Accredited Investor Form (Page 2 of 4) in pdf

Accredited Investor Form Page 2

Accredited Investor Form

Aviva Life and Annuity Company

Mailing Address: P.O. Box 10433, Des Moines, IA 50306-0433

Tel: 888 266 8489 Fax: 866 709 3922

This form is required for Florida applicants age 65 and older who are applying for any Annuity Products with a surrender

charge period longer than 10 years and/or with a surrender charge percentage that is greater than 10% in the first

contract year.

The undersigned (the “Applicant”) herby certifies to Aviva Life and Annuity Company (“Aviva”) that the Applicant is an

accredited investor within the meaning of Florida’s Statute concerning Annuity Investments by Seniors based on the

following:

(please initial the statements that apply to you)

1. The Applicant’s net worth (either individually or with my spouse, if any) exceeds $1,000,000 at the time of

application.

2. The Applicant’s individual annual income is in excess of $200,000 in each of the 2 most recent years, and

expects the same income in the current year.

3. The Applicant’s annual income, jointly with Applicant’s spouse, is in excess of $300,000 in each of the two

most recent years, and expects the same income in the current year.

A P P L I C A N T / O W N E R S I G N A T U R E

By signing below, I certify that the above information is true and correct in all material respects. I recognize that Aviva is

relying on the truth and accuracy of such information in determining whether to permit the Applicant to purchase annuity

products not otherwise available to Florida Applicant’s 65 years or older.

Signature

Date (mm/dd/yy)

A G E N T S T A T E M E N T – Acknowledgement of responsibility for suitability for Accredited Investor

By signing below I certify that I have reasonable grounds for believing that the recommendation to purchase this annuity is

suitable for the Applicant/Owner based upon the information they provided.

Agent Signature

Agent Number

Date (mm/dd/yy)

*50593121001*

Page 1 of 1

50593FL

ver. 12/16/10

Accredited Investor Form Page 2