SOURCES OF FUNDS FOR INVESTMENT A Clause Samples

SOURCES OF FUNDS FOR INVESTMENT A. (f) What is your estimated annual family income? [ ] less than $15,000 [ ] $15,000-$30,000 [ ] $30,000-$50,000 [ ] $50,000-$100,000 [ ] Over $100,000 (g) What is your estimated net worth (exclude home, furnishings and automobiles)? [ ] less than $25,000 [ ] $25,000 - $50,000 [ ] $50,000 - $100,000 [ ] Over $100,000 (h) Are you responsible for the financial welfare of anyone other than your immediate family (i.e. alimony, child or parental support,etc.)? [ ] Yes [ ] No (i) Do you own other securities? [ ] Yes [ ] No Types: [ ] Stocks [ ] Bonds [ ] Mutual Funds [ ] Variable Products [ ] Other I (we) furnished the above suitability information and it has been accurately recorded. _________________________________________________________________ __________________________________________________________ Purchaser Signature Joint Owner Signature continued on reverse side STATEMENT OF REFUSAL TO PROVIDE FINANCIAL INFORMATION I (we) fully understand that the Registered Representative, acting on behalf of American National Insurance Company and Securities Management & Research, Inc., has requested the above suitability information to determine whether my (our) purchase of American National's Variable products is an appropriate investment considering my (our) financial situation. I (we) refuse to provide the requested information and by my (our) signature(s) below agree not to seek rescission of the applicable variable product issued or damages based on its unsuitability. _____________________________________ __________________________________ Purchaser Signature Joint Owner Signature REGISTERED REPRESENTATIVE NOTICE - Should the Purchaser sign the above Statement of Refusal to Provide Financial Information, it is still an NASD requirement that you have reasonable grounds to recommend the purchase of this investment as suitable. Therefore, you must complete the suitability information to the best of your knowledge and certify that you have done so when signing the Registered Representative's Statement below. PURCHASER AGREEMENT TO ARBITRATION (THIS SECTION IS NOT APPLICABLE TO MISSOURI RESIDENTS) The following conditions are agreed to by all parties to this agreement. 1. Arbitration is final and binding on the parties.