(Please Select) 12 Year Term 7 Year Term 5 Year Term 14 Year Term 8 Year Term 6 Year Term 4 Year Term 10 year Term
Index Annuity Design:
	{Please Select One} I Don't Know which is BEST! Please Recommend the Best 4 Available on the Market for ME to Consider. I want an Index Participation Rate Only with Annual Point-to-Point and Annual Reset. I want an Index Participation Rate Only with Monthly Average and Annual Reset. I want an Index CAP Rate Only with Annual Point-to-Point and Annual Reset. I want an Index CAP Rate Only with Monthly Average and Annual Reset. I want an Index Margin Rate Only with Annual Point-to-Point and Annual Reset. I want an Index Margin Rate Only with Monthly Average and Annual Reset.
Bonus Percentage Added to Account on Day One? Bonuses can be viewed as paid in exchange for a Longer-Term commitment. (I understand that for receiving a bonus on day one a trade off may exist over the long-term. That trade off may be in the form of a Lower Participation Rate / CAP Rate / Fixed Interest Rate and a Higher Margin over time. I also understand that a Bonus may work to my benefit under some market conditions {"a bird in hand is worth two in the bush"}.) Therefore I Want an:
	{Please Select One} I DO NOT Want a Bonus! 10.00% Bonus on 14 Year Term 10.00% Bonus on 10 Year Term 7.00% Bonus on 10 Year Term I want the Highest Bonus Available (fully earned on day one) Highest Bonus Available for Term of 10 Years OR Less(fully earned on day one)
Option Now Available for NO Annuitization.....LifeTime Income!.....Are You Interested?
	NO YES
Amounts You Have Available to Invest?
Available for All Types of Instruments / Products:$
Enter Amount/Lump-Sum you will Deposit: $50 thousand Minimum ..........Up to $2 Million FOR
Each Index Annuity:$	*
How Many Index Annuities Will You Buy?
	1 2 3 4 5 or more
Total Value of Your Entire Portfolio:$	*
Please Select the ONE that best describes the Primary Source of Funds for this Index Annuity:
Non-Qualified:	(Please Select)InheritanceSale of 2nd 3rd or other HomeSale of other Real EstateInvestment Account (Bonds and/or Stocks)Money MarketSavings AccountChecking AccountMaturing CD'sMaturing Deferred AnnuityVariable AnnuityLife Insurance Cash Value (1035 Exchange)Lawsuit Settlement
OR:
Qualified (Pre Tax Funds):	(Please Select)IRA and IRA Rollovers (Retirement Account)401K (Pension Account)Profit Sharing Plan403b (TSA Account)457 Plan (Pension Account)SEP or Keoh (Pension Account)Defined Benefit Plan Termination or Lump-Sum Settlement (From Pension)
Do You want to Move BOTH Non-Qualified and Qualified Funds (If Yes indicate source for BOTH Above)?
	NO YES
Will you let Interest Earned Compound and Grow?(If not please explain in comments below.)
	YES NO
Annuitant Personal Information:
Name (Skip if same as contact person):
Gender:	(Please Select)MALEFEMALE
Date of Birth (mm/dd/year):	*
State of Residence:	*
Contact Information:
First Name:	*
Middle Initial:
Last Name:	*
Email Address:	*
Re-Enter Email Address:	*
DayTime Phone#:	*
Home Phone #:
Fax #:
Address:	*
City:	*
State:	*
Zip Code:	*
Spouse Information:
Spouse Name:
Spouse Gender:	(Please Select)MALEFEMALE
Spouse Date of Birth (mm/dd/year):
*Other Details:
Please Explain your Objectives in more Detail and Provide any other information you think I should know in order to show you the very best Index Annuities on the market:
Comments: Objectives and More Detail:
* When Do You Intend to Buy this Index Annuity?
	Right Now (Within Day's) Immediately (Within 3 Weeks) Immediately (Within 5 weeks) Within 2 to 3 Months Within 4 to 6 Months Within 7 Months to 1 Year Longer than 1 Year
Important Information:
Where Do You INTEND to BUY this Index Annuity?
	Move from Here to Select the TRUE Choice...OR...We Will NOT Respond!!! I prefer to Buy Directly (Over Phone & FedEX) without meeting with an Agent or Broker or Advisor. I intend to buy through an Agent or Broker or Advisor I already know. I want to meet with an Agent or Broker or Advisor from JDSAnnuities.com. I am the Agent or Broker or Advisor. I am a Trustee or CPA or Attorney. I am already a client of Joseph D. Salvemini - JDSAnnuities.com / JDS FS.
All information is required in order to provide you with accurate quotes/information and detailed brochures.
All information you provide will be kept confidential.

* indicates a required field