0000881453-98-000009 Sample Contracts

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Sex Male Female Date of Birth Sex Male Female Date of Birth Social Security/Tax I.D. No. Social Security/Tax I.D. No. --------------------------------------------------------------- -------------------------------------------------------------------...
Annuity Application • March 2nd, 1998 • American Skandia Life Assur Corp Var Acct B Cl 1 Sub Accts

Agreement I/We represent to the best of my/our knowledge and belief the statements made in this application are true and complete; including, under penalty of perjury, the Social Security or Tax ID numbers provided. It is indicated and agreed that the only statements which are to be construed as the basis of the contract are those contained in this application or in any amendment to this application. I/WE HAVE ALSO RECEIVED A COPY OF THE PROSPECTUS AND I/WE UNDERSTAND THAT: (A) ANNUITY PAYMENTS OR SURRENDER VALUES, WHEN BASED ON THE INVESTMENT EXPERIENCE OF THE SEPARATE ACCOUNT, ARE VARIABLE AND NOT GUARANTEED AS TO A DOLLAR AMOUNT; AND (B) ALL PAYMENTS AND VALUES BASED ON THE FIXED ACCOUNT ARE SUBJECT TO A MARKET VALUE ADJUSTMENT FORMULA, THE OPERATION OF WHICH MAY RESULT IN EITHER AN UPWARD OR DOWNWARD ADJUSTMENT. Signatures Owner(s) X /s/John Doe Proposed Annuitant (if other than Owner) X Dated at (location) Anytown, Anystate Date 01/03/92 Signature of Agent X /s/ Robert Smith Agent

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