EX-99 5 ex99b418ga-cdf11050807.htm EXHIBIT 99-B.4.18 VA APPLICATION (GA-CDF-1105(8/07)) ex99b418ga-cdf11050807.htm -- Converted by SEC Publisher, created by BCL Technologies Inc., for SEC Filing  

                                                                        EX 99-B.4.18                                                 Annuities

VARIABLE ANNUITY APPLICATION

ING USA Annuity and Life Insurance Company (“ING USA”)
[ Service Office: P.O. Box 9271, Des Moines, IA 50306-9271

Overnight Address: 909 Locust Street, Des Moines, IA 50309-2899; Phone: 800-366-0066 ]

_____________________________________________________________________________________________________________________________________

For Agent Use Only: Client’s Account Number

If this customer data form is being signed in a state other than the owner’s resident state, please specify the state where the business was solicited and the
purpose of the visit.

_____________________________________________________________________________________________________________________________________

1(A). OWNER          
Name ___________________________________       Trust Date ______________________  
SSN/TIN _________________________________ Birth Date __________________   ________________________¨Male ¨   Female
Street Address____________________________          
                                                                 (No P.O. Box addresses.)   City State  ZIP
Mailing Address____________________________          
                                                                 (If different than above.)   City State  ZIP
Phone #__________________________________     Email Address__________    
Country of Citizenship ______________________          
1(B). NON-QUALIFIED CONTRACTS ONLY - JOINT OWNER (Optional.)    
Relationship to Owner          
Name____________________________________       Trust Date_______________________  
SSN/TIN__________________________________ Birth Date___________________   ________________________¨ Male ¨  Female
Street Address_____________________________          
                                                                 (No P.O. Box addresses.)                  City State  ZIP
Mailing Address____________________________          
                                                                 (If different than above.)                  City State  ZIP
Phone #__________________________________     Email Address_________    
Country of Citizenship          
2. ANNUITANT (For Qualified accounts, Annuitant must be the Owner.)    
Relationship to Owner: ¨Owner ¨ Joint Owner ¨ Other (Please complete the information below if this choice is selected.)
Name____________________________________     Relationship to Owner___________________________________  
SSN_____________________________________ Birth Date___________________   ________________________¨ Male ¨ Female
Permanent Street Address___________________          
City______________________________________     State_________________ _____________________________ZIP  
Country of Citizenship          
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3. BENEFICIARY(S) (All fields for each Beneficiary must be completed. Precentages must be in whole numbers.)  
Beneficiary proceeds will be split equally if no percentages are provided.    
Primary Beneficiary    
Name                                                                                                                 Birth Date   Percent %
SSN/TIN                                                                                                                 Relationship to Owner    
Address                                                                                                                                                                                                                     
                                                                                                                                                                                                                                      
¨ Primary ¨Contingent Beneficiary    
Name                                                                                                                  Birth Date Percent                                      %
SSN/TIN                                                                                                                  Relationship to Owner    
Address
     
¨Primary ¨Contingent Beneficiary    
Name                                                                                                                    Birth Date Percent %
SSN/TIN                                                                                                                   Relationship to Owner    
Address      
¨ Primary ¨ Contingent Beneficiary    
Name                                                                                                                   Birth Date Percent %
SSN/TIN                                                                                                                   Relationship to Owner    
Address         
Please use the space in Section 11 if you need to list additional Beneficiaries.

 

  
__________________________________________________________________________________________________________________________

SAMPLE BENEFICIARY DESIGNATIONS

Be sure to use given names such as “Mary M. Doe”, not “Mrs. John Doe”, and include the address and relationship of the beneficiary
or beneficiaries to the owner. The following designations may be helpful to you:

    Relationship      
  Name to Owner Birth Date SSN/TIN Percent
One Primary Beneficiary Mary M. Doe Sister 03/31/1950 123-45-6789 100%
Two Primary Beneficia- Jane J. Doe Mother 04/01/1940 ###-##-#### 50%
ries John J. Doe Father 05/01/1935 ###-##-#### 50%
One Primary Beneficiary Jane J. Doe Wife 11/30/1923 ###-##-#### 100%
One Contingent John J. Doe Son 06/18/1951 ###-##-#### 100%
Estate Estate of John Doe Estate N/A 67-981239 100%

Trust
                                          

ABC Trust
Dtd 1/1/85   		  Trust  N/A   44-234567   100%
Testamentary Trust1
 (Trust established within the
 owner’s will)   		 Trust created by the
  Last Will and Testa-
ment of John Doe 		  Testamentary
  Trust 		 N/A 38-078602   100%

1If the Trust is terminated or if no trustee is qualified to receive the proceeds within six months of the insured’s death, then the proceeds go to the Owner or
Owner’s Estate.

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_________________________________________________________________________________________________________________________________________

4. INITIAL INVESTMENT (Select one.)

Please make all checks payable to ING USA Annuity and Life Insurance Company.

¨ Initial Premium Paid $_____________________________________________________________________________________________________________________

¨ Estimated amount of Transfer/1035 Exchange $________________________________________________________________________________________________

5. PRODUCT SELECTION
[þ ING Rollover Choice Variable Annuity ]

[Death Benefit Option Packages (Select one. If no selection is made, the death benefi t will default to “Option Package I”.)

¨ Option Package I

¨ Option Package II

¨ Option Package III (Not available in WA.)

Death Benefi t, withdrawal options and expenses will vary depending on the Option Package chosen. Please refer to your prospectus
for further details on the Option Packages available under this contract.]

___________________________________________________________________________________________________________

[ Optional Living Benefit (Select one.)

¨ Minimum Guaranteed Income Benefi t (MGIB) (Not Available in ...)
¨ [ING LifePay Plus]Minumum Guaranteed Withdrawal Benefit [ ] 1 (Not Available in ...)
¨ [ING Joint LifePay Plus]Minimum Guaranteed Withdrawal Benefit [ LifePay ] 1 (Not Available in ...)

If your contract is a 403(b), the [Joint LifePay Plus]benefit option cannot be selected. There are specific ownership and
beneficiary requirements for election of the[Joint LifePay Plus]benefit option.

1Funds must be allocated per[LifePay Plus][and Joint LifePay Plus] requirements detailed on page 6. Read your prospectus carefully
regarding details about[LifePay ] and Joint LifePay Plus. Applications that do not comply with these requirements will be deemed [ ]
not in good order, and the contract will not be issued until correct investment instructions are received. If you choose[LifePay ] or [
Joint LifePay ] use only section 9B to complete your allocation selection. ]
____________________________________________________________________________________________________________

6. TELEPHONE/ELECTRONIC TRANSMISSION AUTHORIZATION

I authorize ING USA Annuity and LifeInsurance Company to act upon reallocation instructions, given by electronic means or voice
command from the agent named in section 15 and/or the following individuals listed below upon furnishing their Social Security Number
or alternative identifi cation number.

To authorize an individual (including an agent), the Owner must initial: _________________
Provide the name and Social Security Number of other authorized individuals below1:

Name ________________________________________________________________

Name________________________________________________________________

SSN ________________________________

SSN________________________________


Neither the Company nor any person authorized by the Company will be responsible for any claim, loss, liability or expense in
connection with instructions received by electronic means or voice command from such person if the Company or other such person
acted on such electronic means or voice command in good faith in reliance upon this authorization. The Company will continue to
act upon this authorization until such time as the person indicated above is no longer affi liated with the broker/dealer under which
my contract was purchased or until such time as I notify ING USA in writing of a change in instructions.

1If a Social Security Number/Tax ID Number is not provided, the proposed individual will not be authorized for certain transactions.
_________________________________________________________________________________________________________________________________________________________________

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_______________________________________________________________________________________________________________________

7. PLAN TYPE FOR NEW CONTRACT

Non-Qualified: [   ¨   Non-qualified
        ¨ Non-qualified Transfer/1035 Exchange (“Like to Like” transfer) ]
_______________________________________________________________________________________________________________________
Qualified:        [   ¨   IRA*                         ¨ IRA Transfer 
       ¨ TSA/403(b)                 ¨  IRA Rollover from Qualified Plan

*If this is an IRA contribution, please indicate the amount and tax year.______________________________________________________________________________
_______________________________________________________________________________________________________________________________________  ]

¨ Roth IRA. If this is a transfer, provide the original conversion/establishment date and amount]

_______________________________________________________________________________________________________________________
8. REPLACEMENT

Do you currently have any existing individual life insurance policies or annuity contracts?     ¨ Yes ¨ No

contract replace any life insurance policy or annuity contract in this or any other company? ¨Yes  ¨ No
s”, please identify each policy or contract and the issuing company.

Company_______________________________________________ Policy/Contract #__________________________________________________________________

Company_______________________________________________ Policy/Contract #__________________________________________________________________

Company_______________________________________________ Policy/Contract #__________________________________________________________________

Company_______________________________________________ Policy/Contract #__________________________________________________________________

If either or both of the questions in this section are answered “Yes”, please complete and return with this form a copy of any state
replacement form(s), as applicable.

_______________________________________________________________________________________________________________________________________________________________
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___________________________________________________________________________________________________________________
9A. ALLOCATION SELECTION - USE IF YOU HAVE NOT ELECTED THE[LIFEPAY PLUS] [OR][JOINT LIFEPAY PLUS]BENEFIT OPTION
Complete page 6, Section 9B if you have elected the[LifePay ][or Joint LifePay Plus]Benefit Option.
To elect an optional DCA transfer program, allocate money to[ING Liquid ][6-Month DCA, or ][ ][ -Month DCA, and indicate the]
funds the DCA is to go to by writing percentages in the “DCA (Optional)” columns. Enter allocations in whole percentages. The initial and
DCA allocations must each total 100%.
Monthly transfer amount $_____________(Maximum 1/12 of amount allocated to divisions below. Not applicable for 6-Month DCA.) [ ]
                                                                                                        Variable Investments [1]

Initial
   Allocation %
       (Required)		   DCA  
Allocation %
(Optional)		 Initial  
Allocation %     
 (Required)  		        DCA  
Allocation %
 (Optional)
 
 
[ ______% Fidelity® VIP Contrafund ______%  ______% ING Solution 2045 ______%
  ______% Fidelity® VIP Equity-Income ______%  ______% ING Solution Income2 ______%
  ______% Franklin Small Cap Value Securities ______%  ______% ING T. Rowe Price Diversified Mid Cap Growth ______%
  ______% ING American Century Large Company Value ______%  ______% ING T. Rowe Price Equity Income ______%
  ______% ING American Century Small-Mid Cap Value ______%  ______% ING T. Rowe Price Growth Equity ______%
  ______% ING American Funds Growth ______%  ______% ING Thornburg Value ______%
   ______% ING American Funds Growth-Income ______%  ______% ING UBS U.S. Large Cap Equity ______%
   ______% ING American Funds International ______%  ______% ING Van Kampen Comstock Fund ______%
   ______% ING Baron Small Cap Growth ______%  ______% ING Van Kampen Equity and Income ______%
   ______% ING BlackRock Large Cap Growth ______%  ______% ING VP Balanced ______%
   ______% ING Davis Venture Value ______%  ______% ING VP Financial Services ______%
   ______% ING Evergreen Omega ______%  ______% ING VP Global Science and Technology ______%
   ______% ING FMR (SM) Large Cap Growth ______%  ______% ING VP Growth and Income ______%
   ______% ING Fundamental Research ______%  ______% ING VP Index Plus International Equity ______%
   ______% ING Goldman Sachs Capital Growth ______%  ______% ING VP Index Plus LargeCap ______%
   ______% ING JPMorgan International ______%  ______% ING VP Index Plus MidCap ______%
   ______% ING JPMorgan Mid Cap Value ______%  ______% ING VP Index Plus SmallCap ______%
   ______% ING Legg Mason Aggressive Growth ______%  ______% ING VP Intermediate Bond2 ______%
   ______% ING Legg Mason Value ______%  ______% ING VP International Equity ______%
   ______% ING Liquid Assets2 ______%  ______% ING VP International Value ______%
   ______% ING MFS Total Return ______%  ______% ING VP MidCap Opportunities ______%
   ______% ING OpCap Balanced Value ______%  ______% ING VP Real Estate ______%
   ______% ING Oppenheimer Global ______%  ______% ING VP Small Company ______%
   ______% ING Oppenheimer Strategic Income2 ______%  ______% ING VP SmallCap Opportunities ______%
   ______% ING PIMCO Core Bond2 ______%  ______% ING VP Strategic Allocation Conservative ______%
   ______% ING PIMCO High Yield ______%  ______% ING VP Strategic Allocation Growth ______%
   ______% ING PIMCO Total Return2 ______%  ______% ING VP Strategic Allocation Moderate ______%
   ______% ING Pioneer Fund ______%  ______% ING VP Value Opportunity ______%
   ______% ING Pioneer Mid Cap Value ______%  ______% Oppenheimer Main Street Small Cap ______%
   ______% ING Solution 2015 ______%  ______% PIMCO VIT Real Return ______%
   ______% ING Solution 2025 ______%  ______% Pioneer Equity-Income VCT ______%
   ______% ING Solution 2035 ______%       ]
Fixed Investment Options[ 3 ]
[ (Not Available in WA & OR.) ]
[ ______% 6-Month DCA     NA %  ______% Fixed Account 5-Year Term        NA %
  ______% 12-Month DCA          NA % ______% Fixed Account 7-Year Term        NA %
  ______% Fixed Account 1-Year Term     NA % ______% Fixed Account 10-Year Term          NA% ]
  ______% Fixed Account 3-Year Term     NA %        

[ 1 The available share class is subject to service and/or 12b-1 fees.
2 These portfolios are “special funds.” Transfers to and from and amounts invested in these portfolios may affect death benefi t and living benefi t guarantees.
3 May not be available in all states. Read the appropriate Prospectus and any Prospectus Supplements for more information.]

GA-CDF-1105(08/07) Page 5 of 9 - Incomplete without all pages. Order #137872 08/20/2007

9B. ALLOCATION SELECTION - USE IF YOU HAVE ELECTED THE [LIFEPAY PLUS] [OR] [JOINT LIFEPAY PLUS] BENEFIT OPTION
Complete page 5, Section 9A if you did not elect the[LifePay ][or][Joint LifePay Plus Benefit Option.]
Enter allocations in whole percentages according to the following options. Dollar Cost Averaging (DCA) allocations also must follow
the option limitations.

To elect an optional DCA transfer program, allocate money to [either 6-Month DCA] [or] [12-Month DCA,] and indicate the funds the DCA
is to go to by writing percentages in the “DCA (Optional)” columns. The initial and DCA allocations must each total 100%.

Monthly transfer amount $_____________(Maximum 1/12 of amount allocated to divisions below. Not applicable for[6-Month DCA.)]
________________________________________________________________________________________________
Option 1 - You may allocate entirely among Accepted Funds without restriction.
Option 2 - You may elect not to allocate any account value to Accepted Funds and allocate entirely among the[LifePay Plus]Fixed
                Allocation Fund(s) and Other Funds. However, at least[20%]of the account value must be invested in the[LifePay Plus]
                Fixed Allocation Fund(s).
Option 3 - You may allocate among a combination of Accepted Funds, the[LifePay Plus Fixed Allocation Fund(s), and Other Funds. However,]
                at least[20% of the account value] not invested in Accepted Funds must be invested in the[LifePay Plus]Fixed Allocation Fund(s).
Accepted Funds

 Initial    DCA  Initial    DCA  
Allocation % Variable Investments [1,3] Allocation %     Allocation % Fixed Investments [3,4] Allocation %
(Required)     (Optional) (Required) [ (Not Available in WA & OR) ] (Optional)
______% ING Solution 2015 ______% [______% 6 Month DCA      NA %
______% ING Solution 2025 ______% ______% 12-Month DCA      NA %
______% ING Solution 2035 ______% ______% Fixed Account 1-Year Term      NA %
______% ING Solution Income2 ______% ______% Fixed Account 3-Year Term      NA %
______% ING Liquid Assets2 ______% ] ______% Fixed Account 5-Year Term      NA %
        ______% Fixed Account 7-Year Term      NA %
        ______% Fixed Account 10-Year Term      NA % ]
________________________________________________________________________________________________________________

[ LifePay Plus Fixed Allocation Fund(s) ]                                                       If you have chosen to allocate according to Option 2 or 3 above, at least
                                                                                                                      [20%]of the account value not invested in Accepted Funds must be invested
[ ______% ING VP Intermediate Bond                                          _____%]        in the [LifePay Plus]Fixed Allocation Fund(s).
 ________________________________________________________________________________________________________________________________

 Other Funds        
[ ______% Fidelity® VIP Contrafund ______% ______% ING T. Rowe Price Diversified Mid Cap Growth ______%
 ______% Fidelity® VIP Equity-Income ______% ______% ING T. Rowe Price Equity Income ______%
 ______% Franklin Small Cap Value Securities ______% ______% ING T. Rowe Price Growth Equity ______%
 ______% ING American Century Large Company Value ______% ______% ING Thornburg Value ______%
 ______% ING American Century Small-Mid Cap Value ______% ______% ING UBS U.S. Large Cap Equity ______%
 ______% ING American Funds Growth ______% ______% ING Van Kampen Comstock Fund ______%
 ______% ING American Funds Growth-Income ______% ______% ING Van Kampen Equity and Income ______%
 ______% ING American Funds International ______% ______% ING VP Balanced ______%
 ______% ING Baron Small Cap Growth ______% ______% ING VP Financial Services ______%
 ______% ING BlackRock Large Cap Growth ______% ______% ING VP Global Science and Technology ______%
 ______% ING Davis Venture Value ______% ______% ING VP Growth and Income ______%
 ______% ING Evergreen Omega ______% ______% ING VP Index Plus International Equity ______%
 ______% ING FMR (SM) Large Cap Growth ______% ______% ING VP Index Plus LargeCap ______%
 ______% ING Fundamental Research ______% ______% ING VP Index Plus MidCap ______%
 ______% ING Goldman Sachs Capital Growth ______% ______% ING VP Index Plus SmallCap ______%
 ______% ING JPMorgan International ______% ______% ING VP International Equity ______%
 ______% ING JPMorgan Mid Cap Value ______% ______% ING VP International Value ______%
 ______% ING Legg Mason Aggressive Growth ______% ______% ING VP MidCap Opportunities ______%
 ______% ING Legg Mason Value ______% ______% ING VP Real Estate ______%
 ______% ING MFS Total Return ______% ______% ING VP Small Company ______%
 ______% ING OpCap Balanced Value ______% ______% ING VP SmallCap Opportunities ______%
 ______% ING Oppenheimer Global ______% ______% ING VP Strategic Allocation Conservative ______%
 ______% ING Oppenheimer Strategic Income2 ______% ______% ING VP Strategic Allocation Growth ______%
 ______% ING PIMCO Core Bond2 ______% ______% ING VP Strategic Allocation Moderate ______%
 ______% ING PIMCO High Yield ______% ______% ING VP Value Opportunity ______%
 ______% ING PIMCO Total Return2 ______% ______% Oppenheimer Main Street Small Cap ______%
 ______% ING Pioneer Fund ______% ______% PIMCO VIT Real Return ______%
 ______% ING Pioneer Mid Cap Value ______% ______% Pioneer Equity-Income VCT ______%
 ______% ING Solution 2045 ______%                            ]

[  1 The available share class is subject to distribution and/or service (12b-1) fees.  
   2 Death benefit and living benefit guarantees may be affected by amounts invested in or transferred to and from these investment options.
   3 DCA does not ensure a profit or guarantee against loss in a declining market.  
   4 May not be available in all states. Read the appropriate Prospectus and any Prospectus Supplements for more information. ]  
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____________________________________________________________________________________________________________
10. OPTIONAL ACCOUNT REBALANCING PROGRAM (May not use with DCA.)

Automatic Allocation Rebalancing will occur on the last business day of the next scheduled rebalancing date. Please consult your
prospectus for details regarding this feature as well as restrictions, minimum or maximum limitations, fees and other applicable
information. Automatic Allocation Rebalancing does not apply to the Fixed Investments and cannot be elected if you participate
in Dollar Cost Averaging. The percentages will be proportionally recalculated for subsequent reallocations if you have chosen
Fixed Allocation Election. Any subsequent reallocation, add-on or partial withdrawal you direct, other than on a pro rata basis, will
terminate this program.
Please rebalance my portfolio to the allocations on this application: ¨ Quarterly ¨ Semi-Annually ¨ Annually
____________________________________________________________________________________________________________
11. SPECIAL REMARKS

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
____________________________________________________________________________________________________________
12. STATE REQUIRED NOTICES

Below are notices that apply only in certain states. Please read the following carefully to see if any apply in your state.

Arizona: On receiving your written request, we will provide you with information regarding the benefits and provisions of the annuity
contract for which you have applied. If you are not satisfied, you may cancel your contract by returning it within 20 days, or within 30 days
if you are 65 years of age or older on the date of the application for the annuity, after the date you receive it. Any premium paid for the
returned contract will be refunded without interest.

California Reg. 789.8: The sale or liquidation of any asset in order to buy insurance, either life insurance or an annuity contract, may have
tax consequences. Terminating any life insurance policy or annuity contract may have early withdrawal penalties or other costs or penalties,
as well as tax consequences. You may wish to consult independent legal or financial advice before the sale or liquidation of any asset and
before the purchase of any life insurance or annuity contract.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or
award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime.

New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.

Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a
claim containing a false or deceptive statement is guilty of insurance fraud.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement may have violated the state law.

Arkansas, Washington D.C., Hawaii, Louisiana, Maine, New Mexico, Oklahoma, and Tennessee: Any person who knowingly
and with intent to injure, defraud or deceive any insurance company, submits an application for insurance containing any materially false,
incomplete, or misleading information, or conceals for the purpose of misleading, any material fact, is guilty of insurance fraud, which is a
crime and in certain states, a felony. Penalties may include imprisonment, fine, denial of benefits, or civil damages.

Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

GA-CDF-1105(08/07) Page 7 of 9 - Incomplete without all pages. Order #137872 08/20/2007

___________________________________________________________________________________________________________
13. APPLICANT SIGNATURES AND ACKNOWLEDGEMENTS

(Please read carefully, fi ll in all requested information, and sign below.)

Important Information: To help the government fi ght the funding for terrorism and money laundering activities, federal
law requires all fi nancial institutions to obtain, verify, and record information that identifi es each person who opens an
account. What this means to you: When you apply for an annuity, we will ask for your name, address, date of birth, and
other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying
documents.

By signing below, I acknowledge receipt of the Prospectus. I agree that, to the best of my knowledge and belief,
all statements and answers in this form are complete and true and may be relied upon in determining whether to
issue the applied for variable annuity. Only the owner and ING USA Annuity and Life Insurance Company have the
authority to modify this form.

The Annuity applied for does not take effect until ING USA Annuity and Life Insurance Company receives the
premium payment. Make checks payable ONLY to ING USA Annuity and Life Insurance Company. Do not make
checks payable to the agent, an agency or other company.

Variable Annuities and the underlying series shares or securities which fund them are not insured by the FDIC or
any other agency. They are not deposits or other obligations of any bank and are not bank guaranteed. They are
also subject to market fluctuation, investment risk and possible loss of principal invested.

I understand that when based on the investment experience of the Separate Account Division, the variable annuity
cash surrender values may increase or decrease on any day and that no minimum value is guaranteed. The variable
annuity applied for is in accord with my anticipated financial objectives.

I understand that the value allocated to any Account subject to a Market Value Adjustment may increase
or decrease if surrendered or withdrawn prior to a specified date(s) as stated in the contract.

I understand that IRAs and other qualified plans already provide tax deferral like that provided by the contract.
For an additional cost, the contract provides additional features and benefits, including death benefits and the
ability to receive a lifetime income. I should not purchase a qualified contract unless I want these benefits,
taking into account their cost.

In certain circumstances, Fixed Allocation Fund Automatic Rebalancing may result in a reallocation into the
[LifePay Plus]Fixed Allocation Fund(s), even if you have not previously been invested in them. By electing to
purchase the [ING LifePay Plus] [or] [ING Joint LifePay Plus]option (if chosen), you are providing ING USA Annuity and
Life Insurance Company with direction and authorization to process these transactions, including reallocations
into the [LifePay Plus] Fixed Allocation Fund(s).  You should not purchase the [LifePay Plus] [or] [Joint LifePay Plus]
option if you do not wish to have your contract value reallocated in this manner.

TAXPAYER CERTIFICATION
Under penalties of perjury, my/our signature(s) certifies/certify that:

1.      The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).
 
2.      I am not subject to backup withholding because (a) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (b) the IRS has notified me that I am no longer subject to backup withholding.
 
3.      I am a U.S. citizen or U.S. resident alien.
 

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.

Owner Signature ____________________________________      
Signed at (City, State)________________________________   Date_______  
Joint Owner Signature (if applicable)_____________________      
Signed at (City, State)________________________________   Date_______  
Annuitant Signature (if other than owner)_________________      
Signed at (City, State)   Date_______  
GA-CDF-1105(08/07) Page 8 of 9 - Incomplete without all pages.   Order #137872 08/20/2007

______________________________________________________________________________________________________________
14. AGENT INFORMATION AND SIGNATURE
Does the applicant have existing individual life insurance policies or annuity contracts?
¨Yes ¨No

Do you have reason to believe that the contract applied for will replace any existing annuity or life insurance coverage?
¨ Yes ¨ No (If “Yes”, complete and attach a copy of any state replacement forms that apply.)

If either or both of the questions in this section are answered “Yes”, please complete and return with this form a copy of any state
replacement form(s), as applicable.

____________________________________________________________________________________________________________
If your state has adopted the NAIC Model Replacement Regulation or other state specifi c replacement regulations, did
you remember to do the following?

¨ Provide any required replacement notice to the client and offer to read it aloud? (Note: If any of the questions in Replacement
    Section 8 or in this Section 14 are answered “Yes”, you must provide a replacement notice.)

¨ Complete any required state specifi c paperwork?

By signing below you certify: 1) replacement questions were answered, 2) any sales material was shown to the applicant and a copy
was left with the applicant, 3) you used only insurer-approved sales material, 4) you have not made statements that differ from the
sales material, and 5) no promises were made about the future value of any contract elements that are not guaranteed. (This includes
any expected future index gains that may apply to this contract.)

______________________________________________________________________________________
[ Compensation Alternative 

¨ Option A ] 
_________________________________________________________________________________________________
¨ Check here if there is more than one agent on this contract.

Split for Agent #1_________________%, Agent #2_________________%, Agent #3_________________%

Please note: Compensation will be split equally if no percentages are indicated. Partial percentages will be rounded up. Agent #1 will
be given the highest percentage in the case of unequal percentages. Agent #1 will receive all correspondence regarding the policy.
_______________________________________________________________________________________________________________
Agent #1

Print Name ______________________________________________ Signature_______________________________________________

SSN____________________________________________________  Agent Phone____________________________________________

[FL License #/Broker Code_________________________________ ] Broker/Dealer Branch_____________________________________

Agent #2

Print Name ______________________________________________ Signature_______________________________________________

SSN____________________________________________________  Agent Phone____________________________________________

[FL License #/Broker Code_________________________________ ] Broker/Dealer Branch_____________________________________


Agent #3

Print Name ______________________________________________ Signature_______________________________________________

SSN____________________________________________________  Agent Phone____________________________________________

[FL License #/Broker Code_________________________________ ] Broker/Dealer Branch_____________________________________
________________________________________________________________________________________________________________

GA-CDF-1105(08/07) Page 9 of 9 - Incomplete without all pages. Order #137872 08/20/2007