VARIABLE ANNUITY TRANSACTION...

VARIABLE ANNUITY TRANSACTION WORKSHEET

(MUST BE COMPLETED FOR ALL VARIABLE ANNUITY INITIAL PURCHASES)

©2008 Cetera Advisors LLC14-0431 MFSC 398 08/14

*MFSC-398------*

Please note: form must be completed in its entirety. Please do not leave any portion blank as it may delay the processing of your request. The registered representative should complete Sections A, B and D, and the client should complete Section C.

Client Name

$ Company and Product Name Investment Amount

Account Type: Qualified Non-Qualified

A. SOURCE OF FUNDS (Please check all that apply)

1035 Exchange (VA to VA) An Exchange Disclosure Form is attached

AND A Side-by-Side Summary from the VA Comparison Tool has been provided to the client

Liquidation of a VA, VUL, fixed or index annuity, fixed life or mutual fund An Exchange Disclosure Form is attached

AND A Side-by-Side Summary from the VA Comparison Tool has been provided to the client (required if this was the liquidation of a VA)

Checking, savings or money market account or certificate of deposit Please Note: If funds have come from a VA, VUL, fixed or index annuity, fixed life or mutual fund within the last 90 days, an Exchange Disclosure Form is required. If funds have come from a VA within the last 90 days, a Side-by-Side Summary from the VA Comparison Tool is also required.

Rollover from a qualified plan (e.g., 401(k), 403(b), 457, profit sharing plan) This is not a forced distribution – an Exchange Disclosure Form is attached This is a forced distribution – an Exchange Disclosure Form is not attached This is a rollover from a VA – a Side-by-Side Summary from the VA Comparison Tool has been provided to the client

Other (specify):

A1. Has client liquidated or exchanged any other deferred variable annuity at any broker-dealer Yes No in the past 36 months? If yes, please provide details in question B9 on page 3.

A2. Have all state specific requirements for sales to seniors been met, if any? If client is not a senior, check N/A. Yes No N/A

A3. Was a hypothetical illustration shown to client? If yes, attach a copy. Yes No

I have provided a prospectus and explained the material features and costs of variable annuities Yes Noto the client.

B. SUITABILITY INFORMATION

I understand that the Firm’s systems must match the suitability information provided in this section that pertains to the client.

The suitability information that pertains to the client has been updated in the Firm’s systems as applicable. Yes No

or

I have attached an updated Account Information Form so that the information is the same. Yes No

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4600 S Syracuse St, Ste. 600Denver, CO 80237 • 800.929.3485


B1. Complete the following information as it pertains to the client. (Please note: this information must match the Firm’s systems, and you must update the records as appropriate, if needed.)

Client Age(s):

Investment Experience:Stocks: years Bonds: years Mutual Funds/ETF: years Options: years DPPs: years

REITs: years Other (identify): : years

Annuities: Variable Annuities: years VUL: years Fixed Annuities: years Fixed Life: years

Annual Income (approximate): $ Sources (specify):

Liquid Net Worth: $ (Liquid Net Worth is Adjusted Net Worth minus assets not readily convertible to cash.)

Account Liquidity Needs (over next 3 years): $

Federal Tax Bracket: 0 – 15% 16 – 28% 29 – 36% >36%

Asset Breakdown: (regardless of where held)

Checking, Savings, Money Market $ Certificate of Deposits $Equities $ Unit Investment Trusts $Annuities – Variable $ Annuities – Fixed $Options $ Exchange-Traded Funds $VUL:

Death Benefit $Fixed Life:

Death Benefit $Cash Value $ Cash Value $

Fixed Income $ Real Estate $Precious Metals $ Mutual Funds $Insurance $ Commodities & Futures $Other: $

Please list type and amount

B2. Complete the following information as it pertains to the investment. (Please note: this information may or may not be the same as the overall client profile.)

Primary Sub-Account Investment Objective: (select one) Capital Preservation Income Total Return Growth Aggressive Growth

Risk Tolerance: Conservative Moderately Conservative Moderate Moderately Aggressive Significant Risk

Investment Time Horizon: 4 years or less 5 – 8 years More than 8 years

B3. What is the percentage surrender charge schedule for this VA?

_________/_________/_________/_________/_________/_________/_________/_________/_________/_________

B4. Annual free withdrawal percentage per year: %

B5. Surrender charges waived: at death? Yes No For long-term and/or nursing home care? Yes No

B6. If this is a recommendation to purchase a variable annuity to fund a tax-qualified retirement plan (eg., 401(k), 403(b), 457 or IRA), what additional benefits or features are provided in the VA? Check all that apply

Living benefit Death benefit Consolidation of funds with a variety of investment choices Lifetime income options Other:

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B7. Describe in detail how the client will benefit from certain features of variable annuities (e.g., tax deferred growth, death benefit, retirement, income and/or annuitization).

B8. Describe in detail the benefits to this client of each rider, bonus or other additional features selected in this particular variable annuity and why each is suitable for the client.

B9. If the answer to question A1 on page 1 is “yes,” describe in detail the reasons for the liquidation or 1035 exchange from another variable annuity, if known.

C. CLIENT ACKNOWLEDGEMENT

I acknowledge that the client information provided on this form is complete and accurate to the best of my knowledge. I further acknowledge that I have been provided with a prospectus and an explanation of the material features and costs of variable annuities.

Print Client’s Name Client’s Signature Date

D. REGISTERED REPRESENTATIVE AND DESIGNATED SUPERVISOR SIGNATURES

I have provided a prospectus and explained the material features and costs of variable annuities to the client.

I have updated the suitability information in the Firm’s systems as applicable so that the information is the same as the client information shown in question B1 of the Suitability Information section above.

Print Registered Representative’s Name Rep Number Registered Representative’s Signature Date

Designated supervisor’s additional comments or information:

Print Designated Supervisor’s Name Designated Supervisor’s Signature Date

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