EXHIBIT 99(5)(I)
------------------------------------------------------------------------------------------------------------------------------------
THE AMERICAN LIFE INSURANCE APPLICATION FORM
COMPANY OF NEW YORK XXXX-IRA
000 XXXX XXXXXX XXX XXXX XX 00000-6839
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
SOCIAL SECURITY # APPLICANT'S NAME First Initial Last
------------------------------------------------------------------------------------------------------------------------------------
MAILING ADDRESS Street and Number (Include Apartment Number) City State Zip Code
------------------------------------------------------------------------------------------------------------------------------------
IF FOREIGN RESIDENT Province Country
------------------------------------------------------------------------------------------------------------------------------------
DATE OF BIRTH |_| MALE INITIAL CONTRIBUTION DISTRIBUTION # I elect to make contributions by:
|_| FEMALE $ 1937 |_| Preauthorized |_| direct payment
/ / Checking
------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
ALLOCATION OF CONTRIBUTIONS
====================================================================================================================================
Show the percentage of your contributions you want to place in the interest account and/or investment funds. Use whole numbers only,
and make sure the percentages total 100%.
Amounts you place in the interest account will be credited with the rate of interest currently applicable to that account. Your
balance in any investment fund will fluctuate to recognize investment results.
================= ======================================================================================================
INTEREST ACCOUNT INVESTMENT FUNDS
================= ======================================================================================================
AMERICAN LIFE MUTUAL OF AMERICA
----------------- ------------------------------------------------------------------------------------------------------
Interest Money Market All America Equity Index Short-Term
Accumulation Fund Fund Fund Bond Fund
Account % % % % %
----------------- ------------------------------------------------------------------------------------------------------
Mid-Term Bond Composite Agressive Equity
Bond Fund Fund Fund Fund
% % % %
------------------------------------------------------------------------------------------------------
XXXXXXX AMERICAN CENTURY
------------------------------------------------------------------------------------------------------
Xxxxxxx Xxxxxxx Xxxxxxx American Century
Capital Growth Bond International VP Capital
Fund Fund Fund Appreciation Fund
% % % %
------------------------------------------------------------------------------------------------------
FIDELITY XXXXXXX
------------------------------------------------------------------------------------------------------
Fidelity VIP II Fidelity VIP Fidelity VIP II Xxxxxxx Social
Asset Manager Equity-Income Contrafund Balanced
Fund Fund Fund
% % % %
------------------------------------------------------------------------------------------------------
REPLACEMENT
Is the contract applied for intended to replace another contract?..... |_| Yes |_| No
If yes, Company______________________________Contract/Account Number___________________ Amount $_______________
====================================================================================================================================
BENEFICIARY DESIGNATIONS (Please Read Reverse Side Before Completing This Section)
====================================================================================================================================
Beneficiary Type: Beneficiary Type:
|_| Primary |_| Primary |_| Secondary
Relationship: Relationship:
|_| Spouse |_| Child |_| Parent |_| Estate |_| Other |_| Spouse |_| Child |_| Parent |_| Estate |_| Other
------------------------------------------------------------------------------------------------------------------------------------
FULL NAME First Initial Last FULL NAME First Initial Last
------------------------------------------------------------------------------------------------------------------------------------
DATE OF BIRTH (Optional) SOCIAL SECURITY # (Optional) DATE OF BIRTH (Optional) SOCIAL SECURITY # (Optional)
/ / / /
------------------------------------------------------------------------------------------------------------------------------------
ADDRESS Street ADDRESS Street
------------------------------------------------------------------------------------------------------------------------------------
City State Zip Code City State Zip Code
------------------------------------------------------------------------------------------------------------------------------------
IF FOREIGN RESIDENT Province Country BENEFIT PERCENT IF FOREIGN RESIDENT Province Country BENEFIT PERCENT
% %
------------------------------------------------------------------------------------------------------------------------------------
APPLICANT MUST COMPLETE REVERSE SIDE
A Subsidiary of Mutual of America Life Insurance Company
6827-AX 11/97
================================================================================
BENEFICIARY DESIGNATIONS
================================================================================
The XXXX XXX provides that if you die before the date payments begin under your
XXXX XXX contract, the Accumulation Value of your contract on the date Mutual of
America receives due proof of death will be payable as a death benefit. Please
name one or more beneficiaries on this application to receive any death benefits
payable.
If you wish to name an organization or an estate to receive any benefits
payable, show the name of the organization or the estate in the section labeled
"FULL NAME" in the portion of this form provided for naming beneficiaries.
You have the right to change your beneficiary at any time. Use the Mutual of
America form, CHANGE OF BENEFICIARY DESIGNATION.
DIVISION OF BENEFITS
IF A NAMED BENEFICIARY is living at the time of your death, any benefits will be
paid to that person. IF YOU NAME MORE THAN ONE PRIMARY BENEFICIARY, Mutual of
America will pay the benefits in equal shares to the surviving primary
beneficiaries. If no primary beneficiary is living upon your death, Mutual of
America will pay the benefits to the SECONDARY BENEFICIARY. IF YOU NAME MORE
THAN ONE SECONDARY BENEFICIARY, Mutual of America will pay the benefits in equal
shares to the surviving SECONDARY BENEFICIARIES. If you wish to provide payment
in proportions other than equal shares, you must state the percentage you wish
each beneficiary to receive.
ORDER OF PAYMENT OF BENEFITS
IF NO NAMED BENEFICIARY is living at the time of your death, any benefits
payable under the terms of the plan will be paid to the first surviving class of
the following preference beneficiaries: (a) your spouse; (b) your children in
equal shares; (c) your parents in equal shares; (d) your brothers and sisters in
equal shares; and (e) the executors or administrators of your estate.
================================================================================
STATEMENT AND SIGNATURE
================================================================================
I acknowledge that: (a) I have received a copy of the current Prospectus; (b) I
have read the Prospectus and understand its terms; (c) I am familiar with the
objectives of the Investment Funds; (d) my election or authorization made under
my XXXX XXX contract as part of this application is subject to the conditions
and limitations set forth in the Prospectus; (e) I may not roll over
contributions or transfer amounts from existing annuity contracts or IRA type
arrangements other than as described in Section 408A(c) of the Internal Revenue
Code; (f) I have determined that the XXXX XXX applied for above is suitable to
(i) my investment objectives and (ii) my financial situation; and (g) account
transaction information sent to me will be conclusive unless I make any needed
correction by calling 0-000-000-0000 no later than four weeks from the date of
the transaction at issue.
I UNDERSTAND THAT: (A) ANY AMOUNTS PLACED IN THE INTEREST ACCUMULATION ACCOUNT
WILL EARN INTEREST AT THE RATES DETERMINED BY MUTUAL OF AMERICA; AND (B) ANY
AMOUNTS PLACED IN THE INVESTMENT FUNDS ARE NOT GUARANTEED AS TO FIXED DOLLAR
AMOUNTS AND MAY INCREASE OR DECREASE IN VALUE BASED UPON THE FUNDS' INVESTMENT
RESULTS.
I AFFIRM THAT THE ABOVE INFORMATION IS CORRECT:
________________________________________ _________________________
Signature of Applicant Date
Signed at: _____________________________________________________________________
(City and State)
================================================================================
FOR INTERNAL USE ONLY
================================================================================
________________________________________ _________________________
Print Name of Registered Representative Regional Office Location
________________________________________ _________________________
Signature of Registered Representative Date
