Information about the annuitant

Complete the following information. We need your birth date to calculate your life expectancy, which will partly determine your annuity payment:

If you are purchasing the annuity for someone in addition to yourself (a joint annuitant), complete the following:

How are you funding your income annuity? Indicate the type of assets you'll use to purchase your Vanguard Lifetime Income Program annuity contract. The asset type will determine how your annuity payments are taxed. If you do not select one of the options, we will assume you are purchasing your annuity with qualified assets.

 Qualified (pre-tax) assets
 Roth IRA
 Nonqualified (after-tax) assets
 1035 Exchange -- Cost basis (1035 only): $

Amount you want to commit

You may wish to create an income stream that covers the gap between your fixed expenses and your guaranteed income from other sources, such as Social Security or an employer-sponsored pension plan.

Enter one of the following:

About your income stream

• Type of income stream you want:
  Fixed income payment
  Fixed income payment with inflation adjustments
  Fixed income payment with 0% 1% 2% 3% 4% 5%  graded payment option
  Variable income payment with 3.50% 5.00%  AIR
• Length of time you want the income payments to last: -Select one- Single life only Single life with guaranteed period Single life with installment refund Single life with full cash refund Joint and survivor life only Joint and survivor with guaranteed period Joint and survivor with installment refund Joint and survivor with full cash refund Guaranteed period only -Select one- Single life only Single life with guaranteed period Single life with installment refund Single life with full cash refund Joint and survivor life only Joint and survivor with guaranteed period Joint and survivor with installment refund Joint and survivor with full cash refund -Select one- Single life only Single life with guaranteed period Joint and survivor life only Joint and survivor with guaranteed period
  Number of years:
  Percentage of survivor benefit: -Select one- 50% 66.67% 75% 100%
• Frequency with which you want to receive your income payments: -Select one- Monthly Quarterly Semi-annually Annually
• Date you want your income payments to begin (mmddyyyy):
  This assumes we receive your premium on Thursday, September 9, 2010 , which is the quote expiration date. The date you want your income payments to begin must be at least 30 days, but no more than one year, after the quote expiration date (between Saturday, October 9, 2010 and Friday, September 9, 2011).
• Select one of the following:
  
No, I do NOT elect the Cancellation Option
Yes, I want the Cancellation Option
     (selecting this option will reduce your income payments)