[USAA logo] USAA LIFE INSURANCE COMPANY VARIABLE ANNUITY EXHIBIT 5(C)
AGREEMENT FOR EXCHANGE OF INSURANCE AND NONQUALIFIED ANNUITY CONTRACTS
UNDER SECTION 1035 OF INTERNAL REVENUE CODE
USAA number ________________________
Social Security number _________________________
ATTACH THIS FORM AND YOUR CURRENT CONTRACT TO YOUR APPLICATION
FOR THE USAA LIFE VARIABLE ANNUITY.
I, _____________________________________, the undersigned, own the following:
POLICY/CONTRACT ISSUED BY: ADDRESS: INSURED/ANNUITANT'S NAME
NUMBER:
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collectively called "Old Contract(s)" which I hereby agree to exchange pursuant
to Section 1035 of the Internal Revenue Code for a USAA Life Variable Annuity,
called "New Contract," if USAA Life Insurance Company ("USAA Life") approves my
application, dated _____________________ for the New Contract and I accept it.
In consideration of USAA Life's furnishing this form and assisting me with the
exchange of contracts under Section 1035 of the Internal Revenue Code, I hereby
further represent and agree as follows:
At the time of the exchange, is the Old Policy a Modified Endowment Contract
(MEC) under Internal Revenue Code Section 7702A? [ ] YES [ ] NO
1. OWNERSHIP OF OLD CONTRACT(S)
I am the sole owner of the Old Contract(s). No other person (including
fiduciaries whether or not court-appointed), firm, corporation or
governmental unit has any legal or equitable claim or interest in or against
the Old Contract(s), except as follows (describe):
NOTE: COLLATERAL ASSIGNEES, IRREVOCABLE BENEFICIARIES, ETC., MUST SIGN ON
BACK OF FORM AS INDICATED.
2. ABSOLUTE ASSIGNMENT OF OLD CONTRACT(S)
I hereby assign, irrevocably transfer and deliver the Old Contract(s) described
above to USAA Life Insurance Company, Federal ID #00-0000000, together with
all right, title and interest therein and thereto. My copy of this form is my
receipt for the Old Contract(s).
3. USAA LIFE WILL NOT PAY PREMIUMS ON OLD CONTRACT(S)
I understand and agree that USAA Life is not obligated to and will not make
any premium payments on the Old Contract(s). Therefore, I further agree for
myself, my heirs and assigns that USAA Life is not liable if the Old
Contract(s) lapses for non-payment of premiums. I understand that if the Old
Contract(s) is reassigned to me under the terms of Paragraph 5, and it has
lapsed because premiums have not been paid, I can reinstate it only if the terms
of the Old Contract(s) permit it to be reinstated.
4. SURRENDER OF OLD CONTRACT(S)
I understand and agree that:
USAA Life will apply for the surrender of the Old Contract(s) for its cash
value. Upon receipt of the cash proceeds, USAA Life will issue a New Contract
for delivery to me. USAA Life will apply the entire cash surrender value or a
portion thereof that it receives from the Old Contract(s) as a non-repeating
premium for the New Contract issued by USAA Life.
5. REASSIGNMENT OF OLD CONTRACT(S)
In the event:
[ ] I refuse to accept the New Contract; or
[ ] I return the New Contract to USAA Life under the Free Look Provision
of the New Contract; then this Agreement shall be null and void and
USAA Life shall reassign the Old Contract(s) to me or my legal
representative, whereupon USAA Life shall have no further obligation
with respect to the Old Contract(s).
I UNDERSTAND THAT AFTER THE SURRENDER DATE, THE OLD CONTRACT(S) CANNOT BE
RETURNED TO ME AND THAT NO DEATH BENEFIT WILL BE PAID UNDER IT.
"THE USAA LIFE VARIABLE ANNUITY IS DISTRIBUTED BY USAA INVESTMENT MANAGEMENT
COMPANY, A REGISTERED BROKER DEALER."
USAA LIFE VARIABLE SERVICE XXXXXX 0000 XXXXXXXXXXXXXX XXXX, XXX
XXXXXXX, XX 00000-0000 TOLL-FREE 0-000-000-0000
24922-0198
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LLL608ST
6. OUTSTANDING CONTRACT LOAN CONSEQUENCES
If there are any loans on the cash value(s) in this/these contract(s), there
could be negative tax consequences and taxes could be owed on this
transaction. If a loan exists on the contract(s) being exchanged, call your
Sales Team at 0-000-000-0000.
7. ACKNOWLEDGMENT OF RESPONSIBILITY FOR TAX OBLIGATIONS
I understand and agree that USAA Life is furnishing this form and
participating in this transaction at my specific request. Accordingly, I am
not relying on USAA Life, its agents or employees for any tax advice
whatsoever with respect to this transaction. I understand that any tax
obligations resulting from this transaction are mine. Further, I assume any
and all risk with respect to the accomplishment of a valid Section 1035
exchange under the Internal Revenue Code.
I also request that the surrendering company send to USAA Life a report on
any taxable gain or loss on Old Contract(s).
8. I WOULD LIKE TO HAVE MY FUNDS SENT BY:
[ ] REGULAR MAIL [ ] CERTIFIED MAIL* [ ] FEDERAL EXPRESS* [ ] WIRE*
*I UNDERSTAND THE ORIGINATING COMPANY MAY CHARGE A FEE FOR THIS SERVICE
WHICH MAY BE DEDUCTED FROM MY BALANCE. THERE IS NO GUARANTEE THAT ALL
OPTIONS ARE AVAILABLE. CONTACT ORIGINATING COMPANY FOR FEES OR OPTIONS.
9. SIGNATURE AS REQUIRED:
SIGNED AT __________________________________________________ ON
_____________________________________________
(CITY AND STATE) (DATE)
X_________________________________________________
X______________________________________________
(OWNER) (WITNESS)
X_________________________________________________
X______________________________________________
(IRREVOCABLE BENEFICIARY, IF ANY) (COLLATERAL ASSIGNEE, IF ANY)
FOR USAA LIFE VARIABLE ANNUITY OFFICE USE ONLY
Received and recorded by USAA Life Insurance Company:
Date: _________________________________ By:
_______________________________________________________________________
24922-0198
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LLL608ST
