Fillable Certification Of Trust Agreement Form (Page 2 of 3) in pdf

6. The Trustee acknowledges that this contract/policy is in no way required in conjunction with the establishment of a Trust

and that any fees, costs and/or expenses associated with the establishment or maintenance of the Trust are independent of

any premium paid for this contract/policy.

❑ Yes ❑ No

Please be advised that North American reserves the right to request and receive a copy of the Trust documents if it determines that it is necessary to do

so. Before North American pays proceeds at the death of the Annuitant/Owner/Insured of the Policy/Contract(s) it may also require proof that the Trust

is then in full force and effect.

NOTICE: THIS SECTION CONTAINS A WAIVER AND RELEASE OF LIABILITY. PLEASE READ CAREFULLY.

This section is to be completed and signed by ALL Trustees required by the response to Question 1. For purposes of this section, “Trust” and “Trustees”

refer to the trust and its trustee(s) identified on the first page of this form. “Annuity Policy/Contract” refers to the annuity policy(ies), contract(s), or

certificate(s) referenced on the first page of this form together with any associated riders. “Owner”, “Beneficiary”, and “Annuitant” have the same

meaning as defined in the Annuity Policy/Contract, and include multiple or joint Owners, Beneficiaries, or Annuitants where applicable. When not

capitalized, “owners” and “beneficiaries” refer to the designated legal owners or beneficiaries of the Trust.

The undersigned persons (“the Trustees”) represent, certify, and agree as follows:

A. The Trustees are the authorized Trustees of the Trust identified above, and are authorized and legally capable of purchasing the Annuity Policy/Contract.

North American may rely upon the signatures of the Trustees on behalf of the Trust as if they were the actual Owner or Beneficiary of the Annuity Policy/

Contract.

B. If the Trust is to be named the Owner of the Annuity Policy/Contract, the Trust is authorized under the terms of the Trust to purchase and hold the

Annuity Policy/Contract, and if the Trust is to be named the Beneficiary of the Annuity Policy/Contract, the Trust is authorized under the terms of the

Trust to receive the Annuity Policy/Contract proceeds.

C. No additional authorizations are necessary to purchase the Annuity Policy/Contract.

D. The Trustees acknowledge and agree that North American has no responsibility for reviewing or interpreting Trust or Trust-related documents, that North

American will issue and administer the Annuity Policy/Contract based solely upon the representations made by the Trustees in this form, and that any

consequence of any error, inaccuracy, or misunderstanding in interpreting the Trust will be borne solely by the Trustees.

E. The Trustees have reviewed all provisions of the Trust and Annuity Policy/Contract. By accepting the Annuity Policy/Contract, the Trustees certify they

have determined that:

i. None of the provisions of the Trust (including income and corpus distribution requirements) conflict or will interfere with the terms and operation

of the Annuity Policy/Contract; and

ii. None of the provisions of the Annuity Policy/Contract (including distribution requirements of section 72(s) of the federal Internal Revenue Code

as incorporated into the terms of the Annuity Policy/Contract and applicable surrender charges) conflict or will interfere with the terms and

operation of the Trust.

F. The Trustees have determined the Annuity Policy/Contract is suitable for the purposes of the Trust, and the Annuity Policy/Contract conforms to the

income distribution requirements of the Trust and to applicable state and federal laws. The Trustees acknowledge that distribution of the Annuity

Policy/Contract funds may result in surrender charges and/or interest adjustments pursuant to the terms of the Annuity Policy/Contract.

G. The Trustees acknowledge that the purchase and ownership of an Annuity Policy/Contract by the Trust may have significant tax, estate/probate, and

other legal and financial consequences for the Trust and the Trust’s owners and beneficiaries. The Trustees have sought advice from their own legal,

tax, trust, and financial advisors regarding any questions related to the suitability, purchase, and ownership of an Annuity Policy/Contract by the Trust,

and have independently determined that purchase of the Annuity Policy/Contract is appropriate for the Trust.

h. The Trustees further acknowledge and agree that:

i. North American does not make and has not made any recommendations regarding the use of a Trust for any purpose, North American’s agents

are not authorized to recommend or sell Trusts while acting in their capacity as an agent for North American, and any Trust recommendation

should be provided by a qualified advisor;

ii. Neither North American nor its agents, employees, or representatives are authorized to give tax, estate/probate, or other legal advice. Although

some North American agents may also be duly licensed professionals (e.g. attorneys or accountants), any tax, estate/probate, or other legal

advice provided by such individuals is solely in their capacity as an independent professional, and not in their capacity as an agent of North

American;

iii. The Trustees have not relied upon any representation or advice of any of North American’s agents, employees, or representatives with respect

to the validity, terms, or utilization of the Trust as the Owner or Beneficiary of the Annuity Policy/Contract; and

iv. The establishment of the Trust is not required in conjunction with the purchase of the Annuity Policy/Contract, and that any fees, costs, and/or

expenses associated with the establishment of the Trust are independent of any premium paid for the purchase of the Annuity Policy/Contract.

NORTh AMERICAN FOR LIFE AND hEALTh INSURANCE

| 4350 WESTOWN PARKWAY | WEST DES MOINES, IA 50266

10112Z

REV 7-14

Certification Of Trust Agreement Form Page 2

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