Exhibit 4(i)


 


PROTECTIVE LIFE AND ANNUITY
INSURANCE COMPANY • P. O. BOX 10648 • BIRMINGHAM, ALABAMA

35202-0648


 


ROTH INDIVIDUAL RETIREMENT ANNUITY (IRA) ENDORSEMENT


FOR ANNUITY CONTRACTS


 


	
  Check if
  this endorsement supersedes a prior Roth IRA endorsement

  	
   

  	
  o

  
	
  Check if
  Roth Conversion IRA

  	
   

  	
  o

  



 


This Roth Individual Retirement
Annuity Endorsement is made a part of the annuity Contract to which it is
attached, and the following provisions apply in lieu of any provisions in the
Contract to the contrary.


 


The Annuitant is establishing a
Roth Individual Retirement Annuity (“Roth IRA”) under section 408A to provide
for his or her retirement and for the support of his or her Beneficiaries after
death.


 


Article I


 


If this Roth IRA is not
designated as a Roth Conversion IRA, then, except in the case of a rollover
contribution described in section 408A(e), the issuer will accept only cash
contributions. The total cash contributions shall not exceed $3,000 for any taxable year beginning in 2002
through 2004, $4,000 for any taxable year beginning in 2005 through 2007, and
$5,000 for any taxable year beginning in 2008 and years thereafter. After 2008,
the limit will be adjusted by the Secretary of the Treasury for cost-of-living
increases under Code Section 219(b)(5)(C). Such adjustments will be in
multiples of $500.


 


If this Roth IRA is designated
as a Roth Conversion IRA, no contributions other than IRA Conversion
Contributions made during the same tax year will be accepted.


 


Article II


 


The contribution limits
described in Article I is gradually reduced to $0 between certain levels of
adjusted gross income (“AGI”). For a single Annuitant, the annual contribution
is currently phased out between AGI of $95,000 and $110,000; for a married
Annuitant who files jointly, between AGI of $150,000 and $160,000; and for a
married Annuitant who files separately, between $0 and $10,000. In the case of
a conversion, the issuer will not accept IRA Conversion Contributions in a tax
year if the Annuitant’s AGI for that tax year exceeds $100,000 or if the
Annuitant is married and files a separate return. Adjusted gross income is
defined in section 408A(c)(3) and does not include IRA Conversion
Contributions.


 


Article III


 


The Annuitant’s interest in the
Contract is non-forfeitable and nontransferable.


 


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Article IV


 


The Contract does not require
fixed contributions.


 


Any dividends (refund of
contributions other than those attributable to excess contributions) arising
under the Contract will be applied before the close of the calendar year
following the year of the dividend as contributions toward the Contract.


 


Article V


 


If the Annuitant dies before
his or her entire interest in the Contract is distributed to him or her and the
Annuitant’s surviving spouse is not the sole Beneficiary, the entire remaining
interest will, at the election of the Annuitant or, if the Annuitant has not so
elected, at the election of the Beneficiary, either:


 


(a)                                  be
distributed by December 31 of the calendar year containing the fifth
anniversary of the Annuitant’s death, or


 


(b)                                 be
distributed over the life, or a period not longer than the life expectancy, of
the designated Beneficiary starting no later than December 31 of the calendar
year following the calendar year of the Annuitant’s death. Life expectancy is
computed using the expected return multiples in Table V of section 1.72-9 of
the Income Tax Regulations.


 


If distributions do not begin
by the date described in (b), distribution method (a) will apply.


 


If the Annuitant’s spouse is
the sole Beneficiary on the Annuitant’s date of death, such spouse will then be
treated as the Annuitant.


 


Article VI


 


The Annuitant agrees to provide
the issuer with information necessary for the issuer to prepare any reports
required under sections 408(i) and 408A(d)(3)(E),  Regulation sections1.408-5 and 1.408-6, and
under guidance published by the Internal Revenue Service.


 


The issuer agrees to submit
reports to the Internal Revenue Service and the Annuitant as prescribed by the
Internal Revenue Service.


 


Article VII


 


Notwithstanding any other
articles which may be added or incorporated, the provisions of Articles I
through IV and this sentence will be controlling. Any additional articles that
are not consistent with section 408A, the related regulations, and other
published guidance will be invalid.


 


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Article VIII


 


This endorsement will be
amended from time to time to comply with the provisions of the Code, related
regulations, and other published guidance. Other amendments may be made with
the consent of the persons whose signatures appear on the Contract.


 


Article IX


 


The Annuitant must be an
individual who is the sole Owner. Neither the Annuitant nor Owner may be
changed while the Annuitant is living. All payments made under the Contract
while the Annuitant is alive must be made to the Annuitant. The Contract is
established for the exclusive benefit of the Owner and his or her beneficiaries.
The Contract is not transferable, and may not be sold, assigned, discounted or
pledged as collateral for a loan or as security for the performance on any
obligation or for any other purpose, to any person.


 


If the Annuitant’s spouse is
the sole Beneficiary on the Annuitant’s date of death, such spouse may elect
not to be treated as the Annuitant and the entire interest in the Contract must
be distributed under the rules set out in Article V, paragraph 1, above.


 


If your ROTH IRA is amended
pursuant to Article VIII, above, we will obtain all necessary approvals
including, where required, that of the Owner and will send you a copy of the
endorsement that modifies your ROTH IRA.


 


The provisions of this ROTH IRA
endorsement apply from the Effective Date.


 


Protective Life and Annuity Insurance
Company


	
  

  	
   

  
	
  Deborah J. Long

  	
   

  
	
  Secretary

  	
   

  



 


The required instructions on
the following page are provided by the Internal Revenue Service in connection
with your Roth IRA. These instructions are not part of your Roth IRA Contract
and do not change or modify the Contract in any way but do provide information
about the way your Contract will be administered.


 


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GENERAL INSTRUCTIONS


(Section references are to the Internal Revenue Code unless otherwise
noted.)


 


Purpose
of Form –– Form AF-2069 is a model annuity endorsement
that meets the requirements of section 408A and has been automatically approved
by the IRS. A Roth individual retirement annuity (Roth IRA) is established
after the contract, which includes this endorsement, is fully executed by both
the individual (annuitant) and the issuer. The contract must be for the
exclusive benefit of the annuitant or his or her beneficiaries.


 


Do not file Form IPV-2028 with
the IRS. Instead, keep it for records purposes.


 


Unlike contributions to
traditional individual retirement arrangements, contributions to a Roth IRA are
not deductible from the annuitant’s gross income; and distributions after 5
years that are made when the annuitant is 591⁄2 years of age or older or on
account of death, disability, or the purchase of a home by a first-time
homebuyer (limited to $10,000), are not includable in gross income. For more
information on Roth IRAs, including the required disclosure the annuitant can
get from the issuer, get Pub. 590, Individual Retirement Arrangements (IRAs).


 


This Roth IRA can be used by an
annuitant to hold: (1) IRA Conversion Contributions, amounts rolled over or
transferred from another Roth IRA, and annual cash contributions of up to
$2,000 from the annuitant; or (2) if designated as a Roth Conversion IRA (by
checking the box on page 1), only IRA Conversion Contributions for the same tax
year.


 


To simplify the identification
of funds distributed from Roth IRAs, annuitants are encouraged to maintain IRA
Conversion Contributions for each tax year in a separate Roth IRA.


 


DEFINITIONS


 


Roth Conversion IRA. Roth Conversion IRA is a
Roth IRA that accepts only IRA Conversion Contributions made during the same
tax year.


 


IRA Conversion Contributions. IRA Conversion
Contributions are amounts rolled over, transferred, or considered transferred
from a non-Roth IRA to a Roth IRA. A non-Roth IRA is an individual retirement
account or annuity described in section 408(a) or 408(b), other than a Roth
IRA.


 


Issuer. The issuer is the insurance company
providing the annuity contract. The insurance company may use other terms
besides “issuer” to refer to itself, such as “company”, “insurer”, or “us”.


 


Annuitant. The annuitant is the person who
establishes the annuity contract. The insurance company may use other terms
besides “annuitant” to refer to the person who establishes the annuity
contract, such as, “owner”, “applicant”, “insured”, or “you”.


 


SPECIFIC INSTRUCTIONS


 


Article
I –– The annuitant may be subject to a 6-percent tax
on excess contributions if (1) contributions to other individual retirement
arrangements of the annuitant have been made for the same tax year, (2) the
annuitant’s adjusted gross income exceeds the applicable limits in Article II
for the tax year, or (3) the annuitant’s and spouse’s compensation does not
exceed the amount contributed for them for the tax year. The annuitant should
see the disclosure statement of Pub. 590 for more information.


 


Article
IX –– Article IX and any that follow it may
incorporate additional provisions that are agreed to by the annuitant and
issuer to complete the contract. They may include, for example, definitions,
investment powers, voting rights, exculpatory provisions, amendment and
termination, removal or the issuer, issuer’s fees, state law requirements,
beginning date of distributions, accepting only cash, treatment of excess
contributions, prohibited transactions with the annuitant, etc. Use additional
pages if necessary and attach them to this form.


 


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