Geokinetics international retirement plan

Termination form
IMPORTANT NOTE: This form should be completed and returned to your employer.

1.

Employee details

First name

Last name

Address
(do not use a P.O. box or
an in care of address)

Address
City
Postcode/Zip code

Country

Work email
Personal email
Employee ID number
Nationality
Hire date (dd/mm/yyyy)

Country of residence (host country)

Termination date (dd/mm/yyyy)

Reason for termination (please select one of the following):

Retirement

2.

Resignation

Disability

Death

Other (please specify):

Wire transfer

Correspondent bank name

Correspondent bank address

Address
City
Country
Postcode/Zip code

Important notes:
A charge of US$50 applies.
Incomplete or incorrect
banking details will delay
your request and you will
incur additional fees.
Please check with your bank
for their instructions on
receiving an international
wire.
Returned wires are normally
charged a fee by your bank.
You will also be responsible
for the US$50 fee to resend
the wire.

ABA routing number (US banks 9 digits)

(if applicable)
SWIFT code (required)
IBAN number (if applicable)
Beneficiary (your) bank name

Beneficiary (your) bank address

Address
City
Country
Postcode/Zip code

Beneficiary (your) account name

Beneficiary (your) account number
I hereby authorise the trustees to distribute the benefits from my plan in accordance with the above instruction. I understand that any
income tax liabilities that arise from this process will be dealt with by me on a personal basis and no liability rest with my employer or the
trustees of the plan. I confirm that if my employer or the trustees of the scheme are approached by any fiscal authority for information
relating to the benefits I have taken they have my full authority to comply with such requests. I agree that any bank charges relating to the
payment of benefits are deducted from my account, together where applicable with a fee of $100 for cost of reporting under US FATCA/UK
FATCA (please refer to the online member website for further information on US FATCA/UK FATCA).
Employees signature:

Employers signature:

Date (dd/mm/yyyy):

Date (dd/mm/yyyy):

For official use

Trustees
signature:

Trustees
signature:

Total net withdrawal amount:

(please specify currency)

Date

Date

Please ensure that you complete the Individual Self Certification (ISC) form on the next page. The ISC form must be completed.

Individual Self Certification

Tax regulations require us to collect information about each investors tax residency. In certain circumstances (including if we do not
receive a valid selfcertification from you) we may be obliged to share information on your account with the relevant taxation body.
If you have any questions about your tax residency or question on how to complete this form, please contact your tax advisor.
Should any information provided change in the future, please ensure you advise us of the changes promptly.

1.

Tax Residency*

You are required to indicate all countries in which you are resident for tax purposes and the associated Tax Reference Number in the table
below. If you are a US citizen or resident, please include United States in the table along with your US Tax Identification Number.
If you are a UK, Jersey, Guernsey, Isle of Man or Gibraltar resident then please supply your National Insurance or Social Security Number as
appropriate, in addition to your Tax Reference Number.
Tax Reference Number

Country / Countries of Tax Residency

If you are not a resident in any country for tax purposes, please tick this box and provide in the table below details of your employment and
country of location for the last 36 months. Checking the box to indicate you are not a tax resident of any country without explanation may
delay the payment of your plan benefits.
Country / Countries of employment

2.

Employer

Dates

Declaration

I declare that the information provided on this form is to the best of my knowledge and belief, accurate and complete.
I agree that I will submit a new form within 30 days if any certification on this form becomes incorrect.
Print Name

Signature

Date (dd/mm/yyyy):

Please submit the original form, duly completed and signed and retain a copy for your records.

*As you may be aware, the US passed the Foreign Account Tax Compliance Act, (FATCA) in 2010. Beginning on July 1, 2014 foreign financial
institutions (FFI) such as the Participants in the Plan are required to report information regarding accounts of relevant US persons.
Additionally, certain other countries including the UK have passed similar laws where reporting is required upon payment of funds from a
foreign account. Consequently all plan participants are required to provide information regarding their tax residency.