Fixed Annuity Compliance Form

Hilltop Securities Independent Network Inc. 1201 Elm St., Suite #3500, Dallas, TX 75270 Fixed Annuity Compliance Form Select One: Individual Joint Trust Other Non-Natural Entity (Specify) 1. Representative/ Product Information Representative Name: Rep #: Branch #: Insurance Company: Product: Select One: Non-Qualified OR Qualified Select One: Fixed Indexed SPIA DIA 2. Annuitant/ Applicant Information Name of Contract Owner (First, Middle, Last) or Business/ Trust/ Entity Name Social Security #/ Tax ID # of Birth (Month/Day/Year) Name of Joint Contract Owner (First, Middle, Last) (If applicable) Social Security #/ Tax ID # of Birth (Month/Day/Year) Name of Annuitant (First, Middle, Last) Social Security #/ Tax ID # of Birth (Month/Day/Year) 3. Customer Identification USA PATRIOT Act - Important Information About Opening A New Account To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means to you: When you open an account, we will require your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver s license or other identifying documents. For Contract Owner: Driver s License Passport/Visa Other Issuer: of Issuance (If applicable): ID Number: of Expiration (If applicable): For Owner Co-Applicant (If applicable): Driver s License Issuer: Passport/Visa Other ID Number: of Issuance (If applicable): of Expiration (If applicable): For Annuitant (if different from Owner): Driver s License Passport/Visa Other Issuer: ID Number: of Issuance (If applicable): of Expiration (If applicable): 4. Customer Profile Marital Status: Single Married Divorced Widowed Number of Dependents: Citizenship Status: photo ID and a completed W-8BEN) U.S. Citizen Resident Alien Non-Resident Alien (If a Non-Resident Alien, you must provide a valid government-issued Country of Citizenship if Non-U.S. : Owner s Employment Information (Please specify if self-employed, unemployed, retired, homemaker, student or other): Employer (If self-employed or retired, specify type of business.) Occupation/Job Title Business Telephone Employer s Address City State/Province Country Zip Code For Entity Applicant (Must include copy of organizational document and appropriate trading authorization): Trust Agreement Articles of Incorporation Partnership Agreement Other Fixed Annuity Compliance (11/1/2015) 1

Customer Affiliations and Disclosures Indicate the affiliation of yourself, your spouse, or any other immediate family members (i.e. parents, siblings, children or inlaws) with the following (Please include name and relationship as is applicable): A senior military, governmental or political official in either the U.S. or a foreign jurisdiction? (If yes, identify the name of the official, office held, and country.): Self Family Member No Yes Yes Customer Investment Objectives and Risk Tolerance Select the categories that best describe your investment objectives (and if joint that of any co-applicants) and the risk that you are willing to assume in this account. Different investment products and strategies involve different degrees of risk. The greater the expected returns of a product or strategy, the greater the risk that you could lose some or all of your investment. Investments should be chosen based on your objectives, timeframe, and tolerance for market fluctuations. Select One Primary Investment Objective with Your Associated Risk Tolerance (Check one box only) Capital Preservation Low Risk Tolerance Descriptions Low (Conservative): I want to preserve my initial principal in this account, with minimal risk, even if that means this account does not generate significant income or returns and may not keep pace with inflation. Income Low Moderate High tolerate some volatility to seek higher returns, and understand I could lose a portion of the money invested. Moderate: I am willing to accept some risk to my initial principal and Growth Moderate High principal, including high volatility, to seek higher returns over time, and understand I could lose all or a substantial amount of the money High (Aggressive): I am willing to accept high risk to my initial invested. Investment Objective Descriptions Capital Preservation: The object of capital preservation is to protect your initial investment by choosing investments that minimize the potential of a loss of principal. The long-term risk of this strategy is that returns may not offset inflation. Income: The primary objective of the income strategy is to provide income rather than the long-term growth of principal. Growth: The objective of the growth strategy is to increase the value of your investment over time while recognizing a high likelihood of volatility. Customer Financial Information Financial Information Contract Owner (Please check this box if for joint applicants you would like to combine your incomes and net worth: ) Investment Experience (Years) Stock Bonds Mutual Funds Annuities Options Commodities Other (List) Annual Income 1 Net Worth 2 Liquid Net Worth 3 Federal Tax Rate % Time Horizon - When will you use the annuity for your stated objective(s)? Under 3 years 3-5 years 6-10 years 11-20 years Over 20 years Fixed Annuity Compliance (11/1/2015) 2

Additional Customer Information (Combine Information for Joint Accounts) Annual Expenses 4 (Recurring) 50,000 and under 50,001-100,000 100,001-250,000 250,001-500,000 Over 500,000 The investments in this account will be: (Check one) Less than 1/3 of my financial portfolio Roughly 1/3 to 2/3 of my financial portfolio More than 2/3 of my financial portfolio Special Expenses 5 (Future/ Non-Recurring) Not Applicable (N/A) 50,000 and under 50,001-100,000 100,001-250,000 Over 250,000 Timeframe for Special Expenses Special Expense: Not Applicable (N/A) Within 2 years 3-5 years 6-10 years 11 years or more Description of Terms 1 Annual income includes income from sources such as employment, alimony, social security, investment income, etc. 2 Net worth is the value of your assets minus your liabilities. For purposes of this application, assets include stocks, bonds, mutual funds, other securities, bank accounts, and other personal property. Do not include your primary residence among your assets. For liabilities, include any outstanding loans, credit card balances, taxes, etc. Do not include your mortgage. 3 Liquid net worth is your net worth minus assets that cannot be converted quickly and easily into cash, such as real estate, business equity, personal property and automobiles, expected inheritances, assets earmarked for other purposes, and investments or accounts subject to substantial penalties if they were sold or if assets were withdrawn from them. 4 Annual expenses might include mortgage payments, rent, long-term debts, utilities, alimony or child support payments, etc. 5 Special expenses might include a home purchase, remodeling a home, a car purchase, education, medical expenses, etc. I plan to use this account for the following (Check all that apply) Retirement Income Tax-deferred Growth (not applicable for qualified plans) Death Benefit Creditor Protection (not applicable for qualified plans) Other: What is your source of funds for this account (Check all that apply) Income from Earnings Investments/ Transfer from Brokerage Account 1035 Exchange or Qualified Transfer from Annuity or Life Insurance (fill out side by side comparison and include recent statement) Gift Sale of Business or Real Estate Inheritance Pension/401k Spouse/ Parent/ Relative Legal/ Insurance Settlement Matured CD Mutual Funds * Other: * Use Long Term Investment Exchange Form for Mutual Funds Customer Other Investments Information Please provide us with additional information about your other investments to help us more fully understand your financial situation and the types of investments or strategies that may be appropriate for your total investment portfolio. (Use additional pages if needed) Investment Type/Description Firm Holding Your Investment Amount of Investment Customer Other Annuities Information Variable or Fixed Insurance Company Amount of Annuity Qualified or Non-Qualified Fixed Annuity Compliance (11/1/2015) 3

Annuity Purchase Form Complete Proposed Policy side for new money purchases. (Long Term Investment Exchange form required if source of funds are mutual funds) Complete Existing Policy and Proposed Policy side by side comparison for exchanges/replacements. (Include recent statement of existing policy) Insurance Company Name: Product Name: Type of Contract: Fixed or Variable Annuity/Life policy Issue : Existing Policy Proposed Policy Current Market Value (for existing product) New Estimated Market Value (proposed policy) (less surrender charges plus applicable bonus) Existing Policy Surrender Charges: N/A Cash Surrender Value: N/A (market value less surrender charge) Surrender Period Remaining A: Years A: A: Guarantee Period & Fixed Interest Rate: B: % by year B: B: Death Benefit Value: List the death benefit that applies & cost: Cost Cost Living Benefit Value: List the living benefit and other features (i.e. bonus) that apply & their costs: TOTAL Annual Charges (%) to include M&E, Admin. and Features (excludes subaccount management expenses) Explain the client s intentions for the annuity purchase, and for exchanges, how does the exchange benefit the client: We have confirmed with the existing carrier that the additional benefits are not able to be added to the current contract. Owner s Initials Representative s Initials Owner Signature: : Joint Owner Signature: : Representative Signature: : Fixed Annuity Compliance (11/1/2015) 4

5. Fixed Annuity Disclosures PLEASE READ ALL OF THE DISCLOSURES BELOW. SIGN TO ACKNOWLEDGE YOU HAVE READ AND UNDERSTAND THEM. I/We agree that this annuity is suitable for my insurance and financial objectives. I/We understand fees/charges associated with this annuity have been explained. I/We understand that renewal rates may decrease due to market fluctuations and company practices. I/We understand a Federal income tax penalty of 10% may be imposed on withdrawals taken prior to age 59 1/2. I/We understand that annuities placed in qualified plans do not add any tax-deferral benefits. I/We understand that earnings, when withdrawn, may be taxed as ordinary income. I/We understand that a limited number of insurance companies contribute to the cost of my broker dealer s conferences and education for it s representatives, which does not add any expense to my contract. This company: IS IS NOT one of those contributing insurance companies. I/We: HAVE HAVE NOT had another exchange within the preceding 36 months. If I/we have had an exchange please provide the details of the exchange (i.e. date, policies, representative, company, etc.): For SPIA Purchases: I understand that the format of the immediate annuity payments will be: My payments have been calculated (if fixed), and will be per I (circle one) AM / AM NOT foregoing my principal for the agreed periodic payments. For Indexed Annuity Purchases: I/We understand that the rate of return of this annuity can vary due to the specific crediting methods, participation rates, earnings caps and spreads, as well as performance of the indexes upon which this annuity is based. The method of crediting interest, participation rates and caps for my particular annuity has been explained to me in full. Rates are subject to change. INDEX CREDITING METHOD CAP RATE PARTICIPATION RATE SPREAD % Allocated --add to 100%-- - = 100% 6. Customer Signature(s) I/WE HAVE READ AND UNDERSTAND THE DISCLOSURES LISTED ABOVE. x Contract Owner s Signature Contract Owner s Printed Name x Joint Owner s Signature Joint Owner s Printed Name Fixed Annuity Compliance (11/1/2015) 5

7. Rollover Requirements (if applicable) The funds or securities deposited into the IRA or Qualified Plan must be deposited within 60 days of receipt; Rollover deposits cannot include any distributions which are a part of a series of substantially equal periodic payments; Rollover deposits cannot include any distributions which represent a required minimum distribution; Rollover deposits must consist of the same assets originally distributed; In an IRA to IRA rollover, the assets cannot have been involved in a rollover in the past 12 months; Rollovers from Qualified Plans may consist of the proceeds from the sale of distributed property; Rollovers from Qualified Plans can consist only of tax deferred funds; Rollover deposits to a SIMPLE IRA can consist only of funds or securities distributed from a SIMPLE IRA; If I choose to make contributions to my rollover IRA, I understand that combining regular IRA contributions with rollover/direct contributions from employer plans may preclude me from rolling over these funds into a subsequent employer s plan. 8. Rollover Deposit Certification (if applicable) I understand that there are a number of options available to me which include: Rolling my assets to my current employer s plan (if you have a new job and the plan permits it). Keeping my assets in my former employer s plan (if the plan permits it.) Rolling my plan assets into an IRA. Taking a distribution in cash (taxes will apply and withdrawal penalties may apply). I further understand that before making the decision to rollover my account I considered my retirement plan options carefully which includes but may not be limited to: The benefits and penalties involved including any withdrawal penalties. Investment or account related fees and expenses. Differing levels of services available. Required minimum distributions. Tax consequences which may vary based on my state and individual situation. For more information please see the FINRA Investor Alert entitled 10 Tips to Making a Sound Decision located at: http://www.finra.org/investors/protectyourself/investoralerts/retirementaccounts By signing this form, I certify that this deposit meets all of the above rollover eligibility requirements and assume full responsibility for any tax consequences arising from this rollover. I further understand that rollover contributions have important tax implications, and I have been advised to seek guidance from a tax professional. x Applicant s Signature 9. Non-Natural Person (if applicable) Hilltop Securities Inc. /Hilltop Securities Independent Network Inc. does not offer legal counsel or tax opinions, and we suggest that you consult your personal tax or legal counsel for assistance regarding your specific circumstances. Annuity contracts owned by trusts, Family Limited Partnerships ( FLP ) and other non-natural persons generally will be subject to tax each year on interest or earnings accruing in the annuity contract, unless the trust, FLP or other non-natural person is considered to be an agent of a natural person. Whether a specific non-natural person can hold an annuity contract on a tax-deferred basis will depend on the specific facts and circumstances of the trust, FLP, etc. designated as owner. The purchaser will need to determine whether the trust, FLP or other non-natural person is acting as an agent of a natural person. If a contract is treated as NOT being tax-deferred, earnings and other investment gains may be tax reported (by the insurance company issuing the contract) to the IRS each year. If a contract is treated as tax-deferred, only surrenders or partial withdrawals from the contract will be tax reported, and may be subject to the 10% penalty tax on premature distributions. Information in this letter is subject to change, based on changes in the laws, regulations, or official IRS interpretations thereof. After reading this letter, please sign below indicating that you understand the tax consequences of not being considered an agent for a natural person. Signature of Annuitant or Trustee of Annuity Contract Print name of Annuitant or Trustee Fixed Annuity Compliance (11/1/2015) 6

10. Bonus/Premium Credit Disclosure (if applicable) I am aware that I am purchasing an annuity that has a bonus or premium credit. I am aware that the bonus/premium credit could have the following associated with it and have discussed each with my financial advisor and understand how the purchase of the bonus/premium credit affects my specific annuity. Higher Surrender Charges Longer Surrender Charges Higher Mortality and Expense Charge Additional Charge for Bonus Bonus/Premium Credit Does Not Offset Surrender Costs I have discussed other options available without the bonus/premium credit and their associated costs and surrender period/charges. I would like to continue with the purchase of the annuity with the bonus/premium credit. Owner(s) Printed Name(s) Owner(s) Signature(s) Non-Qualified Transfer of Funds For a Non-Qualified transfer of funds from a Hilltop Securities Account: Please transfer from Hilltop Securities Account # To (Insurance Company): FBO: Owner Signature: X Joint Owner Signature: X : : Representative Information you gave the privacy notice to the client: / / Is the business being conducted in the client s resident state? Yes No Is your license, for this type of business, current in the state of business? Yes No Are you appointed with this insurance company in the state of business? Yes No Are you satisfied this product, as purchased, is suitable for this client? Yes No If this annuity is owned by a non-natural person, have you had the client sign the appropriate form? Yes No N/A I have taken the product training required by the insurance carrier prior to selling this fixed annuity. Yes No Representative Signature: X : Branch Manager/ OSJ Suitability Review Does the broker have the appropriate state insurance license? Yes No Does the annuity create a potential liquidity problem(s) for the client during the surrender charge period? Yes No If yes, explain your approval: In your judgment, is the client s age suitable for the stated time horizon? Yes No Are the riders and options purchased consistent for the client s goals and reasons given for the purchase of the annuity? Yes No Are the options (fixed or indexed) chosen consistent with the client s investment objective? Yes No If this is a replacement or exchange, review the previous contract s statement: What are the surrender costs incurred by the client? Do you agree with the reasoning and economics of the exchange or transfer? Yes No N/A If this contract includes a bonus, are any additional charges or increased surrender periods appropriate for the client? Yes No N/A Branch Manager/ OSJ Printed Name: X Branch Manager/ OSJ Signature: X : Insurance Principal Signature: X : Fixed Annuity Compliance (11/1/2015) 7