TLK Tax & Financial

Index Annuity

Client Name(required)

Age:

Client Name (If Joint)

Age::

Rollover Amount / New Amount

401K

IRA

Cash

Pension

Roth IRA

Other, please explain:

Tax Qualification

Martial Status

Single

Married

Divorced/Separated

Widowed

Number of Dependents:

Employment Status

Unemployed

Self employed

Homemaker

Other

Retired 'if retired enter previous employer and occupation held'

Employed

Occupation

Employer

Employer Address

Liquid Holdings Current Value

Stocks and Bonds $

Mutual Funds (A Shares)$

Annuities (Penalty-Free Value) $

Cash/MMkts/CD $

Retirements Plans (if age 59 1/2 or older) $

Other: $

Total Liquid Assets $

Other Holdings Current Value

Mutual Funds (B or C Shares) $

Life Insurance (Cash Value) $

Annuities (in surrender period) $

Retirements Plans (if younger than age 59 1/2) $

Other: $

Total Non-Liquid Assets $

Owner First Name: (required)

Owner Middle Name:

Owner Last Name:

Gender

Address

City

State

Zip Code

Phone No:

Email: (required)

Owner SSN:

Date of Birth:

Occupation

Type of govt issued photo ID:

Driver License

Passport

Other

State or country of issue

Joint Owner First Name:

Joint Owner Middle Name:

Joint Owner Last Name:

Gender

Address

Phone No:

Email:

Owner SSN:

Date of Birth:

Occupation

Type of govt issued photo ID:

Driver License

Passport

Other

State or country of issue

Financial Status

Indicate total accumulated value(s) of all active Athene annuities for the household and all other pending Athene annuity premium for the household, excluding the premium for this contract. Household means applicant and applicant’s spouse or domestic partner as determined by state law.

Indicate total accumulated value of all active non-Athene annuities for the household. Exclude all premium for this annuity and all other pending Athene annuities.

Monthly household gross income For example: salary, social security payments, pension/retirement benefits, investment and rental income Exclude all income currently earned on the money to be used to purchase the annuity.

Monthly household living expenses For example: housing, transportation, insurance, food, health care and property taxes.

Approximate household net worth NOTE: Additional information may be required if the annuity to net worth ratio exceeds 50%. Approximate net worth = total assets less total debts (not including home and automobile

Available liquid assets after annuity purchase (net of premiums) For example: checking, savings, short term CDs, bonds, stocks, mutual funds, etc.
Exclude: Qualified funds, 401(k)s and all existing annuity values at Athene and/or other carriers

Federal income tax bracket (Select one):

10%

12%

22%

24%

32%

35%

37%

PRIMARY BENEFICIARY

Name:

Gender

Relationship

DOB:

SSN

Address:

Phone#:

Name:

Gender

Relationship

DOB:

SSN

Address:

Phone#:

Name:

Gender

Relationship

DOB:

SSN

Address:

Phone#:

Client Name:

Date

Client Name (If Joint:)

Date

CONTINGENT BENEFICIARY

Name:

Gender

Relationship

DOB:

SSN

Address:

Phone#:

Name:

Gender

Relationship

DOB:

SSN

Address:

Phone#:

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Index Annuity

Index Annuity

Financial Status

PRIMARY BENEFICIARY

CONTINGENT BENEFICIARY

By signing below, I acknowledge that in making this recommendation, I took into account all relevant information as provided by the client.

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