1. Title Mr Mrs Miss Ms Dr Other
2. please specify
3. First names
4. Surname
5. Date of birth D12345678910111213141516171819202122232425262728293031M123456789101112Y19941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930
6. Phone
7. Fax
8. Mobile
9. Email
10. Gender select Male Female
11. Investor Number

1. Title Mr Mrs Miss Ms Dr Other
2. please specify
3. First names
4. Surname
5. Date of birth D12345678910111213141516171819202122232425262728293031M123456789101112Y19941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930
6. Phone
7. Fax
8. Mobile
9. Email
10. Gender select Male Female
11. Investor Number

1. Address
2. Suburb
3. City or town
4. Postcode (postcode finder)

Postal Address Same as residential

1. Address
2. Suburb
3. City or town
4. Postcode (postcode finder)

1. Organisation type select Not applicable Company Trust Society/Club Partnership Estate
2. Organisation name

1. Investor IRD number
2. Withholding tax rate (please tick)
3. 10.5% 17.5% 30% * 30% ** 33%
   NRWT AIL 2% Exempt

Please note if your IRD number and/or an election is not indicated your investment will be taxed at 33% p.a. If exempt from resident withholding tax, please attach a copy of a Certificate of Exemption. If applying for an Approved Issuer Levy, please complete the Approved Issuer Levy section and read the AIL conditions below. * Available for companies only ** Available for individuals and trustees only

Non-Resident address
(full overseas address must be provided if a non-resident tax rate or Approved Issuer Levy is required)

Please invest my/our funds as set out in this application, subject to the terms and conditions of the Trust Deed and the current Prospectus. I/We understand that UDC reserves the right to decline any application. Please read the AIL conditions below before signing the application form.

Application for deduction of cost of Approved Issuer Levy on non-resident income

By completing the Approved Issuer section above, the investor authorises UDC to deduct the cost of the Approved Issuer Levy (currently 2%) from all payments of non-resident income made to the investor on registered securities held in the investors name by UDC.

The investor authorises this deduction on the basis that Approved Issuer Levy will be paid by UDC to the Commissioner of Inland Revenue, as provided for in New Zealand law, in respect of the non-resident income payment from which the deduction has been made.

The authorisation may be revoked by the investor at any time by notice in writing which is received by UDC at the address below ten (10) or more days prior to a payment of non-resident income at which time UDC will deduct any applicable withholding taxes from future payments.

1.  Auto renewal
2. I/We wish for my/our investment to be automatically renewed on maturity for the same term, at the applicable interest rate. In choosing the automatic renewal option, I/we understand that I/we may alter my/our instructions without penalty with 14 days of the reinvestment date.
3.  Maturity notice
4. Please send me/us notification just prior to maturity advising reinvestment and/or repayment options and applicable interest rates. I/We understand that if this option is chosen and instructions are not received by UDC by the maturity date, my/our investment will be held at the applicable 'on demand' rate as set out in the Investment Statement.

1. Bank
2. Branch
3. Account name
4. Bank account number

1. Click here to download a Direct Debit authority form, then print, complete and enclose it with your application.