EXHIBIT 5(c)(x)
American General Life Insurance Company ("AGL")
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A Subsidiary of American General Corporation
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Complete and Return to:
Annuity Administration Houston, Texas
X.X. Xxx 0000 XXXXXXXXXXX(XX)
Xxxxxxx, XX 00000-0000 ===============
(000) 000-0000 Variable Annuity
- SPECIAL DOLLAR COST AVERAGING PLANS -
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SECTION I: ENROLLMENT
Please transfer entire amount allocated to the 1-Year Guarantee Period in equal
monthly amounts over the period indicated below:
[_] 6 Months - 6-Month Dollar Cost Avg (DCA) OR
[_] 12 Months - 12-Month Dollar Cost Avg (DCA)
Balances in the 1-Year Guarantee Period that are subject to the Special Dollar
Cost Averaging Plan, pursuant to this service form, will earn interest at the
rate of _____%, which represents an increase of _____% over the 1-Year Guarantee
Period interest rate currently offered.
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SECTION II: INVESTMENT ALLOCATIONS
Please apply the monthly transfer to the Division(s) as indicated below:
(Use only whole percentages. Total allocation must equal 100%.)
Asian Equity (95) __________%
Domestic Income (80) __________%
Emerging Growth (81) __________%
Emerging Markets Equity (82) __________%
Enterprise (83) __________%
Equity Growth (87) __________%
Fixed Income (84) __________%
Global Equity (85) __________%
Government (86) __________%
Growth and Income (88) __________%
High Yield (89) __________%
International Magnum (90) __________%
Mid Cap Value (91) __________%
Money Market (92) __________%
Xxxxxx Xxxxxxx
Real Estate Securities (93) __________%
Strategic Stock (96) __________%
Value (94) __________%
Other ______________ __________%
NOTE: All money allocated will be transferred in equal monthly amounts over a
6-month or 12-month period, beginning 30 days after the request date. The final
amount transferred will include all of the remaining balance.
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TO INITIATE A SPECIAL DOLLAR COST AVERAGING PLAN:
For new contracts:
. Select your initial allocations in Section 6 of the GENERATIONS(TM)
Variable Annuity Application (L8771), allocating the desired percentage
to the 1-Year Guarantee Period.
(Minimum allocation to the 1-Year Guarantee Period is $5,000.)
. In lieu of Section 8 of the Application, complete this service form to
begin a Special Dollar Cost Averaging Plan from the 1-Year Guarantee
Period.
. Submit this service form with your Application.
For existing contracts-Contract # VA_____________________________________:
. Complete this service form and submit it with an additional purchase
payment.
. The entire additional payment will be applied toward the 1-Year
Guarantee Period and transferred into the specified Division(s) as
indicated in Section II.
. Additional payments may not be invested into the Special Dollar Cost
Averaging Plan while an existing Special Dollar Cost Averaging Plan or
any other dollar cost averaging plan is active.
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SECTION III: SIGNATURES
Your signature below indicates you have received a GENERATIONS(TM) prospectus
and authorizes your request to begin the Special Dollar Cost Averaging Plan.
All transactions will be confirmed. Please review the information on your
confirmation statements carefully. All errors or corrections must be reported
to American General Life Insurance Company ("AGL") immediately to assure proper
crediting. AGL will assume all transactions are accurate unless notified within
30 days.
You may elect to terminate your Special Dollar Cost Averaging Plan by calling
or writing AGL. The termination will become effective prior to the next
transfer following such notification. Upon termination, you will no longer
receive the increased interest rate. AGL may delay processing any additional
transfer or liquidation request if received on the date of a scheduled Special
Dollar Cost Averaging Plan transfer. In addition, AGL reserves the right to
discontinue, modify, or amend this offer at any time. Any changes made to this
offer will not affect Contract Owners currently participating in a Special
Dollar Cost Averaging Plan.
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SIGNATURE OF OWNER SOCIAL SECURITY NUMBER OF OWNER
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PRINT OWNER NAME SIGNATURE OF JOINT OWNER
(IF APPLICABLE)
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PHONE DATE PRINT LICENSED AGENT NAME
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