Variable Annuity Suitability Form

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1 Variable Annuity Suitability Form P.O. Box 64284, St. Paul, MN (800) woodburyfinancial.com This submission must contain the items listed below. If any of the following items in this submission are missing, incomplete, or not signed, the review process will be delayed. Any attached written statements or material changes must be signed and dated by the client. Variable Annuity Point of Sale and completed Suitability Addendum, if applicable. Variable Annuity Application (if pending the sponsor application, please write indication on top of this page.) If this is a Variable Annuity replacement, please attach a current statement. Advisor number V2020 account number Transaction type (please check one) Initial purchase Subsequent purchase Client Financial and Investment Information 1. Owner client or contract name Business type (please check one) Direct Brokerage Brokerage/Subscribe order 1 Pershing # 2. Client age 2 3. Provide a summary of client s total investable assets after this purchase. NON-QUALIFIED QUALIFIED Variable Annuities 3 (including this purchase) $ $ Marketable Securities $ $ Cash & Cash Equivalents $ $ Fixed Annuities $ $ Alternative Investments $ $ TOTAL INVESTABLE ASSETS $ $ Face amount of existing life insurance $ 4. How long does the client intend to hold the proposed product? 0-5 years 6-10 years years 20+ years (or lifetime) 5. If the client intends to take withdrawals/distributions, please indicate the anticipated need/start date. 0-5 years 6-10 years years 20+ years No plans to take withdrawals 5a. During the surrender charge period I anticipate that I will access: RMD 72T/72Q Free out amount Not applicable Other Note: If client plans to do a 72T/72Q, please include calculations, if available, to expedite the review. 6. Please rank (1, 2, 3... ) one or more of the following reasons for recommending a deferred variable annuity. Annuitization Death Benefit Retirement income 7. Please indicate the client s investment experience with annuities. Equity Indexed Annuities years Variable Annuities years Tax Deferral (non-qualified only) Fixed Annuities years Variable Life Insurance years Wealth Transfer/Estate Planning Other Immediate Annuities years 1 You must provide detailed instructions if the purchase amount is an approximation or will differ from the exact amount stated on the application. 2 If client age is older than 70 or younger than 45, please complete the Suitability Addendum. 3 If the client s total VA holdings exceed 50% of the total investable assets, please complete the Suitability Addendum /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 1 of 9

2 Proposed Product and Transaction Information 8. Annuity company 9. Product name 10. Product surrender schedule None years % % % % % % % % % % 11. Enhancement riders (check all that apply) GMWB (long-term withdrawals) GMIB (annuitization) GMAB (lump sum return) Other 12. Is there an enhanced death benefit rider on the proposed contract? Yes No 13. Purchase amount $ 15. Is this purchase in a managed account? (Note: Only approved no-load products can be purchased in a managed account.) Yes No If yes, what is the proposed IA fee? % 16. Do the subaccounts selected on the application correspond to the client s stated risk tolerance? Yes No If no, please explain why the allocation is appropriate. 14. Is the proposed transaction solicited? Yes No 17. Please summarize the rationale for recommending this particular product. 18. Please rank (1, 2, 3... ) one or more of the following reasons for purchasing this variable annuity product. Death benefit Diversification/asset allocation Income/living benefits Lower cost structure (fees and charges) Performance (must provide analysis) Superior insurance rating Tax deferred treatment of earnings Other: 19. Is this transaction part of a recommended investment strategy? Yes No If yes, select the investment strategy for this account. Asset Protection Charitable Giving Education Savings Estate Planning Investment for Future Expenses Investment Speculation 20. Has the client had any variable annuity replacements at this, or any other broker-dealer in the previous 36 months? Yes No Retirement Accumulation Stage Retirement Distribution Stage Other If yes, please provide details indicating how the client s needs and objectives have changed and why the client believes he/she will remain in the annuity for the expected holding period given. Include replaced carrier s name and an approximate date of replacement. 21. Please list all client-owned variable annuities, including any contracts being replaced. Company and product name Purchase date Contract value Surrender value Did advisor sell? Qualified? Result of a replacement? $ $ Yes No Yes No Yes No $ $ Yes No Yes No Yes No $ $ Yes No Yes No Yes No /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 2 of 9

3 Proposed Product and Transaction Information (continued) 22. Please indicate the source of funds for the proposed VA and answer the questions to the right of product type. (check all sources that apply) Variable Annuity (complete the following page and SKIP section below and questions 23-24) Cash/New Money Previous Investment (select below the specific products that were/will be liquidated to purchase the proposed annuity) Check sources that apply * Recent statement required Full surrender? Liquidated amount Liquidation fee/cdsc Guaranteed interest rate Holding period Sold by current advisor? Stock/Bond $ $ % years Yes No Mutual Fund $ $ % years Yes No CD $ $ % years Yes No VUL* Yes No $ $ % years Yes No Fixed Annuity* Yes No $ $ % years Yes No EIA* Yes No $ $ % years Yes No Other: Yes No $ $ % years Yes No 23. If liquidation fee/cdsc charge is incurred as indicated in Section 22 above, please explain why it s advantageous to liquidate now as opposed to waiting for the surrender schedule to expire and complete Section D of Suitability Addendum. Expenses of Proposed Annuity If VA was not checked as a source of funds in Section 22. Please complete only Section 24 below and skip the Replacement Comparison Worksheet on the following page. If VA was selected as a source of funds in Section 22. Please skip Section 24 below and complete the Replacement Comparison Worksheet on the following page. 24. Please complete the expenses below for the proposed variable annuity. Mortality & expense fee % Administrative/distribution expense fee % Living benefit rider expense % Death benefit rider expense % TOTAL CONTRACT EXPENSES (less subaccount expense) % Subaccount expense range % /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 3 of 9

4 P.O. Box 64284, St. Paul, MN (800) woodburyfinancial.com VA Replacement Comparison Worksheet Please complete this page only if the source of funds is a variable annuity. If this replacement involves a 1035 partial exchange, it is recommended that the client consult with a tax specialist to determine if this transaction qualifies for a partial 1035 exchange. Full replacement Partial replacement $ NOTE: If more than one variable annuity is being replaced, please include additional VA Replacement Comparison Worksheets. For replacements, attach a current statement for each contract being replaced. VA REPLACEMENT COMPARISON CURRENT POLICY PROPOSED POLICY Annuity company name Annuity product name Policy/contract # Contract issue date Annuity current total value Initial total premium Net premiums (premiums less withdrawals) NA NA RIDERS Living benefit rider name Guaranteed minimum living benefit base Death benefit rider name Guaranteed minimum death benefit base EXPENSES Mortality & expense risk fee % % Administrative/distribution expense/fee % % Living benefit rider expense % % Death benefit rider expense % % TOTAL CONTRACT EXPENSES (less subaccount expense) % % Subaccount expense range % % Is there a CDSC fee for liquidating the existing contract? Yes No CDSC amount: $ % of transaction amount Total surrender period Years remaining IMPORTANT REMINDER: If the client incurs CDSC exceeding $1,500 or 2% of contract value and/or any benefit losses, please complete section D of the Suitability Addendum /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 4 of 9

5 P.O. Box 64284, St. Paul, MN (800) woodburyfinancial.com Suitability Addendum Complete the applicable section(s) only if one or more of the thresholds below are exceeded. Please note that substantially surpassing the thresholds may decrease the likelihood of approval. Client s total VA holdings exceed 50% of their total investable assets. (Complete section A) Client is age 70 or older (Complete section B) Client is age 45 or younger (Complete section C) Client will incur a loss (surrender charges, benefit value losses, etc.) (Complete section D) Section A: VA Holdings Exceed 50% of Total Investable Assets 1. Please list all major current and future annual sources of income aside from proposed investment. Amount $ /yr Source Start date/age Amount $ /yr Amount $ /yr Source Source Start date/age Start date/age 2. What are the annual expenses (medical, rent/mortgage, food, auto, revolving debt, entertainment, etc.): $ If annual expenses are reduced during retirement, list reduced amount: $ 3. Please list any funds available for emergencies $ Source(s) 4. After purchasing this annuity, will the client have sufficient income and liquid assets to meet monthly expenses, financial emergencies, and/or personal purchases without accessing significant cash values from the annuity? Yes No 5. Did you discuss other potential investment options? Yes No If yes, provide a brief description below. Other asset(s) discussed Were expense comparisons or illustrations given? Yes No It may be helpful to elaborate with any other specific financial details, events, and/or conversations in section E. Section B: Client Age 70 or Older 1. After purchasing this annuity, will the client have sufficient income and liquid assets to meet monthly expenses, health care costs, retirement, and/or estate needs? Yes No 2. Did you discuss all applicable maximum age limitations for the guaranteed benefit values involves? Yes No 3. If choosing an income benefit rider, please indicate the primary need or intention for the distributions Charity/gifting Health/long-term care Living expenses Travel/leisure Other (please describe) 4. If choosing a lifetime withdrawal rider, is the client aware that the principal has to be fully depleted before the rider provide additional guaranteed value? (Withdrawal benefits will typically require as many as years to recognize additional returns due to the maximum withdrawal restrictions of the benefit.) Yes No For clients age 80 or older, please elaborate with any other specific financial details, events, and/or conversations in section E /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 5 of 9

6 Section C: Client Age 45 or Younger If the client has a unique retirement situation (such as a professional athlete, young executive, business owner, high net worth, etc.) where the following questions may not be applicable, please indicate these circumstances in section E. 1. When does the client anticipate using his or her investments for retirement? age 2. If the client s employment situation changed, would he or she anticipate a need to access cash values from this annuity beyond the product and IRS restrictions? Yes No 3. Did you discuss other potential investment options? Yes No If yes, provide a brief description below. Other asset(s) discussed Were expense comparisons or illustrations given? Yes No 4. Does the client have the ability to contribute to an employer sponsored retirement plan? Yes No If yes, is the client contributing or plan on contributing into the plan? Yes No 5. Does the client intend on making continuing contributions into this proposed variable annuity? Yes No If yes, how often? 6. If choosing an income rider: Considering the client is most likely in the accumulation phase, please explain why guaranteeing income is important now. (The likelihood of receiving additional benefits may be decreased with longer holding periods, changing investment needs, change in products or riders, etc.) It may be helpful to elaborate with any other specific financial details, events, and/or conversations in section E. Section D: Client Will Incur a Recognized Loss (check all that apply) Surrender Charges Surrender charge amount $ Years remaining 1. Please explain why you feel it is more beneficial to replace now vs. waiting for the surrender schedule to expire: 2. Please explain why you feel it is more beneficial to replace the full amount now vs. surrender free amounts until the surrender schedule expires: If CDSC exceeds $1,500 or 2% of the contract value, please complete questions 1-3 at right. Loss of Living Benefit Guarantees Living benefit loss amount $ If there is a loss of living benefits, please complete questions 1-2 at right. Death Benefit Guarantees Death benefit loss amount $ 3. Considering the penalty incurred by liquidating the current product before anticipated, how will this be avoided with the proposed VA? 1. What has changed since the existing contract inception date that the current product no longer meets the client s needs and goals as originally intended? 2. If electing a new living benefit rider: Why is the client willing to pay for a new guarantee instead of utilizing the current one? 1. Was the death benefit part of the recommendation for choosing the existing VA? Yes No 2. Has the client purchased any new life insurance since the original contract was purchased? Yes No 3. What are the main reasons the client is willing to forfeit a higher guaranteed death benefit value? If there is a loss of death benefit, please complete questions 1-3 at right. Section E: Advisor Attestation/Additional Rationale for Recommendation /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 6 of 9

7 P.O. Box 64284, St. Paul, MN (800) woodburyfinancial.com Client Acknowledgement GENERAL PRODUCT KNOWLEDGE ALL TRANSACTIONS My Advisor and I have discussed the following features: I/We understand any change in internal contract expenses and are aware of a new surrender period. I/We understand that a variable annuity is intended to be a long-term investment. A Variable Annuity is a contract between you and an insurance company in which the insurer agrees to make periodic payments to you in an amount that will be linked to the performance of underlying investments either beginning immediately or at some future date. You can purchase a Variable Annuity by either making a single purchase payment or a series of purchase payments. A Variable Annuity offers a range of investment options, typically referred to as sub-accounts. These sub-accounts invest in stocks, bonds, money market instruments, or some combination of the three. The value of your investment as a Variable Annuity owner will vary depending on the performance of the sub-accounts you choose. There is a risk that you will lose money. If applicable, state replacement paperwork has been completed. I/We understand the tax deferral feature of this annuity is negated if the purchase/replacement is in a qualified plan account. I/We understand that the Internal Revenue Service may assess a penalty of 10% on either principal or interest if withdrawn prior to age 59½. This account is not currently making distributions pursuant to IRC Section 72(t) or this is a full transfer and I/we have complied with the requirements of the annuity company receiving the transfer. The IRS does not permit moving assets that are under 72(t) systematic distributions, also known as SES distributions via Partial Transfers. BONUS ANNUITIES Special consideration should be given when electing a bonus variable annuity. You may incur additional fees, surrender periods, and/or other added stipulations in order to counterbalance the cost of offering the bonus credit. Additionally, FINRA has indicated in multiple communications that a bonus on premium payments may not be considered an offset against any other fees or expenses, including surrender charges applied to the replaced product. My Advisor and I have discussed the following features: I/We understand charges and fees may be higher on bonus products. In the long term, higher expenses may outweigh the benefit of the bonus credit resulting in lower contract values for bonus annuities vs. non-bonus annuities. I/ We understand that the insurance company may deduct the bonus credit under certain circumstances, such as if I/we exercise the free look option, annuitize the contract, surrender the contract, or incur a death claim within a specified time period. I/ We understand how the bonus credit is applied to my contract value as well as any stipulations towards withdrawals, vesting schedules, sub-account/market participation, and/or any additional surrender schedules involved. LIVING BENEFITS Can often present additional options and features to variable annuities typically at an increased cost. Living benefits should not be chosen simply as a guarantee alone, but rather chosen as an enhancement to the annuity that matches particular income objectives, investment concerns, and/or portfolio intentions of the investor. My Advisor and I have discussed the following features: I/We understand that a long-term investment objective may be needed to utilize the living benefit feature and that I/we should not consider this a way to provide an immediate guaranteed return of investment. I/We understand any effects (and/or restrictions) the living benefit rider may have on sub-account allocation choices. I/We understand how any/all excess withdrawals and/or annuitization will affect my/our guaranteed benefit base amount. (For Guaranteed Minimum Withdrawal Benefit) I/we understand the enhanced rider only provides additional benefit by taking a specified withdrawal amount each year and only when the contract value is depleted. I/We understand any withdrawals from my/our annuity will be taxed (above cost basis) at the ordinary income tax rate as opposed to the capital gains rate of mutual funds or other equity investments. (For Guaranteed Minimum Income Benefit) I/We understand the enhanced benefit may only provide value if my/our contract is annuitized (structured payment stream), therefore losing access to my/our investment. DEATH BENEFITS Can be used to enhance estate planning and/or offer controlled payouts to beneficiaries. An enhanced death benefit should be chosen to match the investment concerns and portfolio objectives of the investor with the intention of accumulating value for beneficiaries rather than personal use. My Advisor and I have discussed the following features: I/We have been made aware of any applicable commencement dates (i.e., forced annuitization) that may negate the enhanced death benefit feature. I/We understand the maximum age at which my/our benefit base will be adjusted and the continuation of expenses thereafter. I/We understand how any/all withdrawals affect and/or limit the death benefit value. I/We understand choosing a living benefit may offset or counteract with the enhanced death benefit. I/We understand any effects (and/or restrictions) the enhanced death benefit may have on sub-account allocation choices. I/We understand that the tax liability on accumulated income will be passed on to beneficiaries at their ordinary income tax rate /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 7 of 9

8 SIGNATURES OF ALL APPLICABLE PARTIES REQUIRED New York State Residents: Additional disclosures required by 11 NYCRR 30 (Regulation 194) My Financial Advisor and I have discussed the following: 1. I/We have been made aware of the role of my financial advisor in this transaction. 2. I/We have been made aware that my financial advisor will receive compensation from the selling insurer or other third party based in whole or part on the insurance contract. 3. I/We have been made aware that the compensation paid to my financial advisor may vary depending on a number of factors, including (if applicable) the variable annuity contract and the issuer (variable annuity contract sponsor company) that I/We have selected, the volume of business my financial advisor provides to the insurer or the profitability of the insurance contracts my financial advisor provides to the insurer. 4. I/We understand that we may obtain information about the amount of the compensation expected to be received by my financial advisor, and the compensation expected to be received based in whole or in part on any alternative quotes presented by my financial advisor, by requesting such information from my financial advisor. Client/owner signature(s) Date Client/owner signature(s) Date I/We have reviewed the information provided in the previous pages, to include the Client Acknowledgement Page, with my/our Advisor and I/we acknowledge that this transaction is consistent with my/our investment objective(s), risk tolerance and time frame. Note: If your financial situation or investment objectives change, please contact your financial advisor to discuss. SHARE CLASS ELECTION Please have client initial here if choosing a share class with added liquidity or bonus options (L, C, X, bonus) I/We reviewed all share classes available and decided to choose the proposed share class based on my/our personal goals and expectations regarding liquidity. I/We understand that fees may be higher for share classes with short or no surrender periods and bonus features, and I/We also understand that higher fees may outweigh the benefit of a shorter surrender schedule and/or bonus and may conflict with certain guaranteed lifetime benefits and contract growth. CLIENT SIGNATURE I/We confirm that I/we have received and carefully reviewed the product brochure and prospectus for the Variable Annuity selected, specifically including but not limited to the disclosures contained therein regarding market risk, sales and surrender charges, fees and expenses, and availability of a free look period for my Variable Annuity investment. I understand that Woodbury Financial s Guide to Investing provides important information about my investment and about doing business with Woodbury Financial and its Advisors, including information about the compensation of Woodbury and its Advisors. I understand that I can obtain the Guide to Investing on Woodbury Financial s website ( and acknowledge by my signature below that this constitutes delivery of the Guide to Investing. If I do not have internet access, I acknowledge that I have received a paper copy of the Guide to Investing from my Advisor as of the date of my signature. I/We confirm that I/we have received a copy of this document. Client/owner name (please print) Client/owner signature Date Joint client/owner name (please print) Joint client/owner signature Date POA or trustee name (please print) POA or trustee signature Date /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 8 of 9

9 ADVISOR SIGNATURE I confirm that I have informed my client(s), in general terms, of the material features of the recommended deferred variable annuity and that I have a reasonable basis to believe, that my client(s) would benefit from the features that the recommended annuity will provide. Also based on information provided by the client(s), I believe the annuity transaction as a whole, and the allocation of funds into sub-accounts, is suitable. I have completed the state-required general and product-specific annuity training as required under the NAIC suitability model law. Yes Role: Not currently required in this state Primary Advisor name (please print) Advisor signature Date ADDITIONAL ADVISOR(S) ON ACCOUNT Role: Servicing Referring Planner/Para-Planner Advisor name (please print) Advisor signature Date Role: Servicing Referring Planner/Para-Planner Advisor name (please print) Advisor signature Date /13 Woodbury Financial Services, Inc. Member FINRA, SIPC, and Registered Investment Adviser Page 9 of 9

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