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Microsoft word - va1 & va3 11-11.doc

Variable Annuity Questionnaire and Disclosure Printed Client Name(s) ______________________________________________________ Current Age: _____ Insurance Company Name: ____________________________________________________________________ Variable Contract Selected from the Insurance Company: ______________________________________________
Approximate Amount of the Contract: $_________________ Features Cost: Living Benefits ____% Enhanced Death Ben.____%
Range (or Average) of “Separate” or “Sub-Account Annual Fees:
Approximate Yearly Mortality & Expense Charges ______% Will this policy replace another variable annuity?  No  Yes (if YES, complete the reverse side of this form) Should you surrender the policy early, the following charges will apply:  No Yes
The amount placed in this policy represents what percent of my investments?  Less than 25% Less than 50%  Over 50% A prospectus dated ___________ has been delivered to me and I will review it in the next 72 hours  No Yes
I anticipate that I will begin to access the money in this policy:
Never
0 - 5 years
6 - 10 years
11 - 15 years
15+ years
after age 59'/2
Client Affirmations:
YES NO
I understand value of the account will fluctuate and may be worth more or less than original amount whenliquidated. The “guarantee” features apply only in case of death or, in certain contracts, as a “living benefit” bya cash payout or a series of payments initially consisting of a return of current capital value in the account.
If I have chosen an "income" benefit, I fully understand that such income is NOT a return ON my investment,but simply a check paid to me out of my own account value. There is no set rate of return assured.
I understand a withdrawal prior to age 59 ½ may result in a 10% IRS penalty on any gains plus ordinary tax.
I understand any “living benefits” paid will be deducted from my account and that any deduction over chosen levelsmay result in a significant decline in the living benefit payment from the date of the excess withdrawal forward.
I understand that the “separate accounts” chosen will differ in risk & volatility & the choices are mine to make &that changes made will be effective as of the close of market. There is no assurance that guidance receivedfrom my FAF representative (if any) or a company administered program will result in market gains.
I understand that, under current tax code, that upon death, a “stepped-up” cost basis is not available and thegain is subject to ordinary income tax.
I understand that by purchasing this product in my IRA or qualified account [including a 403(b) & 457(b)] thatthere are no additional tax advantages from which I will benefit.
8. I understand that if there is a “guaranteed fixed interest account” available under this contract, that transfer of funds between the fixed and variable subaccounts may be limited by time and/or amount.
I understand that there may be a “Market Value Adjustment” (MVA) on this policy, which may reduce theamount received in case of early liquidation. This reduction would be in addition to any surrender charges.
10. I understand that, in times of low interest, the return on “money market” subaccount may be lower than the annual fees charged, resulting in a total return that is negative.
11. I understand that if purchasing a bonus annuity, it may have higher internal charges, reduced crediting or benefits and longer surrender periods.
12. I understand that my First Asset Financial Inc. representative also offers other investment choices, e.g., mutual funds (w/lower fees). I have considered these alternatives and after discussion and after dueconsideration, I consider this variable annuity policy a suitable product for my financial needs and objectives.
13. I understand that there is a “free look” period after the delivery of the contract (length of time varies by state).
14. Based on my current financial status, investment objectives, age, risk tolerance, lack of need for income or liquidity, and investment knowledge, I do verify that a variable annuity is suitable for the portion of moneyinvested in this contract. It is understood that this is a long term investment.
15. I understand the items listed in this disclosure may not include all features of the variable annuity selected. I acknowledge that I have reviewed the above information and agree with the accuracy of the completed
items and have read and understand the items in the “Client Affirmations” section. I believe the policy &
investments meet my needs at this time.
X_________________________________ ______ X__________________________________ ______
M:\FAF\SERVER DOCS\FIRST ASSET FINANCIAL\FAF Forms\VA Forms\VA1 & VA3 11-11.doc Variable Annuity Questionnaire and Disclosure Exchange or Liquidation of a Variable Annuity Policy or a Mutual Fund Investment
(Required for investments made with proceeds from a previous investment liquidated within the last 100 days, Section 1035 exchanges ortransfer of assets from a mutual fund or insurance company, except for a pension or 401(k) rollover).
To First Asset Financial Inc.: I (we) have decided to liquidate or surrender the currently held
mutual fund or policy from:
___________________________________________________________________________________________
which was held for about _____ years & invest the proceeds into the Variable Annuity listed on the
previous page.
I/We have exchanged a deferred variable annuity within the past 36 months:
NO
YES (if “yes,” please offer an explanation to your registered representative) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____ A surrender charge will be incurred on the liquidation of the existing investment in the amount of
-OR- (check upper or  lower statement, whichever applies)
_____No sales charge or surrender charge will be incurred on the liquidation of the currently owned
investment.
My Representative has given me a copy of FINRA’s “Should You Exchange Your Variable Annuity”:
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- This contract offers new or additional benefits that I/we find advantageous over the
policy or the mutual fund formerly held:

Lower M&A costs than the previous VA Account insurance extends to an older age More flexible ownership options available Better suited to my long-term objectives The quarterly reports are easier to understand New contract provides an initial “bonus” of ____% of principal investmentA “living benefit” feature, superior living benefit or "income" features available in this contractProvides specific separate accounts that have different investment objectives, inverse or industry specific accounts, specific index accounts, or other special features desired Availability of professional money manager I/we prefer (consider naming them below)The policy provides tax deferral that could not be obtained with a mutual fundAdditional insurance benefits available upon death not available with mutual fundsThe death benefit has “step up” guarantee features or more favorable “step up” featuresVariety of money managers available versus only one or a few management companiesContract contains asset allocation or other models offered that were not offeredI (We) understand that if the currently owned VA had a higher initial value than the current liquidationvalue, the value of insurance will be less in the new policy by at least that amount if a new VA ispurchased. A decreased death benefit would negatively affect me in such conditions on an exchange ofpolicies.
Other reason(s) for liquidating one investment and investing the proceeds into the new purchase is(are): ___________________________________________________________________________________________ The undersigned hereby affirm that all the above items are understood and acknowledged: X_________________________________ ______ X__________________________________ ______
For More Information, Go To: http://www.sec.gov/investor/pubs/varannty.htm M:\FAF\SERVER DOCS\FIRST ASSET FINANCIAL\FAF Forms\VA Forms\VA1 & VA3 11-11.doc

Source: http://www.firstasset.biz/assets/pdf/VA1_and_VA3.pdf

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