VARIABLE ANNUITY ACKNOWLEDGMENT - Capital Investment …

Indexed & Variable Annuity Acknowledgement

Product Name:

I understand and have discussed the following items with my investment professional:

I am purchasing this product for the following reason(s): (Check each applicable item.)

Death Benefit Principal Protection Tax Deferred Growth

Guaranteed Immediate Income Guaranteed Future Income Guaranteed Accumulation

Step-Ups: Income _____ Death Benefit ______ Long Term Care/Nursing Home Rider Other

Annuities have an objective of tax-deferred growth and are typically used as long-term investments.

Variable and indexed annuities have risk and are subject to market changes, both positive and negative, which could result in losses of principal and

interest. Guarantees provided by this annuity are NOT guaranteed by the Federal Government, only by the annuity insurance carrier.

Annuities are NOT mutual fund products. At the death of the annuitant/owner, gain in the contract may be taxable as income to the beneficiary.

Distributions from an annuity are covered under Internal Revenue Code Section 72. Withdrawals from annuities may be subject to a 10% penalty tax,

unless received after age 59 ?. Any amount that is not received as an annuity is taxable as ordinary income, to the extent that the balance of the

contract is greater than the investment in the contract.

I understand that, if I am purchasing this contract in an Individual Retirement Account or qualified plan, the tax-deferral feature is not an advantage.

My free-look period is

days. During this period of time, I can terminate the contract without paying any surrender charges and

receive a refund of my purchase payments.

I received a prospectus, dated ____________________.(variable annuities only).

I understand I will pay total annual charges of _______________% of the contract value, including rider charges, but excluding sub-account expenses.

I am aware of the surrender penalties for early withdrawals, as well as the management fees, insurance cost, maintenance and expense charges and

annual policy fee. They are as follows:

Year # 1

2

3

4

5

6

7

8

9

10

Penalty:_____% _____% _____% _____% _____% _____% _____% _____% ____% ____%

1.

Client should initial ONLY the blank(s) pertaining to this annuity contract:

For Annuities with Death Benefit Riders: __________ Death Benefit Riders may be lost should the contract's account value fall below contractual minimums. For Annuities with income benefits, accumulation benefits and principal protection: __________ Withdrawals may reduce guarantees, including income benefits, accumulation benefits and principal protection, as detailed in the prospectus given me. . For Annuities with bonus credits: __________ I understand the purchase of bonus credits may result in higher surrender charges, longer surrender periods, and increased annual costs.

CURRENT HOUSEHOLD INVESTMENTS

Stocks, Bonds and Mutual Funds

$

Real Estate (exclude Primary Residence)

$

Cash & Equivalents (not including this annuity) $

Other (please explain)

$

Total Household Net Worth $

Funding Amount (for this contract)

$______________

Total Household Annuities (including this one) $______________

Total Annuities ? Total Net Worth =

%

I, the undersigned, fully understand the above items.

Owner(s):

Name

Signature

Registered Representative:

Name Name

Signature Signature

Securities Offered through Capital Investment Group, Inc. or Capital Investment Brokerage, Inc.

Date Date

Date v. 5/19

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