HKD as the payment method, please process the online payment by logging into Metis website after receiving relevant notification. Please provide a screenshot picture (with the name and bank account number on it) to Metis for further processing (which takes around 7 to 10 business days).
如選擇港幣網上付款做為付款方式，請於收到有關通知後再登入安智網站進行線上付款。並請於付款完成後，提供付款賬戶號碼與付款人姓名的截圖將匯款收據（需可看到匯款人姓名與銀行賬號）連同此申請書一併提供予安智以完成付款作業清算（約需7至10個工作天）。
5. If you have chosen Physical Card Collection in HKD in Hong Kong as the payment method, please contact Metis at least 3 business days before your expected payment date. This payment method is applicable for paying contribution in HKD by credit card or debit card with Union Pay logo only. 如選擇港幣到港刷卡，請於刷卡日3個工作天前與安智進行預約。該付款方式僅供持有銀聯標誌的借記卡或信用卡並以港幣扣款。
6. If you wish to repay contributions during Paid-up status, please be reminded that the Paid-up charges (0.02% per months of Initial Account Value) are not refundable even all contributions in Paid-up status will have been paid after the charges have been applied.
謹提醒如閣下於扣取停供費用（每月首初賬戶價值的0.02%）後欲補繳停供期欠款，已支付的停供費用將不會退還。
Reinstatement / Repayment of Contribution Form
計劃復效/補繳供款申請書
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Plan Number
計劃號碼
3) Asset Allocation 供款配置選擇:
Please select one of the following options 請自以下四選項中擇一選取：
☐ An asset portfolio management service had been chosen under this Plan. I/We would like to continue the same service and appoint the same Portfolio Manager.
本計劃先前已有選擇資產組合管理服務，本人／吾等希望繼續維持相同的服務和組合經理人。
☐I/We would like to ①Appoint/ ①Change / ①Terminate the Asset Portfolio Manager service and please allocate my/our contribution according to the new instruction on Appointment/Change/Termination of Asset Portfolio Manager Service Form.
本人／吾等欲①委任/ ①更改/①終止資產組合經理人服務，請將本人／吾等之供款依照委任／更改／終止資產組合經理人服務申請書上的指示配置。
# Please attach the “Appointment/Change/Termination of Asset Portfolio Manager Service Form” and relev ant service agreement and Acknowledgement or Disclaimer of the Risk (if applicable) with this application.
# 請將「委任／更改／終止資產組合經理人服務申請書」與有關的委任契約書與確認書或風險聲明書（如適用）一併提供。
☐My/Our asset allocation remains the same under this Plan as before.
本人／吾等之資產配置與以往相同維持不變。
☐Revised asset allocation for my/our new total contribution under this Plan as stated below:
更改未來供款配置如下表所示：
Asset Code 資產代號Asset Name
資產名稱
Percentage
百分比
Asset Code
資產代號
Asset Name
資產名稱
Percentage
百分比
% %
% %
% %
% %
Total 合計=100%
Notes / 注意：
1.Please ensure the assets you selected are available in the latest “International Asset Selection”.
請留意閣下選擇的資產乃列於最新的「環球資產選擇簡介」。
2.Please be aware of the minimum required amount on each asset.
請注意單一資產最低持有金額要求。
3.The total percentage must be equal to 100%. Metis can only accept whole percentages for each asset allocation.
資產選擇合計必須等於100%，且個別資產分配百分比只接受至整數位。
4.You could fill in either the Asset Code or Asset Name.
資產代號或資產名稱擇一填寫即可。
4) Declaration and Signature 聲明與簽署
Declaration 聲明
I/We hereby declare that any personal information of third parties provided by me/us to Metis Global Limited/Metis Global (Cook Islands) Limited* (“Metis”) (whether provided under this application or otherwise provided) in relation to this application has been obtained by me/us in compliance with the PDPO/ Personal Information Collection Statement* and the relevant third party has agreed to the disclosure of his/her personal information to Metis in relation to this application for the purposes as set out in the Personal Information Collection Statement. I/We agree to indemnify and hold harmless, on demand against all losses, liabilities and costs which Metis may incur arising out of, or in connection with, any breach of the declaration set forth in this paragraph.
本人／吾等特此聲明，由本人／吾等就此申請提供予安智環球服務有限公司／安智環球服務（庫克島）有限公司*（「安智」）的任何第三方個人資料（無論載於此申請書或從其他途徑所提供）乃由本
人／吾等在遵守個人資料（私隱）例／收集個人資料聲明*的情況下獲得，且有關第三方已同意為此等個人資料收集聲明所載之目的就此申請向安智提供其個人資料。本人／吾等同意應安智要求，就安智因發生任何違反本款所載的聲明，而可能招致或與之相關的任何損失、責任及費用，對安智作出賠償，並使安智免受損害。
Servicing Agent /Portfolio Manager(if applicable)服務代表/組合經理人（如適用）
I/We agree to Metis disclosing all information relating to my/our Plan to my/our appointed Portfolio Manager and Servicing Agent. I /We will let Metis know in writing if I/we decided to change my/our appointed Portfolio Manager or Servicing Agent. I/We also understand that my/our authorized Portfolio Manager or Servicing Agent is acting on my/our behalf and not on Metis’ behalf.
本人／吾等同意，安智揭露有關申請本計劃資料予本人／吾等所指定之組合經理人及服務代表。本人／吾等如欲更換組合經理人或服務代表，本人／吾等將以書面通知安智。本人／吾等同時也明白本人／吾等所指定之組合經理人或服務代表是以本人／吾等的代理人身份行事，並非安智的代理人。
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Availability 可適性
I/We declare that I am/we are not (and I am/we are not making this application on behalf of) a U.S. resident/citizen or a U.S. person as defined under FATCA (Foreign Account Tax Compliance Act). If my/our tax residency and status changes or I/we become a U.S. citizen or tax resident, I/we must notify Metis immediately (and in any event within 30 days of I/we becoming a US citizen or US tax resident) and submit a new “Decla ration of Self-Certification Form” or US IRS Form W- 9.
本人／吾等聲明不是（且不代表）美國居民／公民，或是美國FATCA （外國賬戶稅收遵從法）認定之美國人。若本人／吾等的稅務居民身份與狀況有更改，或成為美國公民或稅務居民，本人／吾等會盡快通知安智（且在任何情形下成為美國公民或稅務居民的30日內），並重新提交一份新的「自我證明聲明書」或美國稅務局規定之W-9表格。
Commission/Referral Fee Disclosure for Intermediaries 中介人的佣金/介紹費披露
I/We understand, acknowledge and agree that, as a result of my/our purchasing and taking up the Plan issued by Metis, Metis will pay the Intermediaries Commission/Referral Fee during the continuance of the Plan including renewals, for arranging the said Plan. Where I am/we are a body corporate, the authorized person who signs on behalf of myself/ourselves further confirms to Metis that he or she is authorized to do so. I/We further understand that the above agreement is necessary for Metis to proceed with the application.
本人／吾等明白、確知及同意，安智會就本人／吾等購買及接受信託公司簽發的計劃，於計劃有效期內（包括續供款期），向負責安排有關計劃的中介人支付佣金／介紹費。假如本人／吾等為法人團體，代表本人／吾等簽署的獲授權人員須向安智確認他／她已獲法人團體授權簽署。本人／吾等亦明白安智必須取得本人／吾等的同意，才可以處理有關申請。
Legal 法規
I/We understand that Metis is an authorized Trust Company in Hong Kong/Cook Islands*. I/We acknowledge and agree that the Plan Schedule, if issued, will be governed by the laws of Hong Kong/Cook Islands* and be subjected to the jurisdiction of the Hong Kong/Cook Islands* courts. I/We fully understand the risks (including but not limited to the counterparty risks, market and financial risks associated with assets in the Plan) and merits, as well as the legal, tax and accounting characteristics and the consequences of asset allocation in the Plan. I/We have consulted my/our own financial, accounting, tax and legal advisors as I/we deem necessary or appropriate.
本人／吾等明白安智是獲香港／庫克島*授權之信託公司，本人／吾等了解並同意計劃契約書若發出，乃受香港／庫克島*法令規管並以香港／庫克島*法院為管轄地。本人／吾等完全明白申購本計劃的風險（包括但不限於本計劃資產所涉及的交易對手風險、市場及財務風險）及利弊，以及有關
本計劃的法律、稅務、會計特點及資產配置的結果。本人／吾等若覺有需要或適當，將向本人／吾等的財務，會計、稅務、法律顧問尋求諮詢。
*Please delete as appropriate 請刪除不適用
Signature of the Plan Owner/ Authorized Signatory 持有人/被授權人簽名 Signature of the Plan Owner/ Authorized Signatory 持有人/被授權人簽名 Printed Name 姓名
Printed Name 姓名
Signature of the Plan Owner/ Authorized Signatory 持有人/被授權人簽名 Signature of the Plan Owner/ Authorized Signatory 持有人/被授權人簽名
Printed Name 姓名
Printed Name 姓名
Plan Number 計劃號碼
Date Signed 簽署日期
D M Y 日 月 年
Notes / 注 意：
Apart from this “Reinstatement /Repayment of Contribution Form”, p lease also enclose the following forms/documents and send them to Metis together: 除此「計劃復效／補繳供款申請書」外，敬請連同下列表格及文件等，一同寄送至安智： 1. Certified ID Card copy / Passport copy must be provided by each Plan Owner. 每位計劃持有人必須提供經核實之身分證影本或護照影本。
2. Certified address proof issued within the last 3 months must be provided by each Plan Owner. 每位計劃持有人必須提供經核實之最近三個月內的地址證明。
(If the provided address proof is different from your last known address in our record, please also complete the “Change of Personal Information From” to update your latest address. 如地址證明上之地址與登錄於安智之地址不同，請提交填寫完整的「更改個人資料申請表」以更新閣下之登錄地址。） 3. The relevant payment method form (if applicable) or wire transfer receipt (the name and bank account must be visible). 需提供相關付款方式表格（如適用）或電匯收據副本供查核（收據上需可看到匯款人姓名與銀行賬號）。
4. “Appointment/Change/Termination of Asset Portfolio Manager Service Form” and relevant service agreement and Acknowledgement or Disclaimer of the Risk (if applicable). 「委任／更改／終止資產組合經理人服務申請書」與有關的委任契約書與確認書或風險聲明書（如適用）。
5. We reserve the right to request additional information or documentation on source of wealth where we deem necessary or an updated “Personal Details and Financial Needs Analysis form ”. 我們保留權利要求閣下提供財富來源的證明文件或更新的「個人資料及財務分析表」。
6. Please complete the “Declaration of Self -Certification Form” if you have not submitted this form previously or your tax residency has been changed since your previous submission. 請填寫「自我證明聲明書」，若閣下未曾提交過此聲明書」者，或自上次提交後閣下之稅務居民身份有變更。
R e i n s t a t e E C 201901
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