EX-99.4.33 4 ex4p33.txt FORM OF CONTRACT DATA PAGES - RVSL CONTRACT DATA Contract Number: [9920-SAMPLE] Contract Date: [November 1, 2006] Initial Purchase Payment: [$25,000] Retirement Date: [November 1, 2046] Annuitant: [John Doe] Contract Type: [Non-Qualified] Contract Owner: [John Doe]
Upon issuance of this contract your initial purchase payment has been applied as shown below. You may make additional payments and change the purchase payment allocation as provided in this contract. For more information, please refer to the Purchase Payments Provision.
Allocation Payment Allocation Percentage RiverSource Life One-Year Fixed Account [___ % [6-month DCA Fixed Account ___% 12-month DCA Fixed Account ___% 1 Year Guarantee Period Account ___% 2 Year Guarantee Period Account ___% 3 Year Guarantee Period Account ___% 4 Year Guarantee Period Account ___% 5 Year Guarantee Period Account ___% 6 Year Guarantee Period Account ___% 7 Year Guarantee Period Account ___% 8 Year Guarantee Period Account ___% 9 Year Guarantee Period Account ___% 10 Year Guarantee Period Account ___% AIM V.I. Basic Value Fund - Series II Shares ___% AIM V.I. Capital Development Fund - Series II Shares ___% AIM V.I. Mid Cap Core Equity Fund - Series II Shares ___% AllianceBernstein VP Growth and Income Portfolio (Class B) ___% AllianceBernstein VP International Value Portfolio (Class B) ___% AllianceBernstein VP Total Return Portfolio (Class B) ___% American Century(R) VP Inflation Protection, Class II ___% American Century(R) VP International, Class II ___% American Century(R) VP Ultra, Class II ___% American Century(R) VP Value, Class II ___% Colonial Small Cap Value Fund, Variable Series, Class B ___% Columbia High Yield Fund, Variable Series, Class B ___% Dreyfus IP Midcap Stock Portfolio, Service Share Class ___% Dreyfus IP Technology Growth Portfolio, Service Share Class ___% Dreyfus VIF Appreciation Portfolio, Service Share Class ___% Dreyfus VIF International Value Portfolio, Service Share Class ___% Fidelity VIP Contrafund(R) Portfolio Service Class 2 ___% Fidelity VIP Growth Portfolio Service Class 2 ___% Fidelity VIP Investment Grade Bond Portfolio Service Class 2 ___% Fidelity VIP Mid Cap Portfolio Service Class 2 ___% Fidelity VIP Overseas Portfolio Service Class 2 ___% FTVIPT Franklin Income Securities Fund - Class 2 ___% FTVIPT Franklin Rising Dividends Securities Fund - Class 2 ___% FTVIPT Franklin Small-Mid Cap Growth Securities Fund - Class 2 ___% FTVIPT Mutual Shares Securities Fund - Class 2 ___% FTVIPT Templeton Growth Securities Fund - Class 2 ___% FTVIPT Templeton Global Income Securities Fund - Class 2 ___% Goldman Sachs VIT Mid Cap Value Fund ] ___%]
273954DPFCC Page 2[.0 ] CONTRACT DATA - Continued Contract Number: [9920-SAMPLE] Contract Date: [November 1, 2006]
[MFS(R) Investors Growth Stock Series - Service Class [___% MFS(R) New Discovery Series - Service Class ___% MFS(R) Total Return Series - Service Class ___% MFS(R) Utilities Series - Service Class ___% Oppenheimer Capital Appreciation Fund/VA, Service Shares ___% Oppenheimer Global Securities Fund/VA, Service Shares ___% Oppenheimer Main Street Small Cap Fund/VA, Service Shares ___% Oppenheimer Strategic Bond Fund/VA, Service Shares ___% Putnam VT Health Sciences Fund - Class IB Shares ___% Putnam VT International Equity Fund - Class IB Shares ___% Putnam VT Small Cap Value Fund - Class IB Shares ___% Putnam VT Vista Fund - Class IB Shares ___% RiverSource(SM) VP - Cash Management Fund ___% RiverSource(SM) VP - Diversified Bond Fund ___% RiverSource(SM) VP - Diversified Equity Income Fund ___% RiverSource(SM) VP - Emerging Markets Fund ___% RiverSource(SM) VP - Global Inflation Protected Securities Fund ___% RiverSource(SM) VP - Growth Fund ___% RiverSource(SM) VP - High Yield Bond Fund ___% RiverSource(SM) VP - International Opportunity Fund ___% RiverSource(SM) VP - Income Opportunities Fund ___% RiverSource(SM) VP - Large Cap Equity Fund ___% RiverSource(SM) VP - Large Cap Value Fund ___% RiverSource(SM) VP - Mid Cap Growth Fund ___% RiverSource(SM) VP - S&P 500 Index Fund ___% RiverSource(SM) VP - Select Value Fund ___% RiverSource(SM) VP - Short Duration US Government Fund ___% RiverSource(SM) VP -Small Cap Value Fund ___% Van Kampen LIT Comstock Portfolio Class II Shares ___% Van Kampen UIF U.S. Real Estate Portfolio Class II Shares ___% Wanger International Small Cap ___% Wanger US Smaller Companies ] ___%]
[Portfolio Navigator Asset Allocation Program model: [model name] ] [Death Benefit: Return of Purchase Payment] [Death Benefit: Maximum Anniversary Value] [Death Benefit: 5% Accumulation] [Death Benefit: Enhanced] [Guaranteed Minimum Accumulation Benefit Rider Initial Annual Rider Charge of [0.55%] Duration of Waiting Period: [10] Years Maximum Annual Rider Charge of 1.75% Automatic Step-up Percentage: [80%]
[Allocation Restrictions/Limitations: This rider requires specific investment allocations to, or Asset Allocation Models containing, certain variable subaccounts, Guarantee Period Accounts, if applicable, the One-Year Fixed Account, if applicable, and the DCA Fixed Account, if applicable. Changes to allocations or Asset Allocation Models may increase the Annual Rider Charge.]] 273954DPFCC Page 2[.1 ] CONTRACT DATA - Continued Contract Number: [9920-SAMPLE] Contract Date: [November 1, 2006]
[Guaranteed Minimum Lifetime Withdrawal Benefit Rider Initial Annual Rider Charge [0.60%] Maximum Annual Rider Charge [1.50%] Maximum RBA and GBA [$5,000,000 ] Maximum ALP [$300,000 ] GBP Percentage [7%] ALP Percentage [6%] Annual Lifetime Payment Attained Age Age [65] Waiting Period [3] Years
[Allocation Restrictions/Limitations: This rider requires specific investment allocations to, or Asset Allocation Models containing, certain variable subaccounts, Guarantee Period Accounts, if applicable, the One-Year Fixed Account, if applicable, and the DCA Fixed Account, if applicable. Changes to allocations or Asset Allocation Models may increase the Annual Rider Charge.]] [Guaranteed Minimum Income Benefit Rider Initial Annual Rider Charge of [0.30%] (Maximum Anniversary Value Benefit Base) Maximum Annual Rider Charge of [1.50%]
[Allocation Restrictions/Limitations: This rider requires specific investment allocations to, or Asset Allocation Models containing, certain variable subaccounts, Guarantee Period Accounts, if applicable, the One-Year Fixed Account, if applicable, and the DCA Fixed Account, if applicable. Changes to allocations or Asset Allocation Models may increase the Annual Rider Charge.]] [Guaranteed Minimum Income Benefit Rider Initial Annual Rider Charge of [0.60%] (5% Accumulation Benefit Base) Maximum Annual Rider Charge of [1.75%]
[Allocation Restrictions/Limitations: This rider requires specific investment allocations to, or Asset Allocation Models containing, certain variable subaccounts, Guarantee Period Accounts, if applicable, the One-Year Fixed Account, if applicable, and the DCA Fixed Account, if applicable. Changes to allocations or Asset Allocation Models may increase the Annual Rider Charge. Excluded investment options from the variable account floor: [RiverSource(SM) VP Cash Management Fund, Guarantee Period Accounts, if applicable, and the One-Year Fixed Account, if applicable.]]] [Guaranteed Minimum Income Benefit Rider Initial Annual Rider Charge of 0.[65%] (Greater of Maximum Anniversary Value Benefit Base Maximum Annual Rider Charge of [2.00%] and 5% Accumulation Benefit Base)
[Allocation Restrictions/Limitations: This rider requires specific investment allocations to, or Asset Allocation Models containing, certain variable subaccounts, Guarantee Period Accounts, if applicable, the One-Year Fixed Account, if applicable, and the DCA Fixed Account, if applicable. Changes to allocations or Asset Allocation Models may increase the Annual Rider Charge. Excluded investment options from the variable account floor: [RiverSource(SM) VP Cash Management Fund, Guarantee Period Accounts, if applicable, and the One-Year Fixed Account, if applicable.]]] [Benefit Protector Death Benefit Rider Annual Charge of [0.25%] Rider Benefit Percentage [ 40%] Maximum Earnings at Death Percentage [250%]]
273954DPFCC Page 2[.2 ] CONTRACT DATA - Continued Contract Number: [9920-SAMPLE] Contract Date: [November 1, 2006]
[Benefit Protector Plus Death Benefit Rider Annual Charge of [0.40%] Rider Benefit Percentage [ 40%] Maximum Earnings at Death Percentage [ 250%] Purchase Payment Percentage Schedule Death Occurring in Contract Years Percentage 1 - 2 [ 0%] 3 - 4 [10%] 5 and later [20%]]
Withdrawal Charge Schedule: There are no withdrawal charges for this contract. Annual Mortality and Expense Risk Charge: [1.65% - 2.05% of the daily net asset value] Annual Variable Account Administrative Charge: [0.15% of the daily net asset value] Annual Contract Administrative Charge: [$40], waived at contract values of [$50,000] or more The Maximum Total RiverSource Life Variable Annuity Purchase Payment Per Annuitant Life: [$1,000,000] The Minimum Additional Purchase Payment: [$100] The Minimum Investment in any Guarantee Period Account: [$1,000] The Guaranteed Minimum Effective Interest Rate to be credited to the RiverSource Life Fixed Account is [X]%. One-Year Fixed Account Purchase Payment and Transfer Limits: 1. Payments to the One-Year Fixed Account: Limited to [0%] of each payment. 2. Transfers to the One-Year Fixed Account: Limited to transfer amounts which result in the One-Year Fixed Account Contract Value (after the transfer) being no more than [0%] of the total Contract Value. 3. Transfers (including automated transfers under a dollar cost averaging arrangement) from the One-Year Fixed Account: Limited to the greater of: a. [$0]; or b. [0%] of the One-Year Fixed Account Contract Value at the beginning of the contract year. MARKET VALUE ADJUSTMENT ----------------------- All payments and values based on the Guarantee Period Account(s) are subject to a Market Value Adjustment formula, the operation of which may result in upward and downward adjustments in amounts payable. For more information, please refer to the Market Value Adjustment Provision. 273954DPFCC Page 2[.3 ]