Information Form

Please fill-in the appropriate spaces.  Tell us about yourself and your interests in Retirement annuities.  No sales person or sales agent will contact you.  You may obtain information at no obligation.  You may handle your transaction with RAC by e-mail, fax or telephone.  No RAC employee will ask for you to send money nor will you be asked for a credit card number.

It is safe and easy to purchase your Retirement Annuity through RAC.

Name:    
Email:   
Phone:    
Fax:       
Address: 
          	
City:       
State:   
Zip:     
Your birthdate (MM/DD/YY):	
Male: Female: 
Your questions about Retirement Annuities:


Are you interested in the Retirement Annuities currently recommended by RAC?
YesNo

If yes, approximately what amount of money will your initial premium be?: 


Will your payment be made from an existing tax-deferred plan
(such as IRA of HR-10)?
YesNo

If yes, the name of the financial institution where the funds
will be transferred from:


If your initial deposit will not come from a roll over from an existing
plan, please indicate the source (name of bank, S&L, etc.):


If you are not clear on the difference between "Qualified" and
"Non-Qualified" funds please so indicate here (we will send 
added information regarding the difference):  

If you would like more information about "tax deferred income" from your 
annuity, as compared with "taxable income" please click this box:  

If you prefer to speak with a person at RAC regarding these questions,
you are invited to call during normal business hours line: 1-813-000-0000.
Thank you!

Click here to send above information direct to RAC:           

Click here  if you want to clear the data in the above form:
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