EXHIBIT 99.14
XXX Custodial Agreement
Form 5305-A
This Agreement is made between the individual who signs the Park Avenue
Portfolio XXX Application (the Depositor) and State Street Bank and Trust
Company (the Custodian), c/o National Financial Data Services, X.X. Xxx 000000,
Xxxxxx Xxxx, XX 00000-0000. By executing the XXX Application, the Depositor
establishes an Individual Retirement Account as described in Section 408(a) of
the Internal Revenue Code of 1986 (the Code), in order to provide for his or her
retirement or to provide for income for his or her beneficiary after death.
The provisions of Articles I to VII of this Agreement are in the form
promulgated by the Internal Revenue Service in Form 5305-A for use in
establishing an Individual Retirement Custodial Account. Article VIII contains
additional provisions.
Article I.
The Custodian may accept additional cash contributions on behalf of the
Depositor for a tax year of the Depositor. The total cash contributions are
limited to $2,000 for the tax year unless the contribution is a rollover
contribution described in Section 402(c) (but only after December 31, 1992),
403(a)(4), 403(b)(8), 408(d)(3), or an employer contribution to a simplified
employee pension plan as described in Section 408(k). Rollover contributions
before January 1, 1993 include rollovers described in Section 402(a)(5),
402(a)(6), 402(a)(7), 403(a)(4), 403(b)(8) or 408(d)(3) of the Code or an
employer contribution to a simplified employee pension plan as described in
Section 408(k).
Article II.
The Depositor's interest in the balance in the custodial account is
nonforfeitable.
Article III.
1. No part of the custodial funds may be invested in life insurance contacts,
nor may the assets of the custodial account be commingled with other property
except in a common trust fund or common investment fund (within the meaning of
Section 408(a)(5) of the Code).
11
2. No part of the custodial funds may be invested in collectibles (within the
meaning of Section 408(m) except as otherwise permitted by Section 408(m)(3)
which provides an exception for certain gold and silver coins and coins issued
under the laws of any state.
Article IV.
1. Notwithstanding any provisions of this Agreement to the contrary, the
distribution of the Depositors interest in the custodial account shall be made
in accordance with the following requirements and shall otherwise comply with
Section 408(a)(6) and Proposed Regulations Section 1.408-8, including the
incidental death benefit provisions of Proposed Regulations Section
1.401(a)(9)-2, the provisions of which are incorporated by reference.
2. Unless otherwise elected by the time distributions are required to begin to
the Depositor under paragraph 3, or to the surviving spouse under paragraph 4,
other than in the case of a life annuity, life expectancies shall be
recalculated annually. Such election shall be irrevocable as to the Depositor
and the sun-wing spouse and shall apply to all subsequent years. The life
expectancy of a nonspouse beneficiary may not be recalculated.
3. The Depositor's entire interest in the custodial account must be, or begin to
be, distributed by the Depositor's required beginning date, the April 1
following the calendar year end in which the Depositor reaches age 70 1/2. By
that date, the Depositor may elect, in a manner acceptable to the Custodian, to
have the balance in the custodial account distributed in:
(a) A single-sum payment.
(b) An annuity contract that provides equal or substantially equal
monthly, quarterly, or annual payments over the life of the
Depositor.
(c) An annuity contract that provides equal or substantially equal
monthly, quarterly, or annual payments over the joint and Last
survivor lives of the Depositor and his or her designated
beneficiary.
(d) Equal or substantially equal annual payments over a specified period
that may not be longer than the Depositor's life expectancy.
(e) Equal or substantially equal annual payments over a specified period
that may not be longer than the joint life and last survivor
expectancy of the Depositor and his or her designated beneficiary.
4. If the Depositor dies before his or her entire interest is distributed to him
or her, the entire remaining interest will be distributed as follows:
(a) If the Depositor dies on or after distribution of his or her
interest has begun, distribution must continue to be made in
accordance with paragraph 3.
(b) If the Depositor dies before distribution of his or her interest has
begun, the entire remaining interest will, at the election of the
Depositor or, if the Depositor has not so elected, at the election
of the beneficiary or beneficiaries, either
(i) Be distributed by the December 31 of the year containing the
fifth anniversary of the Depositor's death, or
(ii) Be distributed in equal or substantially equal payments over
the life or life expectancy of the designated beneficiary or
beneficiaries starting by December 31 of the year following
the year of the Depositor's death. If, however, the
beneficiary is the Depositor's surviving spouse, then this
distribution is not required to begin before December 31 of
the year in which the Depositor would have turned age 70 1/2.
(c) Except where distribution in the form of an annuity meeting the
requirements of Section 408(b)(3) and its related regulations has
irrevocably commenced, distributions are treated as having begun on
the Depositor's required beginning date, even though payments may
actually have been made before that date.
(d) If the Depositor dies before his or her entire interest has been
distributed and if the beneficiary is other than the surviving
spouse, no additional cash contributions or rollover contributions
may be accepted in the account.
5. In the case of distribution over life expectancy
12 & 13
in equal or substantially equal annual payments, to determine the minimum annual
payment for each year, divide the Depositors entire interest in the Custodial
account as of the close of business on December 31 of the preceding year by the
life expectancy of the Depositor (or the joint life and last survivor expectancy
of the Depositor and the Depositor's designated beneficiary, or the life
expectancy of the designated beneficiary, whichever applies.) In the case of
distributions under paragraph 3, determine the initial life expectancy (or joint
life and last survivor expectancy) using the attained ages of the Depositor and
designated beneficiary as of their birthdays in the year the Depositor reaches
age 70 1/2. In the case of a distribution in accordance with paragraph 4(b)(ii),
determine life expectancy using the attained age of the designated beneficiary
as of the beneficiary's birthday in the year distributions are required to
commence.
"6. The owner of two" or more individual retirement accounts may use the
alternative method described in Notice 88-38, 1988-1 C.B. 524, to satisfy the
minimum distribution requirements described above. This method permits an
individual to satisfy these requirements by taking from one individual
retirement account the amount required to satisfy the requirement for another.
Article V.
1. The Depositor agrees to provide the Custodian with information necessary for
the Custodian to prepare any reports required under Section 408(i) and
Regulations Sections 1.408-5 and 1.408-6.
2. The Custodian agrees to submit reports to the Internal Revenue Service and
the Depositor as prescribed by the Internal Revenue Service.
Article VI.
Notwithstanding any other Articles which may be added or incorporated, the
provisions of Articles I through III and this sentence will be controlling. Any
additional articles that are not consistent with Section 408(a) and the related
regulations will be invalid.
Article VII.
This Agreement will be amended from time to time to comply with the provisions
of the Code and related regulations. Other amendments may be made with the
consent of the persons whose signatures appear on the XXX Application Form.
Article VIII
1. The Custodian shall invest the amount of each contribution in shares of the
series fund(s) comprising The Park Avenue Portfolio which are designated In the
XXX Application Form filed by the Depositor with the Custodian and any later
written instructions from the Depositor at the price and in the manner in which
such shares are then being publicly offered in accordance with the then current
prospectus for The Park Avenue Portfolio, and shall credit such shares to the
custodial account. Investments shall be held in the name of the Custodian for
the benefit of the Depositor. The Depositor agrees that the choice of
investments made for the custodial account is in the sole discretion of the
Depositor, and that the Custodian does not undertake to render any investment
advice whatsoever to the Depositor. All dividends and capital gains
distributions received on the shares of any Portfolio Fund then held in the
custodial account shall be reinvested in such shares at net asset value in
accordance with the then current prospectus for The Park Avenue Portfolio, and
credited to the custodial account. If any distribution of a Portfolio Fund may
be received at the election of the stockholder in additional shares or in cash
or other property, the Custodian shall elect to receive is in additional shares.
A receipt for each contribution received and each reinvestment showing the
investment or reinvestment and current status of the custodial account
immediately thereafter shall be prepared by the Custodian and promptly delivered
to the Depositor. The Custodian shall not be liable for interest on any cash
balance in the custodial account. Any charges attributable to the acquisition of
shares shall be charged to the custodial account. With respect to a rollover
contribution described in Article I of the Agreement, the Custodian shall not
accept any such contribution unless it is made (i) in cash, or (ii) in shares of
a series of The Park Avenue Portfolio maintained as an investment hereunder.
2. The Custodian shall forward to the Depositor all notices, prospectuses,
financial statements, proxies and proxy soliciting material relating to the
shares of any Portfolio Fund held in the custodial account. The Custodian shall
not vote any of the shares of
14 & 15
any Portfolio Fund held in the custodial account except in accordance with the
written instructions of the Depositor.
3. The Custodian shall, from time to time, on the instructions in writing of the
Depositor, and subject to the provisions of Articles IV and V as amended and
supplemented by this paragraph, make distributions our of the custodial account,
in such manner and amounts as may be specified in such instructions. All such
instructions shall be deemed to constitute a certification by the Depositor that
the distribution so directed is one that is permitted. A declaration of the
Depositor's intention as to the disposition of an amount distributed pursuant to
Article V hereof shall be in writing and given to the Custodian within such
period, not to exceed 30 days prior to such distribution, as the Custodian may
require.
4. By written notice to the Custodian, the Depositor may designate or change the
beneficiary or beneficiaries to receive any benefit payable by reason of the
Depositor's death or the death of his or her surviving spouse before the
Depositor's entire interest in the custodial account has been distributed. In
the absence of a designated beneficiary, the Depositor's estate shall be the
beneficiary.
5. The Depositor shall be charged by the Custodian for its services under this
Agreement in accordance with its current fee schedule. If the Custodian's fees
are nor otherwise paid to it, the Custodian may pay them to itself from the
custodial account by redeeming shares of the Portfolio Fund(s) held in the
custodial account having a value equal to such unpaid fees. The Custodian may
substitute a different fee schedule at any time upon 30 days written notice to
the Depositor.
6. Any income or other taxes of any kind whatsoever that may be levied or
assessed upon or in respect of the custodial account or the income thereof, any
transfer taxes incurred in connection with the investment and reinvestment of
the assets of the custodial account, and all other reasonable administrative
expenses incurred by the Custodian in the performance of its duties hereunder,
including fees for legal services rendered to the Custodian, may, in the
discretion of the Custodian, be charged against and paid from the custodial
account by redeeming shares of the Portfolio Fund(s) held in the custodial
account having a value equal to such taxes or expenses.
7. The Depositor at any time may remove the Custodian upon 30 days written
notice to that effect delivered to the Custodian, which notice shall also
designate a successor custodian. The successor custodian shall satisfy the
requirements of Section 408(h) of the Code, in that it shall be a bank (as
defined in Section 401(d) of the Code) or other person who demonstrates, to the
satisfaction of the Secretary of the Treasury or his delegate, that the manner
in which he or the will hold the assets of the custodial account will be
consistent with the requirements of Section 408 of the Code. Upon receipt by the
Custodian of written acceptance of such appointment by the successor custodian,
the removal of the Custodian shall be effective, and the Custodian shall
forthwith transfer and pay over to such successor custodian the assets of the
custodial account and all records pertaining thereto. The Custodian may, before
transferring the assets of the custodial account to a successor custodian,
withhold its unpaid compensation, fees or expenses and provide for the payment
of all other liabilities which are a charge on or against the assets of the
custodial account or on or against the Custodian. Where necessary, the Custodian
may reserve and redeem Portfolio Fund shares for these purposes. Any balance of
such reserve remaining after the payment of all such items shall be paid over to
the successor custodian.
8. The Custodian may at any time resign as Custodian under this Agreement, upon
30 days written notice to that effect delivered to the Depositor. Upon receiving
such notice of resignation, the Depositor shall forthwith appoint a successor
custodian which satisfies the requirements of Section 408(h) of the Code. Upon
receipt of the Custodian of written acceptance by the successor custodian of
such appointment, the Custodian is authorized to act in the same manner as
provided for in paragraph 7 of this Article as regards the transfer of assets to
the successor custodian and the payment of the items referred to therein. In the
event the Depositor fails to appoint a successor custodian which has accepted
its appointment within 30 days after the Custodian's notice of resignation the
Custodian shall appoint a successor custodian which satisfies the requirements
of Section 408(h) of the Code. Such appointment shall be made in good faith with
reasonable care and shall not make the Custodian liable for any acts or
omissions of its successor(s).
9. The provisions of this Agreement shall apply to
17 & 18
any successor custodian from the effective date of its appointment as such with
the same force and effect as if such successor was the initial custodian
hereunder.
10. The Depositor may at any time and from time to time modify or amend this
Agreement in whole or in part (including retroactive amendments) by delivering
to the Custodian a signed written copy of such modification or amendment. The
Depositor delegates to the Custodian the right to amend the Agreement from time
to time (including retroactive amendments) by written notice to the Depositor,
and the Depositor shall be deemed to have consented to any such amendment.
However, no amendment by the Depositor which increases the duties or obligations
of the Custodian shall be effective unless agreed to in writing by the
Custodian, no amendment by the Depositor or Custodian shall cause or permit any
part of the assets of the custodial account to be diverted to purposes other
than for the exclusive benefit of the Depositor or his or her beneficiaries, and
no such amendment shall be made which would disqualify this Agreement from
complying with Section 408 of the Code or be made except in accordance with any
applicable laws and regulations affecting this Agreement.
11. The Depositor may terminate the custodial account at any time, by delivering
to the Custodian, a signed notice of termination. Upon such termination, and
subject to a reservation of assets in the same manner as provided for in
paragraph 7 of this Article, any and all assets remaining in the custodial
account as of the date of termination shall be distributed to the Depositor, in
cash or in kind as directed by the Depositor (or in the absence of such
direction as determined by the Custodian). This Agreement shall be terminated
upon the complete distribution of the custodial account
12. If, because of an erroneous assumption as to earned income or for any other
reason, a contribution which is an excess contribution within the meaning of
Section 408(d)(4) of the Code is made on behalf of the Depositor for any year,
adjustment of such excess contribution shall be made by the distribution in cash
or in kind to the Depositor, upon written notice so the Custodian from the
Depositor which states the amount of such excess contribution and any net income
attributable thereto. The Custodian shall not be responsible for computing the
amount of any excess contribution and any net income attributable thereto.
13. The Custodian shall not be responsible for the purpose or propriety of any
distribution made pursuant hereto. The Custodian may conclusively rely upon, be
entitled to assume the truth of and be protected in acting upon any written
statement, order, direction, notice, instruction or other written instrument of
or received from the Depositor in connection with this Agreement and believed by
the Custodian so be genuine and to have been properly executed, and shall, so
long as it acts in good faith, have no liability in taking or omitting to sake
any action based thereon. The Custodian shall be under no duty or inquiry with
respect so any such writing, but in its discretion may request any tax waivers,
proof of signatures or other evidence which it reasonably deems necessary for
its protection. The Depositor and the successors of the Depositor, as
appropriate, including any executor or administrator of the Depositor, shall, to
the extent permitted by law, indemnify against and save harmless the Custodian
and its successors and assigns from any and all claims, actions or liabilities
of the Custodian to the Depositor or the successor of the Depositor whatsoever
(including all reasonable expenses incurred in defending against any of the
foregoing which may arise in connection herewith, except such as arise from the
Custodian's own bad faith, gross negligence or willful misconduct). The
Custodian shall not be under any duty to take any action other than as herein
specified wish respect hereto, unless the Depositor shall furnish it with
instructions in proper form and such instructions shall have been specifically
agreed to by the Custodian or to defend or engage in any suit with respect
hereto unless it shall have first agreed in writing to do so and shall have been
fully indemnified to its satisfaction.
14. No interest, right or claim in or to any part of the custodial account, nor
any assess held therein or benefits provided hereunder shall be subject to
alienation, assignment, transfer, sale, mortgage, pledge, hypothecation,
commutation, anticipation, garnishment, attachment, execution or levy of any
kind, and any attempt so cause any such interest right, claim, assess or benefit
to be so subjected shall not be recognized, except to the extent as may be
required by law.
15. The Custodian is authorized to hire an agent to perform certain of its
duties hereunder, which agent may be the transfer agent for The Park Avenue
Portfolio series fund shares authorized so be held hereunder.
18 & 19
16. Any notice required or permitted to be given to the Custodian shall be
effective if mailed by registered or certified mail to the Custodian c/o
National Financial Data Services, 0000 Xxxxxxxxx Xxxxxx, Xxxxxx Xxxx, XX
00000-0000, or such other address as the Custodian shall provide so the
Depositor from time to time. Any notice required or permitted to be given by the
Custodian shall be effective if mailed so the Depositor as the Depositor's last
address or record provided so the Custodian, or, as the case may be, to the
successor of the Depositor at the successor's last address of record provided to
the Custodian.
17. Words in the masculine include feminine, the singular includes the plural,
and vice versa, unless qualified by the context.
18. This Agreement and the custodial account shall be governed by and construed,
administered and enforced according to the laws of the State of Massachusetts.
RETAIN THIS ENTIRE BOOKLET
FOR YOUR RECORDS
20
---------------------------------
The Park Avenue Portfolio
XXX APPLICATION
---------------------------------
Instructions: Use this form to open a new Park Avenue Portfolio XXX. You should
also complete an XXX TRANSFER FORM if you are transferring assets from your
current XXX to open your account. If you are opening more than one account,
complete a separate XXX APPLICATION for each. QUESTIONS? CALL 0-000-000-0000,
OPTION 5.
PLEASE
PRINT
CLEARLY
================================================================================
Mail this form to:
The Park Avenue Portfolio, National Financial Data Services, X.X. Xxx 000000,
Xxxxxx Xxxx, XX 00000-0000
For certified, registered or over-night mail:
The Park Avenue Portfolio, National Financial Data Services, 0000 Xxxxxxxxx
Xxxxxx, Xxx. XX-00, Xxxxxx Xxxx, XX 00000-0000
GISC Registered Representatives only, mail to:
The Park Avenue Portfolio, Guardian Investor Services Corporation, 0000 Xxxxxxx
Xxxxx, Xxx. 00, Xxxxxxxxx, XX 00000
================================================================================
=============================
1
Owner
Information
=============================
================================================================================
-------------------------------------- ---------------------------------------
Name: First Middle Initial Last Social Security Number Date of Birth
-------------------------------------- ---------------------------------------
Street Address or P.O. Box Daytime Phone Number
--------------------------------------
City State Zip
================================================================================
=============================
2
Beneficiary
Designations
=============================
[ILLEGIBLE] beneficiary
[ILLEGIBLE] distributions
[ILLEGIBLE] if there is no
[ILLEGIBLE] Primary
[ILLEGIBLE].
================================================================================
|_| Primary Beneficiary |_| Secondary Beneficiary
-------------------------------------- ---------------------------------------
Name: First Middle Initial Last Name: First Middle Initial Last
-------------------------------------- ---------------------------------------
Relationship Relationship
-------------------------------------- ---------------------------------------
Social Security Number Date of Birth Social Security Number Date of Birth
================================================================================
=============================
3
Type of XXX Account
=============================
[ILLEGIBLE] indicate
[ILLEGIBLE] type of account
[ILLEGIBLE] opening. Each
[ILLEGIBLE] explained in
[ILLEGIBLE] accompanying XXX
[ILLEGIBLE] Statement.
================================================================================
|_| REGULAR CONTRIBUTION
SPOUSAL XXX: Spouse's Name ______________ Social Security Number _______________
Date of Birth ______________
If you are opening a Regular Contribution XXX or Spousal XXX, enclose a check
payable to "The Park Avenue Portfolio."(R)
|_| TRANSFER XXX. Please also complete the separate XXX TRANSFER FORM.
|_| SEP-XXX |_| TRANSFER SEP-XXX. Please also complete the separate XXX
TRANSFER FORM.
|_| ROLLOVER XXX. Please indicate the source of your contribution:
|_| A distribution paid so me from: |_| My contribution is a:
1 |_| Another regular (or annual) 4 |_| Direct rollover of an
contribution XXX or Spousal eligible distribution from a
XXX tax-qualified retirement plan
2 |_| Another XXX where the 5 |_| Direct rollover of an
initial contribution was eligible distribution from a
from a tax-qualified tax-sheltered annuity
retirement plan
3 |_| A tax-qualified retirement
plan
If you checked boxes 1, 2 or 3, enclose a check payable to "The Park Avenue
Portfolio."(*)
If you checked boxes 4 or 5, the plan administrator or tax-sheltered annuity
sponsor should deliver your contribution to "The Park Avenue Portfolio."(*)
*The fee to open an account ($15.00) will be taken from your contribution if not
submitted separately.
================================================================================
=============================
4
Investment
Transactions
=============================
[ILLEGIBLE] indicate the
[ILLEGIBLE] of the
[ILLEGIBLE] Fund(s) in
[ILLEGIBLE] your XXX is to
[ILLEGIBLE]. Each Fund
[ILLEGIBLE] in the
[ILLEGIBLE] for The
[ILLEGIBLE] Avenue Portfolio.
================================================================================
The minimum investment to open an XXX account is $300 per Portfolio Fund. The
minimum subsequent investment is $50 per Portfolio Fund.
Fund Name Tax Year Deductible Amounts Non-Deductible Amounts
Guardian Park Avenue Fund ..... 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Xxxxxxx Xxxxxxx
International Fund ........... 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Asset Allocation Fund 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Investment Quality
Bond Fund .................... 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian U.S. Government
Securities Fund .............. 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Tax-Exempt Fund ...... 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Cash Management Fund.. 19 $ or % $ or %
-------- ----- ---- ----- ----
Please complete other side.
=============================
5
Telephone
Exchanges
=============================
================================================================================
You will NOT receive the Telephone Exchange Privilege unless you check the box
below.
|_| YES. I want Telephone Exchange Privileges and understand that anyone who
supplies the required account information to NFDS can make telephone
exchanges on my behalf.
================================================================================
=============================
6
Letter
of Intent
=============================
I intend so make sufficient investments in the Portfolio Funds (except The
Guardian Cash Management Fund) over a period of 13 months to receive a reduced
sales load based on my aggregate investments. The applicable break-point for my
intended aggregate investment is:
|_| $100,000 |_| $250,000 |_| $500,000 |_| $1,000,000 |_| $2,500,000
|_| $5,000,000
|_| I am already investing under a Letter of Intent. Existing Account
Number __________________________________
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=============================
7
Automatic Investment Plan
=============================
[ILLEGIBLE] Attach a
[ILLEGIBLE] check (for
[ILLEGIBLE] accounts)
[ILLEGIBLE] account
[ILLEGIBLE] slip. Your
[ILLEGIBLE] must be a
[ILLEGIBLE] of the
[ILLEGIBLE] Clearing
[ILLEGIBLE].
================================================================================
I want to establish an Automatic Investment Plan as described In the prospectus
for The Park Avenue Portfolio. I agree so reimburse State Street Bank and Trust
Company ("SSBTC") for any expenses or losses that SSBTC may incur in connection
with my plan, including any expenses or losses caused by my banks failure to act
as I have requested. SSBTC may cancel any purchase caused by erroneous payments
or for which it does not receive payment from my bank. Redemptions and/or
deductions may be made from my XXX account for that purpose. I understand that
the minimum debit to my bank account is $100 and payments over a period of 12
months must total as least $1000. This application must be received at least 30
days before the first payment date.
(Check One)
Amount ------------------------------------------
Invested Monthly Quarterly Semiannually Annually
Guardian Park Avenue Fund $ |_| |_| |_| |_|
-------
Guardian Xxxxxxx Xxxxxxx
International Fund $ |_| |_| |_| |_|
-------
Guardian Asses Allocation
Fund $ |_| |_| |_| |_|
-------
Guardian Investment Quality
Bond Fund $ |_| |_| |_| |_|
-------
Guardian U.S. Government
Securities Fund $ |_| |_| |_| |_|
-------
Guardian Tax-Exempt Fund $ |_| |_| |_| |_|
-------
Guardian Cash Management
Fund $ |_| |_| |_| |_|
-------
First check to be drawn for payment due:
--------------------------------------------------------------------------------
Month/Day (1 through 28 only)/Year
--------------------------------------------------------------------------------
Name of Bank
--------------------------------------------------------------------------------
Branch Name Branch Number Transit Number
--------------------------------------------------------------------------------
Bank Address
--------------------------------------------------------------------------------
City State Zip
--------------------------------------------------------------------------------
Bank Account Number
--------------------------------------------------------------------------------
Signature of Depositor Date
--------------------------------------------------------------------------------
Signature of Depositor Date
(If joint bank account, both must sign.)
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=============================
8
Signature
=============================
By signing this form you:
|_| Establish an XXX account in accordance wish all the terms of the XXX
Custodial Agreement on IRS Form 5305-A which has been provided to you and which
is incorporated herein by reference.
|_| Appoint SSBTC, or its successors, as Custodian of your XXX account.
|_| State that you have received and read an XXX Disclosure Statement, the XXX
Custodial Agreement on IRS Form 5305-A and the prospectus for The Park Avenue
Portfolio, and that you agree so be subject to their provisions as they may be
amended from time to time.
|_| Certify that you have the authority and legal capacity to select the
privileges requested herein and to purchase mutual fund shares, and that you are
solely responsible for your investment choices.
|_| Authorize The Park Avenue Portfolio, SSBTC and their affiliates or agents to
act on any instructions believed to be genuine to carry out any duties
authorized on this form or required by the XXX Custodial Agreement on IRS Form
5305-A, and agree that none of them will be liable for any resulting loss,
expense or consequential damages.
|_| Certify, under penalties of perjury, that the Social Security Number(s)
shown on this form is (are) true and correct, and that you have not been
notified by the IRS that you are subject to back-up withholding.
/s/ /s/
--------------------------------- -----------------------------------------
Signature Date Spouse's Signature (Required in Date
Community Property State)
Your confirmation statement shall also serve as the acceptance by SSBTC of its
appointment as your Custodian.
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=============================
9
Dealer Information
=============================
------------------------------------ -----------------------------------------
Firm Name Registered Representative's Name/Agency
Code/Reg. Rep. Code
------------------------------------ -----------------------------------------
Branch/Agency Address Dealer Code
------------------------------------ -----------------------------------------
City State Zip Authorized Dealer Signature
xxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Xxx Xxxx Xxxxxx Portfolio(*)
XXX TRANSFER FORM
=============================
Instructions: Use this form so transfer XXX assets from your current custodian
to your Park Avenue Portfolio XXX. If you are transferring XXX assets from more
than one custodian, complete one XXX TRANSFER FORM for each custodian. There is
no limit to the number of transfers which you may authorize. You should also
complete an XXX APPLICATION if you are opening a new XXX with the transfer
described herein.
PLEASE
PRINT
CLEARLY
================================================================================
Mail this form to:
The Park Avenue Portfolio, National Financial Data Services, X.X Xxx 000000,
Xxxxxx Xxxx, XX 00000-0000
For certified, registered or over-night mail:
The Park Avenue Portfolio, National Financial Data Services, 0000 Xxxxxxxxx
Xxxxxx, Xxx. XX-00, Xxxxxx Xxxx, XX 00000-0000
GISC Registered Representatives only, mail to:
The Park Avenue Portfolio, Guardian Investor Services Corporation, 0000 Xxxxxxx
Xxxxx, Xxx. 0X, Xxxxxxxxx, XX 00000
================================================================================
=============================
1
Owner
Information
=============================
-------------------------------------- ---------------------------------------
Name: First Middle Initial Last Social Security Number Date of Birth
-------------------------------------- ---------------------------------------
Street Address or P.O. Box Daytime Phone Number
--------------------------------------
City State Zip
================================================================================
=============================
2
=============================
Current XXX
Custodian/
Trustee and
Account
Information
=============================
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Name: First Middle Initial Last Phone Number
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Street Address or P.O. Box Account Number Maturity Date (for
a CD)
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City State Zip Account Number Maturity Date (for
a CD)
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3
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Instructions
[ILLEGIBLE] Current XXX
Custodian/
Trustee
=============================
Please transfer
|_| all or |_| part ($____ or ____%) of my existing XXX account described above
|_| immediately or |_| at maturity (for a CD).
All assets should be transferred as cash on a fiduciary-to-fiduciary basis.
Include my account number and FBO information on a check made payable to "The
Park Avenue Portfolio."(*)
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4
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Type of XXX
=============================
What type of XXX do you have now?
|_| Individual Account (Regular Contribution XXX) |_| Spousal XXX
|_| SEP-XXX |_| Retirement Plan Rollover
(an XXX comprised of
|_| Annuity Rollover (an XXX comprised of distributions from a
distributions from a tax-sheltered annuity) tax-qualified retirement
plan)
|_| Other (Explain) _____________________________
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5
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Investment
Instructions
=============================
[ILLEGIBLE] Fund is described
[ILLEGIBLE] prospectus for
[ILLEGIBLE] Park Avenue
Portfolio.
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Check one box and complete if necessary:
|_| Invest the transferred amount in accordance with the investment instructions
on my XXX APPLICATION.
|_| Invest the transferred amount as follows:
Fund Name Tax Year Deductible Amounts Non-Deductible Amounts
Guardian Park Avenue Fund ..... 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Xxxxxxx Xxxxxxx
International Fund ........... 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Asset Allocation Fund 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Investment Quality
Bond Fund .................... 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian U.S. Government
Securities Fund .............. 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Tax-Exempt Fund ...... 19 $ or % $ or %
-------- ----- ---- ----- ----
Guardian Cash Management Fund.. 19 $ or % $ or %
-------- ----- ---- ----- ----
|_| I am effecting a transfer-in-kind of shares of the Portfolio Funds which
comprise The Park Avenue Portfolio from my current XXX Custodian/Trustee.
Please complete other side.
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6
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Signature
=============================
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By signing this form you:
|_| Acknowledge that you have received and read the prospectus for The Park
Avenue Portfolio, and that you are solely responsible for your investment
choices.
|_| Release The Park Avenue Portfolio and its affiliates or agents from, and
agree to indemnify and hold each and all of them harmless against, any
liability, loss, expense or cost caused by any refusal, failure or delay by a
financial institution to transmit the proceeds of a CD as contemplated herein;
or any delay or failure to provide a signature guarantee.
|_| Authorize the transfer of XXX assets described herein and certify that you
have established a Park Avenue Portfolio XXX.
/s/
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Signature Date
Signature guarantee: Contact your current XXX Custodian/Trustee regarding its
requirements.
-----------------------------------------
Name of Signature Guarantor
By
----------------------------------------- -------------------------------------
Signature of Officer Title
AFFIX SIGNATURE GUARANTEE STAMP
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7
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Dealer
Information
=============================
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Firm Name Registered Representative's
Name/Agency Code/Reg. Rep. Code
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Branch/Agency Address Dealer Code
----------------------------------------- -------------------------------------
City State Zip Authorized Dealer Signature
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PLEASE DO NOT COMPLETE THIS SECTION FOR USE BY SUCCESSOR AND CURRENT CUSTODIANS
ONLY
To the Current Custodian: As agent for State Street Bank and Trust Company
(SSBTC), Custodian for the Depositor's Individual Retirement Account, we agree
to accept the transfer of plan assets on a fiduciary-to-fiduciary basis as
indicated above.
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Authorized Signature Title Date
Instructions so Current Custodian for delivery so SSBTC: Make check payable to:
"The Park Avenue Portfolio"(*)
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FBO Account Number(s)
NFDS
X.X. Xxx 000000
Xxxxxx Xxxx, XX 00000-0000
