ANNUITY REPLACEMENT FORM - ausdalpraxis.com

1 ANNUITY REPLACEMENT FORMC omparison of Features, Fees and ExpensesRev Securities offered through Ausdal Financial Partners, Inc. Member finra | SIPC 5187 Utica Ridge Rd, Davenport, IA 52807 (563) NameProduct TypeCurrent Value Existing/ Amount to Invest in NewLength of Time HeldSurrender ChargeGuaranteed Death BenefitGuaranteed Minimum Income/Withdrawal Benefit Base & %Existing Product (attach a statement)New ProductVAVULF ixedIndexedIndexedFixedVULVA$$year/month s $$$$%%$Fees & ExpensesExisting ProductNew ProductMortality, Expense & Admin FeesRider Name & ChargesRider Name & ChargesOther Benefits/Other ChargesSelected Sub-Account Fees*Total Annual Contract ChargesI understand that upon liquidation my existing and new product is subject to Surrender/Contingent Deferred Sales Charges as Follows:List the surrender charge schedule ( Yr 1 - 8%, Yr 2 - 7%, etc.)

2 If none remains, please indicate:List the surrender charge schedule ( Yr 1 - 8%, Yr 2 - 7%, etc.):%%%%%%%%%%* Calculate the total sub-account fees based on sub-account selections. By signing this form , you attest that you have reviewed all fees associated with this purchase, including the sub-account fees, in the product prospectus. If subaccounts are not chosen at the time of application, then give an estimate of occurred at (B/D Name):Reason for Exchange:Issue Date:Exchanged Date:Exchanged Product:NoYes Has the client exchanged a variable ANNUITY with AFP and/or any other broker/dealer within previous 36 months?

3 Please provide details supporting why this exchange of products is appropriate for the client's objectives and risk tolerance:Vendor/Carrier Name%%I acknowledge that I have received and carefully reviewed the prospectus and any supplements for the variable ANNUITY investment listed on this disclosure form . I have been informed of and fully understand all of the fees, charges, expenses, and risks associated with my decision to make this variable ANNUITY investment. I further understand the variable ANNUITY sub account values are subject to market risk; the value(s) are not guaranteed and may fluctuate.

4 I understand that annuities are structured so that they are meant to be a long term investment (typically held for seven or more years) with penalties for early withdrawals/surrender. If purchasing a variable ANNUITY within a tax qualified account, I am aware there are not any additional tax deferred benefits of an ANNUITY and am purchasing the ANNUITY for the non-tax benefits it provides. In addition, any withdrawals from a qualified plan account and/or ANNUITY prior to age 59 1/2 may result in early withdrawal penalties from the IRS.

5 In addition, I am aware that any investment bonus I may receive from the insurance company will typically result in my paying higher internal charges in the ANNUITY contract. I understand that if switching from a fixed to a variable product I will incur market risk and give up any fixed rate of return. I understand if liquidating mutual funds to purchase the ANNUITY I may incur charges in the form of CDSC (contingent deferred sales charge) and that certain open-end mutual fund families permit switching into other funds within the family at no, or substantially reduced, sales charges.

6 I have reviewed this option and still wish to execute the above transactions with my complete understanding of all sales charges involved. This transaction may result in a taxable gain or loss for Federal and State Income Tax purposes. I am aware the Registered Representative and Ausdal Financial Partners, Inc. will receive a commission for this ATTEST ALL INFORMATION IS CORRECT TO THE BEST OF MY Signature DateJoint Client Signature DateRepresentative Signature DatePrincipal Signature DateBy signing below you acknowledge the following: ANNUITY EXCHANGE form (cont.)

7 Rev Securities offered through Ausdal Financial Partners, Inc. Member finra | SIPC 5187 Utica Ridge Rd, Davenport, IA 52807 (563)