Applicant Information: ID# 656254
Name: XXXX XXXXXXXX   Gender: XXXXXXXX   Birth date: 12/14/48 
Address: XXXXX XXXXXXXXXX XXXX   City: Jacksonville   State: Florida   Zip: XXXXX
Work Phone: XXX-XXX-XXXX   Home Phone: XXX-XXX-XXXX   Best Time To Call: 8-10 a.m.
E-mail Address: 
Quote Information: Investment (Funds) Information
Are you requesting for yourself? Yes Amount of money that you wish to invest: 750,000.00
If no, who is request for? Me Is this a lump sum? Yes
  If "No" how much do you plan to add later? N/A
  How often do you plan to deposit additional funds? Annually
Your Personal Tax Information: Your concerns:
Your tax bracket: 39% Primary reason for annuity purchase: Retirement
Funds from a Tax Qualified Account? Yes Other reasons for annuity purchase: Interest Rate
If "Yes" what type of account? 401K How long would you like your Annuity to grow? 10+ years
Funds from a Non Tax Qualified Account? No  
If "Yes" what type of account? N/A  
If a "CD", the month the CD comes due? N/A  
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