a153740_02012010.htm - Generated by SEC Publisher for SEC Filing


 





















				
	6. IMPORTANT INFORMATION AND STATE REQUIRED NOTICES 	 	 
	To help the government fight the funding for terrorism and money-laundering activities, federal law requires all financial institutions 
	to obtain, verify, and record information that identifies each person who opens an account. What this means for you — when you 
	apply for an annuity, we will ask for your name, address, date of birth, and other information that will allow us to identify you. 
	We may also ask to see your driver’s license or other identifying documents. If you wish to have a more detailed explanation of 
	our 	 	 	 
	information practices, please write to: Customer Service Center, ING Annuities, 909 Locust Street, Des Moines, IA 50309- 	 
	2899. 	 	 	 
	Pursuant to federal law (the Defense of Marriage Act of 1996), certain favorable federal tax treatment available to 
	opposite-sex spouses is not available to same-sex spouses. For instance, federal tax law allows a surviving spouse who is 
	designated the beneficiary under an annuity to continue the annuity when the owner dies. This alternative death benefit option 
	is not available to a same-sex spouse beneficiary. If you are a same-sex spouse, we suggest that you consult with a tax 
	advisor prior to purchasing an annuity contract, such as this one, which provides spousal benefits. 	 	 
	Below are notices that apply only in certain states. Please read the following carefully to see if any apply in your state. 
	Arkansas, Louisiana, Maine, New Mexico, Ohio, Oklahoma, Tennessee, Washington, West Virginia: Any person who 
	knowingly and with intent to injure, defraud or deceive any insurance company, submits an application for insurance containing 
	any materially false, incomplete, or misleading information, or conceals for the purpose of misleading, any material fact, is guilty 
	of insurance fraud, which is a crime and in certain states, a felony. Penalties may include imprisonment, fine, denial of benefits, 
	or civil damages. 	 	 	 
	Arizona: On receiving your written request, we will provide you with information regarding the benefits and provisions 
	of the annuity contract for which you have applied. If you are not satisfied, you may cancel your contract by returning 
	it within 20 days, or within 30 days if you are 65 years of age or older on the date of the application for the annuity, 
	after the date you receive it. Any premium paid for the returned contract will be refunded without interest. 	 
	California Reg. 789.8: The sale or liquidation of any asset in order to buy insurance, either life insurance or an annuity 
	contract, may have tax consequences. Terminating any life insurance policy or annuity contract may have early withdrawal 
	penalties or other costs or penalties, as well as tax consequences. You may wish to consult independent legal or financial 
	advice before the sale or liquidation of any asset and before the purchase of any life insurance or annuity contract. 	 
	Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for 
	the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of 
	insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, 
	incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to 
	defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be 
	reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. 	 	 
	District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of 	 
	defrauding 	 	 	 
	the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, 
	if 	 	 	 
	false information materially related to a claim was provided by the applicant. 	 	 
	Florida: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A 
	STATEMENT 	 	 	 
	OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY 
	OF A FELONY 	 	 	 
	OF THE THIRD DEGREE. 	 	 	 
	Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for 
	insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any 
	fact 	 	 	 
	material thereto commits a fraudulent insurance act, which is a crime. 	 	 
	Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and 
	willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in 
	prison. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy 
	is subject to criminal and civil penalties. 	 	 	 
	Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for 
	insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning 
	any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 
	Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an 
	application or files a claim containing a false or deceptive statement may have violated the state law. 	 	 
	7. ACKNOWLEDGEMENTS AND SIGNATURES (Please read carefully.) 	 	 
	SIGNATURE REQUIRED BELOW! THIS ENTIRE SECTION MUST BE COMPLETED FOR YOUR APPLICATION TO BE PROCESSED IN “GOOD 
	ORDER.” 	 	 	 
	 
	REPLACEMENT 	 	 	 
	If either question below is answered “Yes,” you must complete any state-required replacement forms, as applicable, and 
	submit them with this application. 	 	 	 
	1. Do you currently have any existing individual life insurance policies or annuity contracts? (If “Yes,” complete the 	 	 
	     state-required replacement form(s) and provide details below.) 	c Yes 	c No 
	2. Will this contract replace any existing individual life insurance policies or annuity contracts? (If “Yes,” complete 	 	 
	     the state-required replacement form(s) and provide details below.) 	c Yes 	c No 
	 
	Company _________________________________	Policy/Contract #  _______________________________________________________
	 
	Company _________________________________	Policy/Contract #  _______________________________________________________








			
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	 7. ACKNOWLEDGEMENTS AND SIGNATURES (CONTINUED) (Please read carefully.) 
	 SPECIAL REMARKS 
	  
	  
	  
	  
	 By signing below, I acknowledge receipt of the prospectus. My signature also serves as a representation that: (a) all statements 
	 and 
	 answers in this form are complete and true to the best of my knowledge and belief and may be relied upon in determining whether 
	 to issue the applied for annuity; and (b) the owner has an insurable interest, as defined above and in more detail in the 
	 prospectus, 
	 in the life of the annuitant. Only the owner and the Company have the authority to modify this form. After reviewing my financial 
	 information, I believe this contract is suitable and will meet my financial goals and objectives. 
	  
	 Contracts and policies and underlying Series shares or securities which fund contracts and policies are not insured by the 
	 FDIC or any other agency. They are not deposits or other obligations of any bank and are not bank guaranteed. Also, they 
	 are subject to market fluctuation, investment risk and possible loss of principal invested. 
	  
	 I understand that any amount allocated to a guarantee period may be subject to a market value adjustment, which may cause 
	 the values to increase or decrease, prior to a specified date or dates as specified in the contract. 
	  
	 I understand that Individual Retirement Accounts (IRAs) already provide tax deferral like that provided by the contract. For an 
	 additional cost, this contract provides additional features and benefits, including death benefits and the ability to receive a 
	 lifetime income. I understand that I should purchase an annuity contract only if I have taken into account the cost of these 
	 features and benefits. 
	  
	 Additional information about the contract can be found in the prospectus. 
	  
	 TAXPAYER CERTIFICATION 
	 Under penalties of perjury, my/our signature(s) certifies/certify that: 
	 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me). 
	 2. I am not subject to backup withholding because (a) I have not been notified by the Internal Revenue Service (IRS) that I 
	        am subject to backup withholding as a result of a failure to report all interest or dividends, or (b) the IRS has notified me that 
	        am 
	        no longer subject to backup withholding. 
	 3. I am a U.S. citizen or U.S. resident alien. 
	 The IRS does not require your consent to any provision of this document other than the certifications required to avoid 
	 backup withholding. 











	8. PRODUCER INFORMATION 
	CHECK THE BOXES BELOW ONLY IF THEY APPLY: 
	 ¬ c Check here to confirm that the owner(s) has an insurable interest in the life of the annuitant. As defined in 
	  more detail in the prospectus, an insurable interest means the owner has a lawful and substantial 
	                         economic interest in the continued life of the annuitant. 
	¬ c Check here if the applicant is on active duty with the U.S. Armed Forces or is a dependent of any 
	                         active duty service member of the U.S. Armed Forces. Complete the Military Personnel Financial Services 
	                         Disclosure Regarding Insurance Products and return it with this application. 



		
	If any questions below or in the Replacement section are answered “Yes,” the applicant must complete and submit any 
	state-required replacement forms/sales material, as applicable, with this application. 	 
	Does the applicant have any existing individual life insurance policies or annuity contracts? 	c Yes c 
	No 	 
	Do you have reason to believe that the contract applied for will replace any existing annuity or life insurance coverage? 	c Yes c 
	No 	 
	If your state has adopted replacement regulations, did you remember to do the following? 	 
	Q Provide required replacement notice to the applicant and offer to read it aloud. 	 
	Q Complete required, state-specific paperwork. 	 
	 
	Compensation Alternative 	 
	c A 	 
	 
	Compensation will be split equally if no percentage is indicated. Partial percentages will be rounded up. Percentages 
	must 	 
	total 100%. The primary producer will be given the highest percentage in the case of unequal percentages and will receive 
	all 	 
	correspondence regarding the contract. 	 
	By signing below you certify that: 1) replacement questions were answered; 2) any sales material was shown to the applicant 
	and 	 
	a copy was left with the applicant; 3) you used only insurer-approved sales material; 4) you have not made statements that 
	differ 	 
	from the sales material; and 5) no promises were made about the future value of any contract elements that are not 
	guaranteed. 	 
	(This includes any expected future index gains that may apply to this contract.) 	 
	SIGNATURE REQUIRED BELOW! THIS ENTIRE SECTION MUST BE COMPLETED FOR YOUR APPLICATION TO BE PROCESSED IN “GOOD 
	ORDER.” 	 











			
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