Exhibit 5
THE TRAVELERS INSURANCE COMPANY [Graphic Omitted] PARTICIPATION AGREEMENT
Xxx Xxxxxxxxx
Xxxxxxxx, XX 00000-0000
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1. GENERAL INFORMATION
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o CHECK ALL THAT APPLY: [ ] New Participant [ ] Funding Transfer [ ] Increase [ ] Co-Plan [ ] Decrease
[ ] New Contract [ ] Allocation Change [ ] Step-up [ ] Re-Start [ ] Suspend
[ ] Add GMWB [ ] Data Change [ ] Beneficiary Change [ ] Catch-up [ ] Non-Insurance Services:_________
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o CHECK ONLY ONE: (NOTE: If multiple contribution sources (EE, EB, ER, and EN) are required, you cannot use this form.)
[ ] 403(b) Voluntary Education (E) [ ] 403(b) Voluntary Hospital/Healthcare (H)
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CITISTREET Plan Name: CITISTREET Plan #: [ ] [ ][ ][ ][ ][ ]
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Participant's Name:____________________________________________________________________________ U.S. Citizen [ ] Yes [ ]No
First M.I. Last
[ ] If existing participant, check here if new name (ATTACH PROOF OF NAME CHANGE; I.E., COPY OF MARRIAGE CERTIFICATE OR OTHER COURT
DOCUMENT)
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Social Security #: [ ][ ][ ]-[ ][ ]-[ ][ ][ ] Date of Birth: [ ][ ]-[ ][ ]-[ ][ ][ ][ ]
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M X X X X X X X
Xxxx Xxxxxxx: [ ] Check here if new address
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City: State: Zip: [ ] Single [ ] Married Sex: [ ] M [ ] F
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Home Phone: Work Phone:
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Department Name: Department #: Employee #:
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Date of Hire: Payroll Name/Cycle:
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[ ] Check here if change in TL&A Case #: Current [ ] [ ] [ ] [ ] [ ] [ ] Old [ ] [ ] [ ] [ ] [ ] [ ]
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2. BENEFICIARY DESIGNATION
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[X] Primary [ ] Check here if more than three (3) and attach additional sheets
Name: _______% [ ] Spouse / [ ] Non-Spouse SSN: _______ - ______ - ________
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[ ] Primary [ ] Contingent
Name: _______% [ ] Spouse / [ ] Non-Spouse SSN: _______ - ______ - ________
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[ ] Primary [ ] Contingent
Name: _______% [ ] Spouse / [ ] Non-Spouse SSN: _______ - ______ - ________
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3. PAYROLL INFORMATION
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Effective Date: Annual Salary: $
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Salary Reduction Per Pay: __________% OR $____________ X __________ Number of Pays = Annual Contributions: $
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Increase / Decrease: $ Skip Pays: Total Contributions: $
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Total Contribution Per Pay: $________ -- Normal $________ X ____ # of Pays = Total Catch/Step-up Per Year: $ _______________
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This page creates a legally binding contract with your employer if it accepts it as a salary-reduction agreement.
PARTICIPANT'S SIGNATURE: ______________________________________________________________ DATE: [ ] [ ] - [ ] [ ] - [ ] [ ] [ ] [ ]
M X X X X X X X
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X-00000 Employer (white) New Business (canary) Field Office (pink) Participant (goldenrod) USA (9/04) PAGE 1
[ ][ ]-[ ][ ]-[ ][ ][ ][ ] Social Security #: [ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ]
M M X X X X X X
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0 . XXXXXXXXXX DIRECTION
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CO-PLAN(SM) LIFE INSURANCE
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Check only one: [ ] NEW (YOU MUST ATTACH THE COMPLETED APPLICABLE FORMS)
[ ] EXISTING (APPLY TO EXISTING CONTRACT) Amount Per Pay: $ [ ][ ][ ].[ ][ ]
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FUND
CODE FUND NAME PERCENTAGE
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PF AllianceBernstein Premier Growth Port. - Class B
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US Capital Appreciation Fund (Janus)
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OB CitiStreet Diversified Bond Fund - Class I
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OI CitiStreet International Stock Fund - Class I
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OC CitiStreet Large Company Stock Fund - Class I
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OE CitiStreet Small Company Stock Fund - Class I
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AQ Delaware VIP REIT Series
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DI Dreyfus Stock Index Fund
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XX Xxxxxxx VIF Developing Leaders Portfolio
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FT Fidelity VIP Contrafund(R) Portfolio - SC 2
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FE Fidelity VIP Equity Income Port. - Initial Class
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FS Fidelity VIP Growth Portfolio - Initial Class
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D1 Fidelity VIP Mid Cap Port. - Service Class 2
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FA Fidelity VIP Asset Manager Port. - Init. Class
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R2 Franklin Mutual Shares Securities Fund - SC 2
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UW Franklin Small Cap Fund - Class 2
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XX Xxxxx Aspen Series Int'l Growth Port. - S. Shares
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1C Lazard International Stock Portfolio
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XX Xxxxxx Retirement Small Cap Portfolio
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DQ MFS Mid Cap Growth Portfolio
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HT MFS Total Return Portfolio
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BD MFS Value Portfolio
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PM PIMCO Total Return Portfolio
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UP Pioneer Fund Portfolio
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HP Pioneer Strategic Income Portfolio
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OP Xxxxxx VT Small Cap Value Fund Cl. IB Shares
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FUND
CODE FUND NAME PERCENTAGE
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AD Salomon Brothers Variable All Cap Fund-Class I
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C2 Salomon Bros. Variable Investors Fund - Class I
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XX Xxxxxxx Bros. Variable Small Cap Growth-Class I
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BI SB Adjustable Rate Income Portfolio
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SG Xxxxx Xxxxxx Aggressive Growth Portfolio
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XX Xxxxx Xxxxxx Appreciation Portfolio
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XX Xxxxx Barney Fundamental Value Portfolio
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AB Xxxxx Xxxxxx Large Cap Growth Portfolio
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SA Social Awareness Stock Portfolio (Xxxxx Xxxxxx)
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HA Strategic Equity Portfolio (Fidelity)
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VQ Xxxxxxxxx Dev. Markets Securities Fund-Class 2
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XX Xxxxxxxxx Foreign Securities Fund - Class 2
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IN Xxxxxxxxx Global Asset Allocation Fund - Class 1
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IS Xxxxxxxxx Growth Securities Fund - Class 1
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1M Travelers Disciplined Mid Cap Stock Portfolio
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A Travelers Growth and Income Stock Account
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UB Travelers High Yield Bond Trust
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UA Travelers Managed Assets Trust
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MM Travelers Money Market Account
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A1 Travelers Quality Bond Account
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GV Travelers U.S. Government Securities Portfolio
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X0 XXX Fixed Account
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NJ Xxx Xxxxxx LIT Xxxxxxxx Portfolio - Class II
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OTHER
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PERCENTAGES MUST BE IN INCREMENTS OF 1% AND THE TOTAL OF BOTH COLUMNS MUST EQUAL
100%
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5 . FUNDING TRANSFER
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PLEASE REFER TO FUND CODES ABOVE. TL&A Account #: [ ][ ][ ][ ][ ][ ][ ]
TRANSFER FROM TRANSFER TO
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[ ] FUND CODE MONEY TYPE % OR $ AMOUNT FUND CODE MONEY TYPE % OR $ AMOUNT
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% $ % $
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% $ % $
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% $ % $
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% $ % $
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% $ % $
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6. TELEPHONE TRANSFER AUTHORIZATION
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Telephone transfer capability is automatic for participant.
Do you authorize telephone transfer capability for your spouse? [ ] YES [ ] NO Name of Spouse:__________________________
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7. REPLACEMENT INFORMATION
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> Will the contract(s) applied for replace any existing annuity contract or life insurance policy on the
annuitant's life? [ ] YES [ ] NO
IF YES, please provide details: Insurance Co. Name: Contract Number:
> Do you have any existing life insurance policies or annuity contracts? [ ] YES [ ] NO
IF YES, please provide details: Insurance Co. Name:_____________________________ Contract Number: __________________________
> Will the purchase of this annuity result in the replacement, termination or change in value of any existing life insurance
policy or an annuity contract in this or any other company? [ ] YES [ ] NO
IF YES, please provide details: Attach any required state replacement and/or 1035 exchange/transfer forms, which may also be
required if there is an existing policy/contract and replacement is not involved. Ins. Co. Name: ___________________________
Contract Number:_________________________________
X-00000 XXX (9/04) PAGE 2
DISTRIBUTION RESTRICTION
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i understand that I can not take money out of a SS. 403(B) CONTRACT until I
reach age 59 1/2 or permanently leave employment from my public-school or
charitable-organization employer. If I have a financial hardship, I may take a
limited distribution from my salaryreduction contributions only (not from
investment earnings). I understand that I may transfer ss. 403(b) amounts within
a ss. 403(b) contract or to other ss. 403(b) contracts.
FRAUD WARNING
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IN SOME STATES WE ARE REQUIRED TO ADVISE YOU OF THE FOLLOWING: Any person who
knowingly intends to defraud or facilitates a fraud against an insurer by
submitting an application or filing a false claim, or makes an incomplete or
deceptive statement of a material fact, may be guilty of insurance fraud.
ARKANSAS, COLORADO, DISTRICT OF COLUMBIA, KENTUCKY, LOUISIANA, MAINE, NEW
MEXICO, OHIO AND VIRGINIA RESIDENTS ONLY: Any person who knowingly presents
false, fraudulent, incomplete or misleading information in a claim for payment
of a loss or benefit or in an application for insurance may be guilty of a crime
and subject to criminal and civil penalties and denial of benefits.
NEW JERSEY RESIDENTS ONLY: Any person who includes any false or misleading
information on an application for an insurance policy is subject to criminal and
civil penalties.
FOR PENNSYLVANIA RESIDENTS ONLY: Any person who knowingly and with intent to
defraud any insurance company or other person files an application for insurance
or statement of claim containing any materially false information or conceals
for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
TELEPHONE TRANSFER AUTHORIZATION - RULES AND REGULATIONS
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By signing this form, the contract owner and spouse (if authorized) have the
ability to execute the following transactions:
Transfer all or any part of accumulated variable annuity contract values to
a funding vehicle (hereafter referred to as an "investment alternative") of
the variable annuity contract.
Allocate all or any part of future contributions to the investment
alternative(s) of the variable annuity contract or to a fixed annuity
product.
I authorize The Travelers Insurance Company ["TL&A"] to accept and act upon
telephone instructions from me, my spouse (if authorized) or any person
purporting to be me or my spouse and who provides the identifying contract
information. I understand, promise and warrant that TL&A and all persons acting
on its behalf shall be indemnified, defended and held harmless by me against any
and all claims loss, liability, or demand of whatsoever nature to which said
insurance company its said employees, subcontractors or owners (collectively its
"agents") may be subject or put by reason of real or claimed damaged or injury
arising or resulting in whole or in part from negligence, wrongful act or
wrongful omission of said TL&A, or any of its "agents" so long as it or they
shall have acted in good faith in attempting to perform according to the terms
of this Telephone Transfer Authorization.
Contract Owners that authorize TL&A to accept telephone instructions for
transfers of Contract Values agree to such transfers subject to the following
provisions:
1. Telephone transfer instructions will be accepted between 9:00 a.m. and 4:00
p.m. Eastern Time by calling 0-000-000-0000 for out-of-state calls; or
0-000-000-0000 for Connecticut calls.
2. All callers must identify themselves by providing specific information about
their contract including: name, address, contract number, social security
number and date of birth.
3. Once instructions are accepted by the Telephone Transfer Unit, they may not
be rescinded. New telephone instructions may be given the following business
day.
4. All transfers must be in accordance with the terms of the Variable Annuity
Contract. If the transfer instructions are not in good order, TL&A will not
execute the transfer and will notify the caller before the end of the next
business day.
5. This authorization shall continue in force until TL&A receives written
revocation from the Contract Owner, the ownership of the contract is
transferred, the Annuitant or owner dies, or TL&A discontinues the
privilege.
Social Security #: [ ][ ][ ]-[ ][ ]-[ ][ ][ ][ ]
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8. DEATH BENEFIT SELECTION (BENEFICIARY PROTECTION)
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If the Owner or the Annuitant is age 75 or older, the Death Benefit will
automatically be equal to the greater of the adjusted purchase payment or
contract value.
IF THE OWNER AND THE ANNUITANT ARE CURRENTLY UNDER AGE 75, PLEASE SELECT ONE OF
THE FOLLOWING OPTIONS. If no option is checked, the Annual Step-up to age 65
will apply.
[ ] Annual Step-up to age 65 (NOT AVAILABLE IF EITHER OWNER OR ANNUITANT IS AGE
65 OR OLDER)
[ ] Annual Step-up to age 75 (NOT AVAILABLE IF EITHER OWNER OR ANNUITANT IS AGE
75 OR OLDER)
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9. PRINCIPAL GUARANTEE
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An optional Guaranteed Minimum Withdrawal Rider (AVAILABLE FOR AN ADDITIONAL
COST, NOT AVAILABLE IF ENROLLED IN THE CHART PROGRAM(R))
[ ] I wish to select the Guaranteed Minimum Withdrawal Rider (OWNER MUST BE AGE
55 OR OLDER)
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10. PARTICIPANT'S CERTIFICATION
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I understand that the contract will take effect when the first premium payment
is received, and the application is approved in the Home Office of TL&A. ALL
PAYMENTS AND VALUES PROVIDED BY THE CONTRACT APPLIED FOR, WHEN BASED ON
INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE IN NATURE AND ARE NOT
GUARANTEED AS TO A FIXED DOLLAR. No agent is authorized to make changes to the
contract or application.
By signing this form I confirm and acknowledge all of the following: If I
specified a salary-reduction contribution, my Employer may rely on this form as
my written instruction to reduce my salary or wages and creates a legally
binding Salary Reduction Agreement. If I am purchasing a TL&A fixed or variable
annuity contract, TL&A will rely on this form as an application and as part of
my written instructions. If I am purchasing a variable annuity contract, I
acknowledge having received a current prospectus. I have read and understand the
terms and conditions of the Distribution Restriction, Fraud Warning, and
Telephone-Transfer Rules contained in this form. I have received CitiStreet's
Privacy Notice, Notice of Business Continuity and Compensation Disclosure.
PARTICIPANT'S SIGNATURE: ____________________ DATE: [ ][ ]-[ ][ ]-[ ][ ][ ][ ]
M M D D Y Y Y Y
Application signed at (City and State): ____________________
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11. CITISTREET REPRESENTATIVE'S REPORT
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I acknowledge that all data representations and signatures recorded on pages 1
and 3 were recorded by me or in my presence in response to my inquiry and
request, and that all such representations and signatures are accurate and valid
to the best of my knowledge and belief.
To be signed personally by the representative(s) by whom the application was
solicited.
Will the contract(s) applied for replace any existing annuity contract or life
insurance policy on the Annuitant's life? [ ] Yes [ ] No
Representative's Name:___________________ Representative's Number: [ ][ ][ ][ ]
Print full name
Representative's Signature: _____________ Date: [ ][ ]-[ ][ ]-[ ][ ][ ][ ]
L-19060 M X X X X X X X
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
XXXXXXXX - XXXXXXXXXX INVESTMENT ADVISORY PROGRAMS
================================================================================
Before you complete the CFS CHART or CFS Tactical Adviser Program box below, you
must specify the Program in the space provided for "Non-Insurance Services" on
page 1 and the Program and percentage in the space provided for "Other" on page
2.
------------------------------------------------------------------------ --------------------------------------------------------
CFS CHART PROGRAM(R) CFS TACTICAL ADVISER PROGRAM
======================================================================== ========================================================
[graphic ALLOCATION: FUND: CHOOSE YOUR TACTICAL ASSET ALLOCATION STRATEGY
omitted] _________% International Stock (OI)
_________% Small Company Stock (OE) Check only one:
_________% Large Company Stock (OC) [ ] Growth Stock (GST) [ ] Aggressive Stock (AGS)
_________% Diversified Bond (OB) Strategy Change? [ ] Yes [ ] No
= 100 % TOTAL MUST EQUAL 100% Terminate Investment Advice? [ ] Yes* [ ] No
Are (were) you a Tactical Adviser Program client? [ ] Yes [ ] No *The balance of the Tactical Adviser Funds will be
Recommended Profile:__________ Selected Profile:__________ transferred to corresponding USA Funds. Your current
Profile Change? [ ] Yes [ ] No allocation will be changed to corresponding USA Funds,
Terminate Investment Advice? [ ] Yes [ ] No unless you indicate otherwise in the Funding Transfer.
------------------------------------------------------------------------ --------------------------------------------------------
This Addendum creates a legally binding contract. If you asked for CFS's CHART
Program(R) or Tactical Adviser investment advisory service, you received the
Program's Disclosure Statement and Investment Advisory Agreement (on the reverse
side of page 3 or 4, whichever applies), and you adopt the Investment Advisory
Agreement.
PARTICIPANT'S SIGNATURE: ______________________ DATE: [ ][ ]-[ ][ ]-[ ][ ][ ][ ]
M X X X X X X X
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XXX (9/04) PAGE 3
CFS / THE CHART PROGRAM(R): INVESTMENT ADVISORY AGREEMENT
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This Agreement applies CitiStreet Financial Services LLC's CHART Program to your
proportionate share in any Investment Contract(s) that you own or have a
beneficial interest in and to any Plan Account(s) that directly or indirectly
include(s) shares in the CitiStreet Funds. We'll rebalance and, following your
instructions, change your investment allocation among the CitiStreet Funds on a
periodic basis as provided in this Investment Advisory Agreement and the
Disclosure Statement.
Before you sign this Agreement, you should first read our Disclosure Statement,
which fully explains our CHART Program; the current Prospectus of the CitiStreet
Funds, which explains the investment portfolios to be used with our investment
advisory service; and the current Prospectus for the Investment Contract (if
any) you use. Everything in the Disclosure Statement and in each Prospectus is a
part of this Agreement. If you are still unsure about your decision to use our
CHART Program, ask your CitiStreet representative to explain it again.
Your CitiStreet representative can't make any recommendations or give investment
advice of any kind. Only CitiStreet Financial Services LLC gives investment
advice.
ABOUT OUR RECOMMENDATIONS - We use suitability questions (mostly about your
ability and willingness to tolerate investment risk) together with our
proprietary computer-based investment models to determine your risk Profile and
then to recommend an appropriate asset allocation for you. Please understand
that if you change your risk Profile or recommended investment allocation, it
must be your decision alone.
REBALANCING - According to a regular schedule, we'll rebalance your Program
Money among the CitiStreet Funds so that your investments will conform to your
most currently specified Profile or allocation, as described in the Disclosure
Statement.
PERIODIC REVIEWS - At least once each year, you should arrange to meet with us
for an annual review to see if your circumstances have changed or if you should
change your investment allocation. Also, you can make any change at any time.
IF YOU CHANGE YOUR MIND - You may cancel this Agreement at any time up to five
days after you sign it. To cancel, you must send written notice to our National
Office. (The address is on the Disclosure Statement.)
INVESTMENT TRANSFERS - While this Agreement is in effect, CFS has the right to
move your Program Money among all funds within your Plan Account or the
Investment Contract you own or use. We use this power on a non-discretionary
basis, as explained in the Disclosure Statement. Any power or duty of investment
direction is subject to the provisions of the Investment Contract and the
owner's rights.
NO GUARANTEE - CFS can't guarantee that your investment goals will be met.
WHAT THE ISSUER DOES - The Issuer will make transfers within the separate
account of the Investment Contract that holds shares of the CitiStreet Funds
upon the instructions of CFS. The Issuer isn't liable in any way as long as it
properly executes investment transfers on CFS' instructions.
FEES - Our advisory fee (as explained in our Disclosure Statement) is deducted
from the cash value of the Investment Contract. The fee is deducted prorata from
your CitiStreet Funds. CFS can't increase any fee unless we give you written
notice. CFS won't be compensated on the basis of a share of capital gains upon
or capital appreciation of the Funds or all or any portion of your Program
Money, except as permitted by applicable law.
All fees are withdrawn from the Investment Contract you own or that is held for
your Plan Account (or fees are deducted from your Plan Account), and this
Agreement authorizes those withdrawals or payments. The Issuer (or the Plan
Trustee) pays the fees directly to CFS, and you won't have any other obligation
to pay our fees.
NEW DISCLOSURE STATEMENT - At any time, upon your request to our National
Office, CFS will send you (at no charge) our most recent Disclosure Statement
(at no charge).
CHANGES - CFS can change this Agreement at any time; but the change isn't
binding on you until 30 days after we send written notice to you. Any notice is
properly sent if sent to your address on our records. Failure to insist on
strict compliance with any terms of this Agreement won't be a waiver of our
rights. To the extent required by applicable law, CFS can't assign or sell or
give your Agreement to a business other than CFS without your consent.
HOW YOU CAN END THIS AGREEMENT - This Agreement continues until you take
positive action to inform CFS that you no longer want our investment advice. You
must take one of the steps explained in the Disclosure Statement. Ending this
Agreement won't change the investment; it only stops our right to make changes
for you. After you leave the Program, you must give your own investment
instructions, and make all your investment decisions without our advice.
YOUR LEGAL RIGHTS - This Agreement is governed by the laws of the State where
you live. If you do not live in the United States of America, this Agreement is
governed by the laws of the State of New York, and you agree to exclusive
jurisdiction and venue in the federal and state courts sitting at New York City.
================================================================================
CITISTREET PARTICIPANT SUITABILITY / PROFILE
RETIREMENT PLAN TYPE: [ ] 403(B) [ ] 457(B) [ ] 401(A) [ ] 401(K) [ ] [ ] XXX DATE _______ /_______ /_______
XXX APPOINTMENT TYPE: [ ] NEW [ ] BTC [ ] FPR PFP [ ] CHART ANNUAL REVIEW APPOINTMENT LOCATION: [ ] HOME [ ] WORK
[ ] TACTICAL ADVISER ANNUAL REVIEW
PERSONAL INFORMATION:
NAME ________________________________________________________ MARITAL STATUS___________ SPOUSE NAME____________________
NAME SSN(ITIN) _________________ US CITIZENSHIP [ ]Yes [ ] No SPOUSE SALARY ____________OTHER INCOME___________________
DATE OF BIRTH _____________________ HOME PHONE_______________ DEPENDENTS/CHILDREN (NAME/AGE)
EMPLOYER_____________________________________________________ 1. ______________/_______ 5. __________________/_________
POSITION_____________________________________________________ 2. ______________/_______ 6. __________________/_________
WORK PHONE____________________ YOUR SALARY___________________ 3. ______________/_______ 7. __________________/_________
TOTAL ANNUAL INCOME ________________ DOE____________________ 4. ______________/_______ 8. __________________/_________
================================================================================
RISK TOLERANCE INVESTMENT EXPERIENCE OBJECTIVES FINANCIAL CONCERNS INVESTMENT
CHOOSE ONE EXPERIENCE RANK YOUR INVESTMENT OBJECTIVES I AM INTERESTED IN SAVING FOR: TIME HORIZON
1-4(1=HIGHEST PRIORITY)
[ ] LOW RISK [ ] A 0 YEARS [ ] GROWTH [ ] MY RETIREMENT-DESIRED [ ] A 0 YEARS
(CONSERVATIVE) [ ] B 1-5 YEARS [ ] TAX DEFERRAL [ ] RETIREMENT AGE________ [ ] B 1-5 YEARS
[ ] C 6-10 YEARS [ ] SAFETY OF PRINCIPAL [ ] EDUCATION [ ] SECONDARY [ ] HIGHER [ ] C 6-10 YEARS
[ ] MODERATE RISK [ ] D 11-20 YEARS [ ] CURRENT INCOME [ ] HAVING ADEQUATE PROTECTION [ ] D 11-20 YEARS
[ ] HIGH RISK [ ] E 20+ YEARS [ ] OTHER [ ] E 20+ YEARS
(AGGRESSIVE)
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ARE YOUR CURRENT OBLIGATIONS RESTRICTING YOUR ABILITY TO SAVE? [ ] YES [ ] NO
WILL YOUR RETIREMENT BENEFITS MEET YOUR NEEDS? YES [ ] NO [ ]
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RETIREMENT ACCOUNTS LONG-TERM ACCOUNTS EDUCATIONAL/ SHORT-TERM ACCOUNTS
TYPE AMOUNT TYPE AMOUNT COLLEGE SAVINGS ACCOUNTS TYPE AMOUNT
EMPLOYER ____________ MUTUAL FUNDS ____________ TYPE AMOUNT CHECKING ____________
PRIOR PLAN ____________ STOCKS ____________ 529 PLAN ____________ SAVINGS ____________
TRAD'L XXX ____________ BONDS ____________ UGMA/UTMA ____________ MONEY MKT ____________
XXXX XXX ____________ ANNUITY ____________ EDUCATIONAL XXX ____________ CD ____________
TOTAL ____________ TOTAL ____________ TOTAL ____________ TOTAL ____________
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SOURCE OF FUNDS TO BE INVESTED
[ ] SALARY REDUCTION [ ] CURRENT INCOME/SAVINGS LIQUID NET WORTH TOTAL NET WORTH FEDERAL TAX BRACKET
[ ] 1035 TAX-FREE EXCHANGE [ ] XXX ROLLOVER [ ] A [ ]B [ ] A [ ]B [ ] A 0-15%
[ ] MUTUAL FUND REDEMPTION [ ] INSURANCE PROCEEDS [ ] C [ ]D [ ] C [ ]D [ ] B 16-30%
[ ] QUALIFIED PLAN DISTRIBUTION [ ] OTHER (SPECIFY)_______________ [ ] E [ ]F [ ] E [ ]F [ ] C 31-33%
[ ] G [ ]H [ ] G [ ]H [ ] D 34% OR OVER
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Use These Financial Data Ranges to complete A. LESS THAN $25,000 B. $25,001-$50,000 C. $50,001-$100,000 D. $100,001-$250,000
liquid net worth and total net worth E. $250,001-$500,000 F. $500,001-$750,000 G. $750,001-$1,000,000 H. GREATER THAN
$1,000,000
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ARE YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY AFFILIATED WITH I ALSO UNDERSTAND THAT AN ANNUITY OR LIFE INSURANCE CONTRACT
OR EMPLOYED BY A MEMBER OF THE NATIONAL ASSOCIATION OF MAY IMPOSE ITS OWN CHARGES ON A PRE-RETIREMENT DISTRIBUTION,
SECURITIES DEALERS? [ ] YES [ ] NO TRANSFER OR PAYMENT. KNOWING THIS INFORMATION, I AM
IF YES, NAME AND ADDRESS OF FIRM _______________________________ COMFORTABLE WITH THE AMOUNT I HAVE CHOSEN TO CONTRIBUTE.
[ ] I PREFER NOT TO FURNISH INFORMATION ABOUT MYSELF, AND CHART PROGRAM(R) PARTICIPANTS (CHECK IF APPLICABLE)
THEREFORE I UNDERSTAND THAT CITISTREET CAN'T MAKE ANY
INVESTMENT SUGGESTION. AFTER DISCUSSING MY CURRENT NEEDS WITH MY FINANCIAL COUNSELOR
AND REVIEWING MY ANSWERS TO THE CHART PROFILE QU
[ ] I HAVE NOT FURNISHED INFORMATION ON THIS FORM BECAUSE MY WOULD LIKE TO:
FINANCIAL COUNSELOR PRESENTED A PERSONAL FINANCIAL PLAN FOR
ME IN THE LAST 30 DAYS. [ ] KEEP MY PROFILE THE SAME.
RETIREMENT SAVINGS PLAN OR ARRANGEMENT (CHECK IF APPLICABLE) [ ] CHANGE MY PROFILE AS INDICATED ON THE ACCOMPANYING
INVESTMENT ADVISORY AGREEMENT. (NOTE: CHANGE CAN
[ ] I UNDERSTAND THAT A RETIREMENT PLAN OR ARRANGEMENT USUALLY WITHOUT AN INVESTMENT ADVISORY AGREEMENT).
HAS RESTRICTIONS ON WHEN I MAY WITHDRAW MONEY AND THAT A
PAYMENT BEFORE I AM AGE 59 1/2 (OTHER THAN UNDER A SS.457
PLAN) MIGHT INCUR AN ADDITIONAL 10% PENALTY TAX.
ADDITIONAL NOTES____________________________________________________________________________________________
____________________________________________________________________________________________________________
NEXT APPOINTMENT: DATE ______________________ TIME _______________________________ PLACE ___________________
TOPICS________________________________________
SIGNATURES: PARTICIPANT _____________ DATE ________ CITISTREET FINANCIAL COUNSELOR _____________ FC# _______
5-P115-FRM(9/04)jk #00-00-000
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CFS / TACTICAL ADVISER PROGRAM: INVESTMENT ADVISORY AGREEMENT
--------------------------------------------------------------------------------
Before you can understand this Agreement, YOU MUST FIRST READ THE DISCLOSURE
STATEMENT, which fully explains our Tactical Adviser Program, and each current
Prospectus, which explain the Investment Contract and the Program Funds.
Everything in the Disclosure Statement and in each Prospectus is a part of this
Agreement. If any of this makes you unsure about your decision to buy Tactical
Adviser, ask your CitiStreet representative for further explanation.
PROGRAM MONEY TRANSFERS - While this Agreement is in effect, CFS has the right
to move your Program Money between the Program Funds used for the Strategy you
requested. CFS will use this power solely to implement the Subadviser's transfer
signal. CFS will not have any discretion to vary or delay CFS' implementation of
the Subadviser's signal.
PERIODIC REVIEWS - At least once each year, you should arrange to meet with us
for an annual review to see if your circumstances have changed or whether your
Strategy remains desirable for you. Also, you can make any change at any time.
IF YOU CHANGE YOUR MIND - You may cancel this Agreement at any time up to five
days after you sign it. To cancel, you must send written notice to our National
Office. (The address is on the Disclosure Statement.)
NO GUARANTEE - CFS can't guarantee that your investment goals or any Strategy's
goals will be met.
WHAT THE ISSUER DOES - The Issuer will make transfers within the Investment
Contract that holds shares solely on the instruction of CFS. The Issuer isn't
liable in any way as long as it properly executes investment transfers on CFS'
instructions.
FEES - Our advisory fee (as explained in our Disclosure Statement) is deducted
from the unit value of each Program Fund. The Issuer then pays the fee directly
to CFS. CFS won't be compensated on the basis of a share of capital gains on or
capital appreciation of the Funds or all or any portion of your Program Money,
except as permitted by applicable law.
NEW DISCLOSURE STATEMENT - At any time, on your request to our National Office,
CFS will send you (at no charge) our most recent Disclosure Statement.
CHANGES - CFS can change this Agreement at any time; but the change isn't
binding on you until 30 days after we send written notice to you. Any notice is
properly sent if sent to your address on our records. Failure to insist on
strict compliance with any terms of this Agreement won't be a waiver of our
rights. To the extent required by applicable law, CFS can't assign or sell or
give your Agreement to a business other than CFS without your consent.
HOW YOU CAN END THIS AGREEMENT - This Agreement continues until you take
positive action to inform CFS that you no longer want our investment advice. You
must take one of the steps explained in the Disclosure Statement. When you leave
the Program, you must specify your investment direction for your Program Money
and for any contributions that otherwise would be directed to the Program Funds.
If you don't specify your investment direction, CFS will transfer your Program
Money and redirect your future contributions as explained in the Disclosure
Statement. After you leave the Program, you must give your own investment
instructions, and make all your investment decisions without our advice.
YOUR LEGAL RIGHTS - This Agreement is governed by the laws of the State where
you live. If you do not live in the United States of America, this Agreement is
governed by the laws of the State of New York, and you agree to exclusive
jurisdiction and venue in the federal and state courts sitting at New York City.
