Common use of Tax-Qualified Plans Clause in Contracts

Tax-Qualified Plans. Is this annuity part of a Tax Qualified Plan? ____ Yes ____No If yes, please select one of the following. ___IRA Transfer/Rollover ___403(b)TSA ___Regular Contribution for Tax Year________ ___Roth IRA ___401 (Corporate Plan) ___Other _______________ ______________________________________________________________________________ 7.PURCHASE PAYMENT ____Purchase Payment Enclosed with Application Purchase Payment Amount $_____________________ ____This contract will be funded by a 1035 Exchange, Tax Qualified Transfer/Rollover, CD or Mutual Fund Redemption. (If checked, please attach the appropriate forms). ______________________________________________________________________________

Tax-Qualified Plans. Is this annuity part of a Tax For Tax Qualified Plans, please Qualified Plan? ____ Yes ____No If yes, please select indicate one of the following. ___IRA Transfer/Rollover ___403(b)TSA ___Regular Contribution for Tax Year________ : (b) TSA ___Roth IRA ___401 (Corporate Plan) ___SEP IRA ___Other _______________ ______________________________________________________________________________ 7.PURCHASE PAYMENT ____Purchase Payment Enclosed with Application Purchase Payment Amount $_____________________ ____This contract will be funded by a 1035 Exchange, Tax Qualified Transfer/Rollover, CD or Mutual Fund Redemption. (If checked, please attach the appropriate forms). ______________________________________________________________________________

Tax-Qualified Plans. Is this annuity part of a Tax Qualified Plan? ____ Yes ____No If yes, please select one of the following. ___IRA Transfer/Rollover ___403(b)TSA ___Regular Contribution for Tax Year________ ___Roth IRA ___401 (Corporate Plan) ___Roth IRA Conversion ___Other _______________ ______________________________________________________________________________ 7.PURCHASE PAYMENT ____Purchase Payment Enclosed with Application Purchase Payment Amount $_____________________ ____This contract will be funded by a 1035 Exchange, Tax Qualified Transfer/Rollover, CD or Mutual Fund Redemption. (If checked, please attach include the appropriate forms). ______________________________________________________________________________

Tax-Qualified Plans. Is this annuity part of a Tax Qualified Plan? ____ Yes ____No If yes, please select one of the following. ___IRA Transfer/Rollover ___403(b)TSA Roth IRA Conversion ___Regular IRA Contribution for Tax Year________ ___Roth IRA ___401 (Corporate Plan) ___Other _______________ ______________________________________________________________________________ 7.PURCHASE PAYMENT ____Purchase Payment Enclosed with Application Purchase Payment Amount $_____________________ ____This contract will be funded by a 1035 Exchange, Tax Qualified Transfer/Rollover, CD Transfer or Mutual Fund Redemption. (If Redemption.(If checked, please attach include the appropriate forms). ______________________________________________________________________________