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MINNESOTA LIFE VARIABLE ANNUITY APPLICATION
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Minnesota Life Insurance Company - Annuity Services - 000 Xxxxxx Xxxxxx Xxxxx - Xx. Xxxx, Xxxxxxxxx 00000-0000 -
Toll Free 0-000-000-0000
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OWNER NAME DATE OF BIRTH SEX TAXPAYER I.D. (Soc. Sec. # OR EIN)
(Please print) / /M / /F
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XXXXXX XXXXXXX (Xxxxx) DAYTIME PHONE NUMBER
( )
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CITY, STATE, ZIP CITIZENSHIP
/ /US / /OTHER_________
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OWNER EMPLOYER YRS EMPLOYED OCCUPATION
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EMPLOYER ADDRESS (STREET)
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CITY/TOWN STATE ZIP CODE IS OWNER EMPLOYED/REGISTERED BY A NASD MEMBER FIRM
/ /Y / /N FIRM NAME____________________
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JOINT OWNER NAME DATE OF BIRTH SEX SOCIAL SECURITY NUMBER
(Optional-must be / /M / /F
spouse of owner)
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XXXXXX XXXXXXX (Xxxxx) DAYTIME PHONE NUMBER
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CITY, STATE, ZIP CITIZENSHIP
/ /US / /OTHER_________
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JOINT OWNER EMPLOYER YRS EMPLOYED OCCUPATION
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EMPLOYER ADDRESS (STREET)
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CITY/TOWN STATE ZIP CODE IS JOINT OWNER EMPLOYED/REGISTERED BY A NASD MEMBER FIRM
/ /Y / /N FIRM NAME____________________
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ANNUITANT NAME DATE OF BIRTH SEX TAXPAYER I.D. (Soc. Sec. # or EIN)
(If other than owner) / /M / /F
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STREET ADDRESS (Legal)
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CITY, STATE, ZIP
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JOINT ANNUITANT NAME DATE OF BIRTH SEX SOCIAL SECURITY NUMBER
(Optional-must be spouse / /M / /F
of annuitant) -----------------------------------------------------------------------------------------------------
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STREET ADDRESS (Legal)
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CITY, STATE, ZIP
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BENEFICIARY CLASS NAME RELATIONSHIP DATE OF BIRTH SEX SOCIAL SECURITY NUMBER
/ /M / /F
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/ /M / /F
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TYPE OF PLAN / / Non-Qualified (NQ) / / Public Employee Deferred Compensation (IRC Section 457)
/ / 1035 Exchange (attach appropriate forms) / / Non-Qualified Deferred Compensation
/ / Under the _______(state) UTMA/UGMA / / Simplified Employee Pension (SEP)
Custodian Name ___________________ / / Savings Incentive Match Plans for Employees (SIMPLE)
/ / Individual Retirement Annuity (XXX) / / Tax Sheltered Annuity (IRC Section 403(b)-(TSA)
/ / Purchase Payment for the year ______ / / Qualified Retirement Plan (IRC Section 401)
/ / Rollover (attach appropriate forms) / / Other _____________________
/ / Transfer (attach appropriate forms)
/ / Xxxx Individual Retirement Annuity (XXXX)
/ / Contributory XXXX
/ / Rollover XXXX
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TYPE OF CONTRACT / / MultiOption Achiever / / MultiOption Classic
/ / Immediate / / Deferred / / Immediate / / Deferred
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PURCHASE PAYMENT MAKE CHECK PAYABLE TO MINNESOTA LIFE
METHOD (CHECK ALL
THAT APPLY) / / $_________remitted with application / / Automatic Payment Plan (attach authorization and
/ / $________ as Cash Rollover voided check) Commencing Month __________
/ / for tax year ___________ Day _____ (must be between 1st & 26th of
/ / Direct Transfer/1035 Exchange/Rollover the month)
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PURCHASE PAYMENT / / Send Individual Purchase Reminder Notice (XXX or
REMINDER NOTICE Non-qualified only) on the 1st day of ________(month) for $_________ and continuing
(CHECK ONE IF / / Quarterly / / Semi-Annually / / Annually
APPLICABLE)
/ / Send Purchase Payment Reminder Notice to employer
beginning ___________ (month) for $____________ and continuing
/ / Annually (1) / / Semi-Annually (2) / / Quarterly (4)
/ / Monthly (12) / / Semi-Monthly (24) / / Bi-Weekly (26)
/ / Add to Existing Case _____________________________
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99-70020
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PURCHASE PAYMENT ______% General ______% International Stock
ACCOUNT ALLOCATION ______% Maturing Government Bond-2002 ______% Small Company Growth
______% Maturing Government Bond-2006 ______% Value Stock
______% Maturing Government Bond-2010 ______% Small Company Value
______% Growth ______% Global Bond
______% Bond ______% Index 400 Mid-Cap
______% Money Market ______% Xxxxxxxxx Developing Markets
______% Asset Allocation ______% Macro-Cap Value
______% Mortgage Securities ______% Micro-Cap Growth
______% Index 500 ______% Real Estate Securities
______% Capital Appreciation ______% Other ________________________
______
TOTAL 100%
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SPECIAL INSTRUCTIONS
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INVESTMENT SUMMARY APPROXIMATE ANNUAL INCOME ESTIMATED NET WORTH ESTIMATED LIQUID NET WORTH FEDERAL TAX BRACKET
PROFILE FOR (from all sources) (exclusive of car and home) (cash and cash equivalents) / / 0-15% / / 29%+
ANNUITANT / / 16-28%
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INVESTMENT OBJECTIVE: (CHECK ONE)
/ / Conservative Income / / Current Income / / Conservative Growth / / Growth / / Aggressive Growth
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# of Dependents RISK TOLERANCE: (CHECK ONE) TIME HORIZON / / 9-11yrs
/ / Conservative / / Moderate / / Aggressive / / < 3 yrs / / 4-8 yrs / / 12+ yrs
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PRIOR INVESTMENT EXPERIENCE / / Mutual Funds / / Limited Partnerships / / Bonds
/ / Years of Experience / / Annuities / / Stocks / / Options/Futures
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OWNER/ANNUITANT - I/we represent that the statements and answers in this application are full, complete and true to the
SIGNATURES best of my/our knowledge. I/we agree that they are to be considered the basis of any contract issued to
me/us. I/we have read and agree with applicable statements.
- I ACKNOWLEDGE RECEIPT OF A CURRENT VARIABLE ANNUITY ACCOUNT
PROSPECTUS AND THE CURRENT PROSPECTUSES FOR THE ADVANTUS SERIES
FUND AND XXXXXXXXX DEVELOPING MARKETS FUND. I UNDERSTAND THAT ALL
PAYMENTS AND VALUES OF ANY CONTRACT ISSUED, WHEN BASED UPON THE
INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT, ARE VARIABLE AND ARE NOT
GUARANTEED AS TO A FIXED DOLLAR AMOUNT.
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SIGNED AT (County, State) DATE SIGNATURE OF OWNER SIGNATURE OF ANNUITANT
X X
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AMOUNT REMITTED WITH APPLICATION SIGNATURE OF JOINT OWNER SIGNATURE OF JOINT ANNUITANT
$ X X
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TO BE COMPLETED BY To the best of my knowledge this contract / / will / / will not replace or change an existing insurance or
REPRESENTATIVE annuity contract. I certify that a current prospectus was delivered. No written sales materials were used
other than those furnished by the Home Office. I believe the information provided by this client is true
and accurate to the best of my knowledge.
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REPRESENTATIVE NAME (PRINT) REPRESENTATIVE SIGNATURE AGENCY CODE AGENT CODE
X %
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X %
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TO BE COMPLETED DEALER NAME DATE SIGNATURE OF AUTHORIZED DEALER
BY DEALER X
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This application becomes effective only upon approval of Ascend Financial services, Inc.
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HOME OFFICE PRINCIPAL SIGNATURE DATE CONTRACT NUMBER CASE NUMBER
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