EX-5 2 ex5.htm
Exhibit 5



Individual Flexible Purchase Payment Deferred
Variable Annuity Application


                                                                                                                                                                         Lincoln Life & Annuity Company of New York (Company) Syracuse, New York
Servicing Office: 1300 South Clinton St., Ft. Wayne, IN 46802

Applicants signing in New York must use this form.
Instructions: Please type or print. ANY ALTERATIONS TO THIS APPLICATION MUST BE INITIALED AND DATED BY THE APPLICANT.

ALL “REQUIRED” SECTIONS MUST BE COMPLETED.
Your Registered Representative(s) and his/her Broker-Dealer may be subject to Department of Labor (DOL) fiduciary rules for persons providing investment advice to retirement accounts.

1          Product Options

□: American Legacy(R) Target Date Income B-Share


2          Initial Deposit – Initial Minimum: $1,500 (will be higher if a Living Benefit Rider is selected.)
Please indicate:                                      □ New Deposit                                                                   $_____________
□ 1035 Exchange (Non-Qualified)                                   $_____________
□ Transfer (Qualified)                                                                      $_____________
□ Rollover (Qualified)                                                                      $_____________
Total Expected Amount:                                                            $_____________
Source of Funds:                                                    □ For Non-Qualified (i.e. Brokerage Account, Inheritance, Business Venture, Loan, etc.):
Please check if applicable: _________________________________________________________________________
□ Deceased Contract (Beneficiary IRA, Deceased IRA, Extended Payout, etc. Please complete form AN07361. No  Living Benefit Riders are allowed. Only i4LIFE® Advantage on Non-qualified contracts is allowed.)
● If Automatic Bank Draft (26255) or Automatic Withdrawal Service (28835) is requested, please submit the appropriate election form.
Note: For a copy of Lincoln’s Monetary Instrument Policy refer to form AN10690.

3          Type of Contract Being Applied For - Required
□ Non-Qualified:  (Do NOT select Plan Type)
          □ Tax-Qualified:   (MUST select Plan Type, below)
          Plan Type (Check One): □ Roth IRA
□ Traditional IRA
□ SEP IRA
□Other __________


4a          Contract Owner (Owner) - Required (Minimum and Maximum Ages apply.)
                        □ Male
Full Legal Name of Individual or Trust*                                                                                                                  SSN/TINDate of Birth□ Female

Physical Street Address                                                                                                                    Telephone Number

City                                                                                              State                  Zip Code                                        Citizen of (Country)

Mailing  Address (If different than above, including City, State and Zip Code.)
                          Is Trust revocable                                                      □ Yes                  □ No
Trustee Name(s)                                                                                                                  Date of Trust


Email Address


4b          Joint Contract Owner (Joint Owner), if any - Non-Qualified Contract Only (Minimum and Maximum Ages apply.)
                        □ Male
Full Legal Name of Individual                                                                                                                  SSN/TINDate of Birth□ Female

Physical Street Address                                                                                                                    Telephone Number

City                                                                                              State                  Zip Code                                        Citizen of (Country)
Relationship To Owner:                                                                                              □ Spouse  □ Non-Spouse                                                              
Email Address



 5a
Annuitant - If no Annuitant is specified, the Owner, or Joint Owner if younger, will be the Annuitant. However, if a Living Benefit Rider is selected, the default will be according to the Living Benefit Rider specifications. (Minimum and Maximum Ages apply.)

Same as:                         □ Owner                           □ Joint Owner
 □ Other - complete information below and specify relationship to Owner:                                                                                                                                                                                                        
                        □ Male
Full Legal Name of Individual                                                                                                                  SSN/TINDate of Birth□ Female

Physical Street Address                                                                                                                    Telephone Number

City                                                                                              State                  Zip Code                                        Citizen of (Country)
                                                                                              
Email Address


5b          Contingent Annuitant, if any - (Minimum and Maximum Ages apply.) Same as:  □ Owner
□ Joint Owner
□ Other - complete information below and specify relationship to Owner:                                                                                                                                                                                                        

                        □ Male
Full Legal Name of Individual                                                                                                                  SSN/TINDate of Birth□ Female

Physical Street Address                                                                                                                    Telephone Number

City                                                                                              State                  Zip Code                                        Citizen of (Country)
                                                                                              
Email Address




* Additional documentation required. Please complete and return the Certification of Trustee Powers Form (AN07086).



6          Beneficiary(ies) of Owner - (If additional space is needed, please list additional beneficiaries in Section 14.) Beneficiaries share equally unless otherwise indicated. If a percentage is indicated, use whole number percentages and the
allocation total must equal 100%.


Full Legal Name Primary Beneficiary                                                                                                                                                  Relationship to Owner

              %        □ Male                □ Female
Date of Birth                                                          SSN/TIN


Primary Beneficiary Address                                                                                                                                                              Telephone Number


Full Legal Name  □ Primary                                                                                                                                                  □ ContingentRelationship to Owner

              %        □ Male                □ Female
Date of Birth                                                          SSN/TIN


Beneficiary Address                                                                                                                                                              Telephone Number


Full Legal Name  □ Primary                                                                                                                                                  □ ContingentRelationship to Owner

              %        □ Male                □ Female
Date of Birth                                                          SSN/TIN


Beneficiary Address                                                                                                                                                              Telephone Number

Full Legal Name Primary Beneficiary                                                                                                                                                  Relationship to Owner

              %        □ Male                □ Female
Date of Birth                                                          SSN/TIN


Primary Beneficiary Address                                                                                                                                                              Telephone Number


Full Legal Name  □ Primary                                                                                                                                                  □ ContingentRelationship to Owner

              %        □ Male                □ Female
Date of Birth                                                          SSN/TIN


Beneficiary Address                                                                                                                                                              Telephone Number


Full Legal Name  □ Primary                                                                                                                                                  □ ContingentRelationship to Owner

              %        □ Male                □ Female
Date of Birth                                                          SSN/TIN


Beneficiary Address                                                                                                                                                              Telephone Number






7          Replacement Information - Required (All information needs to be completed.)

□ Yes                □ No  Do you own any existing annuity contracts or life insurance policies?
□ Yes                □ No  Will the proposed contract replace or change any existing annuity or life insurance?
(Representative/Agent: Complete a separate New York Definition of Replacement form. Refer to the annuity Instructions for completing Regulation 60 Forms if any questions on that Definition of Replacement form are answered Yes.)

 
Company
Approximate
Transfer Amount
  
Policy/Contract Number
  
Replacement of
Annuity/Life
 
 
   $    
□ Annuity  □ Life
 
 
   $    
□ Annuity  □ Life
 
 
   $    
□ Annuity  □ Life
 
 
   $    
□ Annuity  □ Life
 
 
   $    
□ Annuity  □ Life
 
 
   $    
□ Annuity  □ Life

8        Dollar Cost Averaging (DCA) – Initial Program Minimum: $1,500. (Indicate the amount of the initial deposit to be allocated to the DCA holding account; NOT the monthly amount. If the holding account is a variable fund only the deposit allocated to DCA will transfer as part of the DCA program.  Investment gain, if any, will not transfer.)

Total Amount to DCA:                                                                                              %            OR            $                                        

Note: If duration or holding account is chosen below, DCA will default to 100% of initial deposit unless indicated above.

Duration of DCA: □ 6 months
  □ 12 months

If elected, subsequent deposits not listed above will be allocated to the future variable fund allocation unless DCA instructions are included with the subsequent deposit.
If DCA program is chosen, the DCA program must follow the same variable fund allocations chosen in Section 10, 11, and 12.

FROM THE FOLLOWING HOLDING ACCOUNT: The DCA holding account elected below and the DCA funds elected for periodic transfers cannot be the same. If no holding account is selected, the entire amount will be allocated to the DCA Fixed Account if available. If the DCA Fixed Account is not available, the entire amount will be allocated to the LVIP Government Money Market Fund.

 Select One:                                      □ DCA Fixed Account
□ Delaware VIP® Limited-Term Diversified Income Series
□ LVIP Delaware Bond Fund
□ LVIP Government Money Market Fund

9        Death Benefits (If no benefit is specified, the death benefit will default to the Guarantee of Principal Death Benefit.)
Select One:                                      □ Guarantee of Principal Death Benefit
□ Highest Anniversary Death Benefit




[Sections 10-12 (list of fund allocations) omitted intentionally.]

13        Portfolio Rebalancing – Do not complete this section if electing any Living Benefit Rider.
If DCA and Portfolio Rebalancing are both requested, Portfolio Rebalancing will begin at the end of the DCA program. Future allocations and DCA or Portfolio Rebalancing must use the same variable fund allocations.
□        By checking this box, I choose the Portfolio Rebalancing program. (The minimum that can be transferred is $50.)
More than one fund must be selected in Section 12. Transfers will occur on the first day through the 28th day of the month. If no start date is indicated or an incorrect start date is chosen, the start date will be the 15th of the month. If no frequency is selected the frequency will be quarterly.
Start Date: (mm/dd/yy):                                                                                              
Select Frequency of Rebalancing:
□ Monthly
□ Quarterly
□ Semi-Annually
□ Annually


14     Additional Remarks
                                                                                                                                                                                                                                




15     Declarations and Signatures - Required
The Owner(s) understands and agrees that:
1.   The information contained in this application is true, complete, and correct to the best of his or her knowledge and belief.
2.   The statements made shall form the exclusive basis of any annuity issued.
3.  Checks must be made payable to Lincoln Life & Annuity Company of New York, not to the Representative/Agent. The cancelled check is the receipt.
4.   Only a Company officer can make, modify, discharge, or waive any of the Company’s rights.
5.  Under penalties of perjury, the Owner(s) certifies that: (1) the Social Security Number(s) or Tax Identification Number(s) reported above for the Owner(s) is the correct number (or the Owner(s) is waiting for a number to be issued); and (2) the Owner(s) is not subject to backup withholding either because (a) the Owner(s) has not been notified by the Internal Revenue Service (IRS) that the Owner(s) is subject to backup withholding as a result of a failure to report all interest or dividends, or (b) the IRS has notified the Owner(s) he or she is no longer subject to backup withholding.
6.   Placing an annuity in a tax qualified retirement plan (for example, an IRA) will result in no additional tax advantage from the annuity.

 7.
Any annuity issued upon this application shall be considered a contract of the state in which the contract is delivered and terms shall be construed in accordance with the laws of the state.
8.   The annuity will become effective on the date of issue. In the event that the initial purchase payment for this application is not acceptable, Lincoln Life & Annuity Company of New York’s liability will be limited to a return of any payment made.
9.  LNY reserves the right to limit total Purchase Payments for all LNY variable annuity contracts, including variable annuity contracts with an affiliated company, for which the Owner, Joint Owner or annuitant is a measuring life.
10. Lincoln Life & Annuity Company of New York reserves the right to discontinue accepting new purchase payments into any DCA Fixed Account.
11. There are charges and fees associated with the annuity contract and there may be additional charges for optional benefits provided through riders, endorsements or amendments.
12. Contingent deferred surrender charges may apply to withdrawals, surrender of the annuity contract or an exchange for another annuity contract prior to the expiration of any surrender charge period.
If this application is for a qualified retirement annuity, I/We acknowledge that I/we did not receive any investment advice from the Company regarding the purchase of or investment in the annuity contract.
I/We acknowledge receipt of a current prospectus and verify my/our understanding that all payments and values provided by the contract, when based on investment experience of the Variable Account, are variable and not guaranteed as to dollar amount.


Contract Owner Signature                                                                                                        Signed in (City and State)                                                                                Date


Joint Contract Owner, if any, Signature                                                                                                        Signed in (City and State)                                                                                Date


Annuitant Signature (if other than Owner)                                                                                                                                                                                          Date


Contingent Annuitant, if any, Signature                                                                                                                                                                                          Date

16    Representative/Agent Signature - Required (All information needs to be completed.)

□ Yes      □ No  Does the applicant have any existing annuity contracts or life insurance policies?
□ Yes      □ No  Will the proposed contract replace or change any existing annuity or life insurance?
(Representative/Agent: Complete a separate New York Definition of Replacement form. Refer to the Annuity Instructions for Completing Regulation 60 Forms if any questions on that Definition of Replacement form are answered Yes.)

The Representative/Agent hereby certifies he/she witnessed the signature(s) in Section 15 and that all information contained in this application is true to the best of his/her knowledge and belief. The Representative/Agent also certifies that he/she has used only Company approved sales materials in conjunction with the sale and copies of all sales materials were left with the applicant(s). Any electronically presented sales material will be provided in printed form to the applicant no later than at the time of the contract delivery.

If this application is for a qualified retirement annuity, I have complied with the requirements of the DOL fiduciary rules, including the conditions of any applicable prohibited transaction exemption, in recommending this annuity to the applicant.



Servicing Representative/Agent Signature