Change of Ownership/Annuitant

Transcription

1 DOC Servce address: RverSource Lfe Insurance Co. of New York Amerprse Fnancal Center Mnneapols, MN Change of Ownershp/Annutant Lfe Insurance Annutes A Clent Profle must be submtted pror to establshng a new account. Ths form may not be used for Qualfed Accounts. For all annutes held wthn a brokerage or SPS Advantage account, before proceedng, ensure the brokerage or SPS Advantage account the annuty s to be lnked wth s of the exact same ownershp. Clent ID 001 Part 1 Gftng/Value Receved Informaton 1. Is the Change of Ownershp due to a dvorce? Yes (go to Part 2) No (go to next queston) 2. Is ths a transfer to a spouse, owner's revocable trust, owner's lvng trust, spouse's revocable trust, or spouse's lvng trust? Yes (go to Part 2) No (go to next queston) 3. You hereby absolutely and uncondtonally sell, transfer and convey. If no opton s selected the default s gft. Wth the ntenton of makng a gft (go to Part 2) For value receved (go to Part 2) If gftng s selected, or defaulted to, a 1099 may be ssued. Generally transfer of annuty ownershp, whether by gft or for value receved, s a taxable event. Please consult your tax advsor. Part 2 Exstng Account Identfcaton Complete ths secton exactly as t appears on our records. Clent/Owner or Fducary Name Trust or Entty Name Jont Owner Name Insured/Annutant Jont Owner Clent ID 001 Exstng Product Type and Account Number (Requred): RAVA 5 : 9935 prefx Account Number 9935 Other: 9900, 9700 or 9790 prefx. Account Number Exstng Product Type and Account Number (Requred): RAVA 5 : 9935 prefx Account Number 9935 Other: 9900, 9700 or 9790 prefx. Account Number Exstng Product Type and Account Number (Requred): RAVA 5 : 9935 prefx Account Number 9935 Other: 9900, 9700 or 9790 prefx. Account Number Exstng Product Type and Account Number (Requred): RAVA 5 : 9935 prefx Account Number 9935 Other: 9900, 9700 or 9790 prefx. Account Number Complete Sutablty Informaton n Part 5 for each new account Sgn on page(s) 2, 10 and RverSource Lfe Insurance Company All rghts reserved. Only RverSource Lfe Insurance Co. of New York s authorzed to sell nsurance and annutes n New York Page 1 of 17

2 DOC Part 3 Authorzaton to Transfer Ownershp Must be sgned by all present owners. Annutes and Lfe Insurance Subject to the approval of RverSource Lfe Insurance Co. of New York, you absolutely and uncondtonally transfer ownershp of the above descrbed lfe nsurance polcy/annuty contract to the person(s) named n Part 4 A, B, C or D and hs/her successors or assgns. Amerprse Fnancal s not responsble for the suffcency or valdty of ths transfer of ownershp. If ths polcy/contract/account has been assgned as collateral, ths transfer of ownershp s made subject to that assgnment. If any contngent owner has been named n ths polcy/contract, or by subsequent nstrument, that desgnaton of contngent owner s hereby revoked. The current benefcary desgnaton wll reman n effect unless changed by the new owner(s). All owners and fducares dentfed n Part 2 must sgn below: X X For UGMA/UTMA Notary Publc n and for sad County and State X Date (MMDDYYYY) Any request for an ownershp change of an account regstered under UTMA/UGMA to an owner other than the former mnor orgnally named on the account wll requre that the mnor, who has now reached age of majorty, sgn below and have ther sgnature notarzed. On ths day of, A.D. (year), before me, a Notary Publc n and for sad County and State, resdng theren, duly commssoned and sworn, personally appeared,known to me to be the person whose name s subscrbed to the wrtten nstrument, and acknowledged to me that he or she executed the same as hs or her free act and deed. In Wtness Whereof, I have hereunto set my hand and affxed my offcal seal ths day and year n ths certfcate frst above wrtten. Part 4 New Owner Informaton (Always Complete Part 4)! New Owners must sgn on Page 8. If you own a varable annuty wth the Guarantor Wthdrawal Beneft for Lfe (GWB for Lfe ) or SecureSource rder sngle lfe beneft, transfer of ownershp may result n a reset of the Annual Lfetme Payment (ALP). If the ALP wll decrease, the Beneft Impact Acknowledgement form wll be requred before processng wll occur. If requred, ths form wll be maled to you or you may contact our offce for assstance. If you own a varable annuty wth the SecureSource Flex or SecureSource Stages NY sngle lfe beneft and the covered person changes as a result of the ownershp change, the rder termnates. If you own a varable annuty wth the SecureSource jont lfe beneft, transfer of ownershp to anyone other than the covered spouses or ther revocable trust, s not allowed. If you own a varable annuty wth the SecureSource Flex or SecureSource Stages NY jont lfe beneft and transfer ownershp to anyone other than the covered spouses or ther revocable trust, the rder termnates. If you own a varable annuty wth the SecureSource 3 NY, SecureSource 4NY SM or SecureSource 4 Plus NY SM beneft, the covered person (for jont, covered spouses) wll not change and the rder wll not termnate as a result of an ownershp change. For sngle lfe beneft, the rder wll termnate at the death of the covered person or any owner (even f the covered person s stll lvng). For jont lfe beneft, the rder wll termnate at the death of the last covered spouse or any owner (unless spousal contnuaton s chosen by a covered spouse). Jont ownershp and jont annutants are not allowed for annuty contracts wth the SecureSource Flex NY or SecureSource Stages NY sngle lfe beneft. Complete the followng clent sutablty nformaton. Incomplete felds may result n any new account beng restrcted to sales only transactons and may delay future tradng. 4A - Indvdual Owner Name as t appears n IRS Records Taxpayer Identfcaton Number Relatonshp to Current Owner(s) n Part 2 Date of Brth (MMDDYYYY) Ctzenshp (Select One): U.S. Ctzen Resdent Alen Non-Resdent Alen Country of Ctzenshp (Requred f Resdent Alen or Non-Resdent Alen) Second Country of Ctzenshp Telephone Number Martal Status (Select One): Marred Dvorced Sngle Wdowed Resdental Address: Gender: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Male Female Cty State ZIP Code Page 2 of 17 New Owner Informaton contnued on next page..

3 DOC A. Employment status A. Employed B. Self-employed C. Not Employed D. Retred E. Other (Homemaker, Mnor, Student, etc.) Industry Classfcaton (Requred f Self-employed) Prmary Occupaton Informaton (Requred f employed or self-employed) Employer 1 (Requred f Employed or Self-employed) Employer Employer Street Address Employer Cty State ZIP Code Employer Country Employer 2 (f Applcable) Employer Employer Street Address Employer Cty State ZIP Code Employer Country B. Are you employed by, or an assocated person of, a regstered broker-dealer, securtes exchange, or the Fnancal Industry Regulatory Authorty (FINRA)? Yes No Whch Employer? (Informaton requred f Yes s selected for B) If the company s not ndcated above, enter the followng requred nformaton: Company Employer 1 Employer 2 Company Street Address Company Cty State ZIP Code Company Country C. Are you an offcer, drector, 10% shareholder or polcymaker of a publcly traded company? Yes No Page 3 of 17

4 DOC Company: (Informaton requred f Yes s selected for C) Same as Employer 1 Company Tcker Symbol Same as Employer 2 Company Tcker Symbol If the company s not ndcated above, enter the followng requred nformaton: Company Company Street Address Company Cty State ZIP Code Company Country Company Tcker Symbol Federal Tax Bracket: 0% 10% 15% 25% 28% and over Annual Income: Lqud Net Worth: Net Worth: Does the clent have nvestment experence? Yes No Select all asset type(s) for whch the clent has experence. For each asset type, select the Years of Investment Experence and Average Number of Buy or Sell Trades per Year. Investment experence should account for years of actve partcpaton, rather than the number of years snce the frst purchase. (Example: If clent purchased optons actvely n 2007 and 2008, but hasn't snce that tme = 2 years) If years of experence has not crossed the mnmum of the range, select the lower range, wth the excepton of anythng greater than none fallng nto 1-2 years. (Examples: 8 months = 1-2 years; 2.5 years = 1-2 years, 5.5 years = 3-5 years) Do not nclude DRIP arrangements for Equtes (ncludes ETFs) or systematc arrangements for Mutual Funds/529s when selectng the average number of buy or sell trades per year. Years of Investment Experence: Avg. # of Buy and Sell Trades per Year: Alternatve Investments (ncludes managed futures/fund of hedge funds) Annutes/Varable Lfe Certfcates/CDs Commodtes Equtes (ncludes ETFs) Fxed Income (ncludes UITs) Lmted Partnershps Mutual Funds/529s Non-Traded REITs/BDCs and non-traded closed end funds Optons Structured Products Does the clent have any nvestments held outsde Amerprse? Yes No Declne to dsclose Approxmate Value Approxmate Value Alternatve Investments Lmted Partnershps Annutes/Varable Lfe Mutual Funds/529s Certfcates/CDs Non-Traded REITs/BDCs Page 4 of 17

5 DOC Commodtes Optons Equtes (ncludes ETFs) Other Fxed Income (ncludes UITs) Structured Products Total Dependents* *Defned as each person the clent can clam on ther IRS Tax Flng. For more nformaton, see IRS Publcaton Exemptons, Standard Deducton and Flng Informaton. 4B - Jont Owner wth Indvdual Owner n Part A (WROS - For annutes, rghts of survvorshp can only be used f jont owners are husband and wfe. All others wll be tenants n common). Name as t appears n IRS Records or tenants n common Taxpayer Identfcaton Number Relatonshp to Current Owner(s) n Part 2 Date of Brth (MMDDYYYY) Ctzenshp (Select One): U.S. Ctzen Resdent Alen Non-Resdent Alen Country of Ctzenshp (Requred f Resdent Alen or Non-Resdent Alen) Second Country of Ctzenshp Telephone Number Martal Status (Select One): Marred Dvorced Sngle Wdowed Gender: Male Female Resdental Address: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Cty State ZIP Code A. Employment status A. Employed B. Self-employed C. Not Employed D. Retred E. Other (Homemaker, Mnor, Student, etc.) Industry Classfcaton (Requred f Self-employed) Prmary Occupaton Informaton (Requred f employed or self-employed) Employer 1 (Requred f Employed or Self-employed) Employer Employer Street Address Employer Cty State ZIP Code Employer Country Employer 2 (f Applcable) Employer Employer Street Address Employer Cty State ZIP Code Page 5 of 17

6 DOC Employer Country B. Are you employed by, or an assocated person of, a regstered broker-dealer, securtes exchange, or the Fnancal Industry Regulatory Authorty (FINRA)? Yes No Whch Employer? (Informaton requred f Yes s selected for B) If the company s not ndcated above, enter the followng requred nformaton: Company Employer 1 Employer 2 Company Street Address Company Cty State ZIP Code Company Country C. Are you an offcer, drector, 10% shareholder or polcymaker of a publcly traded company? Company: (Informaton requred f Yes s selected for C) Yes No Same as Employer 1 Same as Employer 2 Company Tcker Symbol Company Tcker Symbol If the company s not ndcated above, enter the followng requred nformaton: Company Company Street Address Company Cty State ZIP Code Company Country Company Tcker Symbol Federal Tax Bracket: 0% 10% 15% 25% 28% and over Annual Income: Lqud Net Worth: Net Worth: Does the clent have nvestment experence? Yes No Select all asset type(s) for whch the clent has experence. For each asset type, select the Years of Investment Experence and Average Number of Buy or Sell Trades per Year. Investment experence should account for years of actve partcpaton, rather than the number of years snce the frst purchase. (Example: If clent purchased optons actvely n 2007 and 2008, but hasn't snce that tme = 2 years) If years of experence has not crossed the mnmum of the range, select the lower range, wth the excepton of anythng greater than none fallng nto 1-2 years. (Examples: 8 months = 1-2 years; 2.5 years = 1-2 years, 5.5 years = 3-5 years) Do not nclude DRIP arrangements for Equtes (ncludes ETFs) or systematc arrangements for Mutual Funds/529s when selectng the average number of buy or sell trades per year Page 6 of 17

7 DOC Years of Investment Experence: Avg. # of Buy and Sell Trades per Year: Alternatve Investments (ncludes managed futures/fund of hedge funds) Annutes/Varable Lfe Certfcates/CDs Commodtes Equtes (ncludes ETFs) Fxed Income (ncludes UITs) Lmted Partnershps Mutual Funds/529s Non-Traded REITs/BDCs and non-traded closed end funds Optons Structured Products Does the clent have any nvestments held outsde Amerprse? Yes No Declne to dsclose Approxmate Value Approxmate Value Alternatve Investments Lmted Partnershps Annutes/Varable Lfe Mutual Funds/529s Certfcates/CDs Non-Traded REITs/BDCs Commodtes Optons Equtes (ncludes ETFs) Other Fxed Income (ncludes UITs) Structured Products Total Dependents* *Defned as each person the clent can clam on ther IRS Tax Flng. For more nformaton, see IRS Publcaton Exemptons, Standard Deducton and Flng Informaton. 4C - Unform Gfts/Transfers to Mnors Act - Irrevocable Gft to Mnor/Protected Person Name of Custodan Relatonshp to Mnor/Protected Person Custodan Telephone Number Name of Mnor Mnor's/Protected Person Taxpayer Identfcaton Number Mnor's/Protected Person Date of Brth (MMDDYYYY) Gender Male Female State Whch Governs UGMA/UTMA (State of Mnor/Protected Person, Custodan or Donor) Resdental Address: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Cty State ZIP Code A. Employment status A. Employed B. Self-employed C. Not Employed D. Retred E. Other (Homemaker, Mnor, Student, etc.) Industry Classfcaton (Requred f Self-employed) Page 7 of 17

8 DOC Prmary Occupaton Informaton (Requred f employed or self-employed) Employer 1 (Requred f Employed or Self-employed) Employer Employer Street Address Employer Cty State ZIP Code Employer Country Employer 2 (f Applcable) Employer Employer Street Address Employer Cty State ZIP Code Employer Country B. Are you employed by, or an assocated person of, a regstered broker-dealer, securtes exchange, or the Fnancal Industry Regulatory Authorty (FINRA)? Yes No Whch Employer? (Informaton requred f Yes s selected for B) If the company s not ndcated above, enter the followng requred nformaton: Company Employer 1 Employer 2 Company Street Address Company Cty State ZIP Code Company Country C. Are you an offcer, drector, 10% shareholder or polcymaker of a publcly traded company? Yes No Page 8 of 17

9 DOC Company: (Informaton requred f Yes s selected for C) Same as Employer 1 Company Tcker Symbol Same as Employer 2 Company Tcker Symbol If the company s not ndcated above, enter the followng requred nformaton: Company Company Street Address Company Cty State ZIP Code Company Country Company Tcker Symbol Federal Tax Bracket: 0% 10% 15% 25% 28% and over Annual Income: Lqud Net Worth: Net Worth: Does the clent have nvestment experence? Yes No Select all asset type(s) for whch the clent has experence. For each asset type, select the Years of Investment Experence and Average Number of Buy or Sell Trades per Year. Investment experence should account for years of actve partcpaton, rather than the number of years snce the frst purchase. (Example: If clent purchased optons actvely n 2007 and 2008, but hasn't snce that tme = 2 years) If years of experence has not crossed the mnmum of the range, select the lower range, wth the excepton of anythng greater than none fallng nto 1-2 years. (Examples: 8 months = 1-2 years; 2.5 years = 1-2 years, 5.5 years = 3-5 years) Do not nclude DRIP arrangements for Equtes (ncludes ETFs) or systematc arrangements for Mutual Funds/529s when selectng the average number of buy or sell trades per year. Years of Investment Experence: Avg. # of Buy and Sell Trades per Year: Alternatve Investments (ncludes managed futures/fund of hedge funds) Annutes/Varable Lfe Certfcates/CDs Commodtes Equtes (ncludes ETFs) Fxed Income (ncludes UITs) Lmted Partnershps Mutual Funds/529s Non-Traded REITs/BDCs and non-traded closed end funds Optons Structured Products Does the clent have any nvestments held outsde Amerprse? Yes No Declne to dsclose Approxmate Value Approxmate Value Alternatve Investments Lmted Partnershps Annutes/Varable Lfe Mutual Funds/529s Certfcates/CDs Non-Traded REITs/BDCs Page 9 of 17

10 DOC Commodtes Optons Equtes (ncludes ETFs) Other Fxed Income (ncludes UITs) Structured Products Total Dependents* *Defned as each person the clent can clam on ther IRS Tax Flng. For more nformaton, see IRS Publcaton Exemptons, Standard Deducton and Flng Informaton. 4D - Desgnaton of Successor Custodan for UTMA or Successor Owner! Ths desgnaton must be completed by the current Custodan/Fducary named n Part C. If ths desgnaton s for a Successor Custodan under UGMA/UTMA t must be wtnessed by a separate, dsnterested thrd party sgnng below. Ths desgnaton of Successor Custodan s not vald n the State of Oho. Select One: Successor Custodan Name of Successor Custodan/Owner Successor Owner Relatonshp to the Mnor/Protected Person Socal Securty Number Date of Brth (MMDDYYYY) Successor Custodan/Owner Telephone Number Resdental Address: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Cty State ZIP Code Sgnature of Custodan X Sgnature of Wtness (fnancal advsor may serve as wtness) X Date (MMDDYYYY) Date (MMDDYYYY) 4E - Trust or Organzaton A clent profle form must be submtted for trusts and organzatons that are new clents before the change of ownershp can be processed. Trustee or Offcer of Organzaton Name(s) Date of Trust (MMDDYYYY) Trustee or Offcer of Organzaton Name(s) Trustee Telephone Number Trust or Organzaton Name TIN If Trust s new owner (Select One): Revocable Irrevocable (Submt Specal W-9) Busness Address: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Cty State ZIP Code Employment Informaton Employment status of the Trustee: A. Employed B. Self-employed C. Not Employed D. Retred E. Other (Homemaker, Mnor, Student, etc.) Prmary Occupaton Informaton (Requred f employed or self-employed) Page 10 of 17

11 DOC Is the trustee employed, or an assocated person of, by a regstered broker-dealer, a securtes exchange or the Fnancal Industry Regulatory Authorty (FINRA)? If yes, we may be requred to send the trustee's employer a duplcate copy of the trust's statements and confrmatons. Yes No How many companes s the trustee employed by, or an assocated person of? Company Company 1 Street Address Company 1 Cty State ZIP Code Company 2 Company 2 Street Address Company 2 Cty State ZIP Code Is the trustee an offcer, drector, 10% shareholder or polcy maker of a publcly traded company? Yes No How many companes s the trustee an offcer, drector, 10% shareholder or polcy maker of? Same as Company 1 Same as Company 2 Company Tcker Symbol Company Tcker Symbol If the company s not ndcated above, enter the followng requred nformaton: Company 1 Company 1 Street Address Company 1 Cty State ZIP Code Tcker Symbol Company 2 Company 2 Street Address Company 2 Cty State ZIP Code Tcker Symbol Federal Tax Bracket: 0% 10% 15% 25% 28% and over Annual Income: Lqud Net Worth: Net Worth: Does the clent have nvestment experence? Yes No Page 11 of 17

12 DOC Select all asset type(s) for whch the clent has experence. For each asset type, select the Years of Investment Experence and Average Number of Buy or Sell Trades per Year. Investment experence should account for years of actve partcpaton, rather than the number of years snce the frst purchase. (Example: If clent purchased optons actvely n 2007 and 2008, but hasn't snce that tme = 2 years) If years of experence has not crossed the mnmum of the range, select the lower range, wth the excepton of anythng greater than none fallng nto 1-2 years. (Examples: 8 months = 1-2 years; 2.5 years = 1-2 years, 5.5 years = 3-5 years) Do not nclude DRIP arrangements for Equtes (ncludes ETFs) or systematc arrangements for Mutual Funds/529s when selectng the average number of buy or sell trades per year. Years of Investment Experence: Avg. # of Buy and Sell Trades per Year: Alternatve Investments (ncludes managed futures/fund of hedge funds) Annutes/Varable Lfe Certfcates/CDs Commodtes Equtes (ncludes ETFs) Fxed Income (ncludes UITs) Lmted Partnershps Mutual Funds/529s Non-Traded REITs/BDCs and non-traded closed end funds Optons Structured Products Does the clent have any nvestments held outsde Amerprse? Yes No Declne to dsclose Approxmate Value Approxmate Value Alternatve Investments Lmted Partnershps Annutes/Varable Lfe Mutual Funds/529s Certfcates/CDs Non-Traded REITs/BDCs Commodtes Optons Equtes (ncludes ETFs) Other Fxed Income (ncludes UITs) Structured Products 4F - Annutant Change for Non-Qualfed Deferred Annuty Contracts (an annutant cannot be changed f the contract s owned by a nonperson) Any annuty that s not an Advantage Fxed Seres, Bonus Fxed Seres, RverSource Retrement Advsor Advantage Plus varable annuty and all types of RAVA 4 and RAVA 5 Annutes have the followng restrctons: The current annutant must be alve. The contract cannot be n payout. The new annutant must be an owner. No ownershp changes must have occurred wthn the past 12 months, unless due to a documented dvorce settlement. No successor annutant can be named Page 12 of 17

13 DOC Name as t appears n IRS Records Taxpayer Identfcaton Number Telephone Number Relatonshp to Current Owner(s) n Part 2 Date of Brth (MMDDYYYY) Resdental Address: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Cty State ZIP Code 4G - Brokered Annuty Assocaton for RAVA 5 Annuty Contracts Only Choose one f applcable. If no selecton s made, annuty wll be assocated wth a brokerage/managed account n the same ownershp as the annuty. I request the above RverSource annuty account Reman lnked to the exstng brokerage/managed account Be lnked to the followng account Not be lnked wth any account 133 Part 5 Account Sutablty- Change of Ownershp Only!! Basc defntons for Investment Tme Frame, Rsk Tolerance, Investment Objectves and Lqudty Needs are provded below. More detaled descrptons and examples of some of the selectons can be found on your Sutablty Confrmaton. Complete the followng account sutablty nformaton for each new account. Incomplete felds wll result n any new account beng restrcted to sales only transactons and may delay future tradng. The nformaton n ths part s requred for changes of ownershp other than dvorces or change of annutant. If you own a Varable Annuty wth the SecureSource Flex rder sngle lfe beneft and the covered person changes as a result of the ownershp change, the rder termnates. Please Note: Based on product and ownershp lmtatons, the assets you are recevng may be transferred nto your exstng accounts, or combned from multple accounts nto one account wthn the same ownershp and product combnaton. If the sutablty nformaton provded on ths form conflcts wth the nformaton prevously on fle for an exstng account, the new nformaton wll replace the old. If you are recevng assets from multple accounts n the same product type (ncludng share class and strategy where applcable), and the sutablty nformaton you provded on ths form s not the same for all accounts of the same product type, we wll apply the sutablty nformaton gven for the last account of that product type lsted on the form. Account 1 - Complete all of the followng nformaton for each new account. (from Part 2) Page 13 of 17

14 DOC Investment Tme Frame Rsk Tolerance A. Less than 1 Year B. 1-3 Years B. Conservatve / Moderate C. 4-7 Years C. Moderate D Years D. Moderate / Aggressve E. 11+ Years E. Aggressve Lqudty Needs A. Less than 1 Year B. 1-6 Years C. 7+ Years Investment Objectves (Select at least one per order of mportance) 1st 2nd 3rd A. Conservatve A. Captal Preservaton C. Income D. Tax Consderatons E. Protecton F. Educaton G. Estate Plannng H. Speculaton I. Growth J. Growth wth Income Planned Intal Investment Amount Recommendatons for ths account are beng made by consderng Assets held only n ths account Overall assets held at Amerprse Overall assets held at Amerprse and assets held outsde of Amerprse Account 2 - Complete all of the followng nformaton for each new account. (from Part 2) Investment Tme Frame Rsk Tolerance Investment Objectves (Select at least one per order of mportance) 1st 2nd 3rd A. Less than 1 Year A. Conservatve A. Captal Preservaton B. 1-3 Years C. 4-7 Years D Years B. Conservatve / Moderate C. Moderate D. Moderate / Aggressve C. Income D. Tax Consderatons E. Protecton E. 11+ Years E. Aggressve F. Educaton Lqudty Needs G. Estate Plannng H. Speculaton A. Less than 1 Year I. Growth B. 1-6 Years J. Growth wth Income C. 7+ Years Planned Intal Investment Amount Recommendatons for ths account are beng made by consderng Assets held only n ths account Overall assets held at Amerprse Overall assets held at Amerprse and assets held outsde of Amerprse Account 3 - Complete all of the followng nformaton for each new account. (from Part 2) Page 14 of 17

15 DOC Investment Tme Frame A. Less than 1 Year Rsk Tolerance A. Conservatve B. 1-3 Years B. Conservatve / Moderate C. 4-7 Years C. Moderate D Years D. Moderate / Aggressve E. 11+ Years E. Aggressve Lqudty Needs A. Less than 1 Year B. 1-6 Years C. 7+ Years Investment Objectves (Select at least one per order of mportance) 1st 2nd 3rd A. Captal Preservaton C. Income D. Tax Consderatons E. Protecton F. Educaton G. Estate Plannng H. Speculaton I. Growth J. Growth wth Income Planned Intal Investment Amount Recommendatons for ths account are beng made by consderng Assets held only n ths account Overall assets held at Amerprse Overall assets held at Amerprse and assets held outsde of Amerprse Account 4 - Complete all of the followng nformaton for each new account. (from Part 2) Investment Tme Frame Rsk Tolerance Investment Objectves (Select at least one per order of mportance) 1st 2nd 3rd A. Less than 1 Year A. Conservatve A. Captal Preservaton B. 1-3 Years C. 4-7 Years D Years E. 11+ Years B. Conservatve / Moderate C. Moderate D. Moderate / Aggressve E. Aggressve C. Income D. Tax Consderatons E. Protecton F. Educaton Lqudty Needs A. Less than 1 Year B. 1-6 Years Years G. Estate Plannng H. Speculaton I. Growth J. Growth wth Income Planned Intal Investment Amount Recommendatons for ths account are beng made by consderng Assets held only n ths account Overall assets held at Amerprse Overall assets held at Amerprse and assets held outsde of Amerprse Check here f any addtonal New Owner Account Profle Informaton pages are attached. Investment Tme Frame Defnton Investment The expected perod of tme you plan to nvest to acheve your current fnancal goal(s). Tme Frame Rsk Tolerance Defntons Conservatve You accept the lowest return potental, lowest return varablty, and the lowest fluctuaton n account value, n exchange for lower rsk. Conservatve / You accept a relatvely low return potental, relatvely low return varablty, and relatvely low fluctuaton n account value, n Moderate exchange for a below average amount of rsk. Moderate Moderate / Aggressve Aggressve You accept an average amount of rsk n exchange for average return potental, average return varablty, and average fluctuaton n account value. You accept an above average amount of rsk n exchange for a relatvely hgh return potental, relatvely hgh return varablty, and relatvely hgh fluctuaton n account value. You accept the hghest amount of rsk n exchange for the hghest return potental, the hghest return varablty, and the hghest fluctuaton n account value Page 15 of 17

16 DOC Investment Objectve Defntons Captal Preservaton To avod the loss of value. Income Tax Consderatons Protecton Educaton Estate Plannng Speculaton Growth Growth wth Income To receve ncome from the nvestment, wth lttle emphass on ncreasng the value of the nvestment. To mtgate federal, state and/or local taxes. To leave a monetary beneft at death to benefcares or a charty. To pay for educaton related expenses. To transfer assets to benefcares or provde a legacy upon one's death. To take a hgher than average rsk n hopes of makng a hgher than average return. To ncrease the captal or market value of the nvestment, wth lttle emphass on the generaton of current ncome. To provde both growth and ncome, often by choosng nvestments whch pay dvdends and have earnngs growth. Lqudty Needs Defnton Lqudty Needs Perod of tme from the present untl you antcpate you may need access to some of the nvestment dollars. Part 6 Authorzaton and Acknowledgments - (Must be sgned by all new owners or fducares) You confrm that you are at least 18 years of age and full legal age n your state of resdence. You acknowledge that you wll be bound by the terms of the nsurance polcy/annuty contract, as are your hers, executors, admnstrators and successors. Householdng: You understand Amerprse Fnancal may use and combne nformaton concernng accounts, owned by members of a prmary household group to provde members of the group wth paper and/or electronc statements of account(s) and certan account nformaton. These accounts nclude nvestment, nsurance, annuty and brokerage accounts. A prmary household conssts of an ndvdual, hs or her spouse or domestc partner, and any accounts owned for, by or wth ther unmarred chldren under age 21 who resde at the same address. If you want to have a statement coverng only accounts that you own and to not partcpate n household prcng, please call your Amerprse fnancal advsor, or the toll-free number on your statement. Householdng for Shareholder Documents: You understand that Amerprse Fnancal Servces, Inc. may use and combne nformaton concernng accounts owned by members of a household to provde them wth a sngle paper copy of shareholder documents. Prospectuses, supplements, annual reports, semannual reports and proxes may be ncluded. Under ths, household s defned as two or more shareholders who share the same address and ether share the same last name or have ndcated that they are marred or domestc partners. Ths remans n effect unless notfed otherwse. You understand that f you wsh to contnue recevng multple copes of prospectuses, supplements, annual reports, semannual reports and proxes, you can call and reference the clent number found on your statement. Multple malngs wll resume wthn 30 days of the request. Taxpayer's Identfcaton Number to Be Used on Ths Account (See Instructons on Page 18, Part 6) Name (on IRS Records) Assocated Wth Ths Tax Number W-9 TIN Certfcaton Check approprate box for federal tax classfcaton (requred): Indvdual/Sole propretor Corporaton C-Corporaton S-Corporaton Lmted Lablty Company (LLC) C-Corporaton S-Corporaton Partnershp Partnershp Trust Revocable (Optonal Addtonal Trust Detals) Irrevocable (Optonal Addtonal Trust Detals) Estate Other Page 16 of 17

17 DOC Check here f owner s an Exempt Payee (defned n form W-9 nstructons) Exempt Payee code: 1-An organzaton exempt from tax under secton 501(a), any IRA, or a custodal account under secton 403(b)(7) f the account satsfes the requrements of secton 401(f)(2), 2-The Unted States or any of ts agences or nstrumentaltes, 3-A state, the Dstrct of Columba, a possesson of the Unted States, or any of ther poltcal subdvsons or nstrumentaltes, 4-A foregn government or any of ts poltcal subdvsons, agences, or nstrumentaltes, 5-A corporaton, 6-A dealer n securtes or commodtes requred to regster n the Unted States, the Dstrct of Columba, or a possesson of the Unted States, 7-A futures commsson merchant regstered wth the Commodty Futures Tradng Commsson, 8-A real estate nvestment trust, 9-An entty regstered at all tmes durng the tax year under the Investment Company Act of 1940, 10-A common trust fund operated by a bank under secton 584(a), 11-A fnancal nsttuton, 12-A mddleman known n the nvestment communty as a nomnee or custodan, 13-A trust exempt from tax under secton 664 or descrbed n secton 4947 Foregn Account Tax Complance Act Reportng A FATCA exempton code s requred for persons submttng ths form for accounts mantaned outsde of the Unted States by certan foregn fnancal nsttutons. If you are only submttng ths form for an account you hold n the Unted States, no code s requred. Otherwse, submt IRS Form W-9 separately. As used below, the word I refers to the applcant who s the taxpayer on the account. Under penaltes of perjury, I certfy that: 1. The number shown on ths form s my correct taxpayer dentfcaton number, and 2. I am not subject to backup wthholdng because: (a) I am exempt from backup wthholdng, or (b) I have not been notfed by the Internal Revenue Servce (IRS) that I am subject to backup wthholdng as a result of a falure to report all nterest or dvdends, or (c) the IRS has notfed me that I am no longer subject to backup wthholdng, and 3. I am a U.S. ctzen or other U.S. person (defned below), and 4. The payee s exempt from Foregn Account Tax Complance Act (FATCA). Certfcaton Instructons: As used below, the word You refers to the applcant who s the taxpayer on the account. Check ths box f you have been notfed by the IRS that you are currently subject to backup wthholdng because you have faled to report all nterest and dvdends on your tax return. Defnton of a U.S. person. For federal tax purposes, you are consdered a U.S. person f you are: An ndvdual who s a U.S. ctzen or U.S. resdent alen, A partnershp, corporaton, company, or assocaton created or organzed n the Unted States or under the laws of the Unted States, An estate (other than a foregn estate), or A domestc trust (as defned n Regulatons secton ). Non-U.S. persons should submt the approprate Form W-8. Form W-9 and Form W-8 and ther nstructons are avalable upon request or on rs.gov. The Internal Revenue Servce does not requre your consent to any provson of the document other than the certfcatons requred to avod backup wthholdng. All New Owners/Fducares of the accounts dentfed n ths form Must Sgn Here X X Person(s) named n Part 4A, C or D (and Part B n case of jont tenants) must always sgn here. To Be Completed by Amerprse Fnancal Advsor or Area Offce Advsor Name State Date Sgned (MMDDYYYY) Advsor Number Phone Page 17 of 17

18 Instructons for Completng the Change of Ownershp/Annutant Form Please read the nstructons (shown below) completely before completng ths form for submsson to RverSource Lfe Insurance Co. of New York. Part 1 For Lfe Insurance and Annutes, check the box that apples. If nether box s checked, t wll default to gft. Note: There may be tax mplcatons as a result of transferrng ownershp of an annuty. Consult your tax advsor pror to the Transfer of Ownershp. RverSource may report "Gftng" on annutes purchased after Aprl 22, Part 2 Part 3 Gftng/Value Receved Informaton Exstng Account Identfcaton Use ths part of the form to dentfy the accounts that are affected by the nstructon provded on ths form as well as lstng the clent ID numbers of the current account owner(s). Change of ownershp or annutant wll not be completed for account numbers not ncluded n your nstructons. Authorzaton to Transfer Ownershp All current owners must sgn and date. Part 4 New Owner Informaton (Always Complete Part 4) 4A - Indvdual Owner If account s a guardanshp/conservatorshp account, ndcate ths ownershp here, e.g., "John Smth as the guardan (conservator) for Mary Smth." Include the taxpayer dentfcaton number, date of brth, gender and martal status for the mnor/ward/protected person. If new owner s a trust, a completed Certfcate of Trust form (131201) must be submtted wth change of ownershp form. If new owner s an rrevocable trust, a copy of the specal W-9 must also be submtted wth change of ownershp form. To desgnate an Attorney-In-Fact and enable them to act on your behalf, submt the Power of Attorney form (402540). 4B - Jont Owner Check approprate box wth rghts of survvorshp or tenants n common. For annutes, wth rghts of survvorshp can only be used f jont owners are husband and wfe. All others wll be tenants n common. 4C - Unform Gfts/Transfers to Mnors Act Ths ownershp consttutes an rrevocable gft to a mnor/protected person. Only one custodan and one mnor/protected person per account. 4D - Desgnaton of Successor Custodan for UTMA or Successor Owner Complete for Successor Custodan or Successor Owner. 4E - Trust Ownershp or Corporaton If new owner s a corporaton, a completed Corporate Resoluton form (402400) must be submtted wth change of ownershp form. Part 5 Account Sutablty - Change of Ownershp Only The requested account profle nformaton should be provded for each account where account ownershp s changng. The profle nformaton selectons should be based on the preferences of the new owner. Select one Investment Tme Frame for each account that s approprate to the new owner profle/preferences. Select one Rsk Tolerance for each account that s approprate to the new owner profle/preferences. Select at least one but up to three Investment Objectves for each account that s approprate to the new owner profle/preferences. The selectons for 1st, 2nd and 3rd should reflect the prorty rankng of the choces. Part 6 Authorzaton and Acknowledgments Indcate the taxpayer dentfcaton number to be used on the account. If Jont Tenants, only one Owner can be the Taxpayer of record. Please ndcate whch TIN s to be lsted as Taxpayer. If new account s an UGMA/UTMA, the correct TIN s the Socal Securty number of the mnor/protected person. If new account s a guardanshp/conservatorshp account, the correct TIN s the Socal Securty number of the mnor/ward/protected person. If the new account s a trust, ndcate the taxpayer dentfcaton number for the trust. If you have dffculty determnng what TIN to provde, please see the nstructons on IRS Form W-9. Customer Identfcaton Program of USA Patrot Act To help the government fght the fundng of terrorsm and money launderng actvtes, Federal law requres all fnancal nsttutons to obtan, verfy, and record nformaton that dentfes each person who opens an account. We wll ask you for your name, address, date of brth, and other nformaton that wll allow us to dentfy you. We may also ask to see your drvers' lcense or other dentfyng documents. If you are openng an account for a corporaton, trust or other entty, we may also ask for copes of the documents showng the exstence of the entty. Do not send to Home Offce nst Page 18 of 18 AL (09/17)