EX-99.B5F 2 a138311_01122009.htm APPLICATION 138311 a138311_01122009.htm -- Converted by SEC Publisher, created by BCL Technologies Inc., for SEC Filing

Issued by ING USA Annuity and Life Insurance Company
A member of the ING family of companies
Distributed by Directed Services LLC

ING Architect

Variable Annuity Application

Countrywide except CA, FL, IL, MD, MA, MN, NC, ND, NJ, NV, OR, TX and WA

Annuities

  IMPORTANT INFORMATION AND REMINDERS
Page 1

The name, trust date (if applicable), address, birth date, Social Security number/tax identification number, and country of citizenship is provided for each individual/entity named.

  Page 2

The primary or contingent status for each named beneficiary is entered in section 3(A).

Each beneficiary is named individually. If there are any trust designations, the trust name and the trust date are included.

Designated beneficiary percentages are clearly entered and total 100% for all primary beneficiaries and 100% for all contingent beneficiaries. If a separate sheet containing additional beneficiary information is needed, that sheet is signed and dated by the owner.

If the ING Joint LifePay Plus living benefit option is selected on a custodially owned contract, the custodial beneficiary information is entered in section 3(B).

  Page 3

If a transfer is required, the approximate transfer amount is entered in section 4. If there are multiple transfers, each approximate transfer amount is entered separately.

The initial premium meets the selected product’s minimum requirements.

Select one product and one death benefit. If choosing an optional living benefit rider, select only one. Enhanced death benefits cannot be selected with joint owners.

If Telephone/Electronic Transmission Reallocation Authorization is selected, the owner has initialed where required to authorize the agent. The name and Social Security number for each additional person is entered in section 6.

  Page 4

The owner and joint owner (if applicable) have initialed their consent to future electronic information delivery. We will not provide their e-mail addresses to any third party.

The plan type for this new annuity (i. e. Non-Qualified, IRA, or Simple IRA) is indicated in section 8, and any applicable conversion/establishment dates are provided.

If a replacement is involved, the appropriate transfer and state replacement forms are completed and submitted with this application.

  Page 5

Use section 10A only if you have not elected the ING LifePay Plus or ING Joint LifePay Plus living benefit options. All allocations (fixed and variable) total 100% of the initial investment amount.

To elect an optional DCA transfer program, allocate money to either ING Liquid Assets or 6-Month DCA, and indicate the funds the DCA is to go to by writing percentages in the “DCA Allocation % (Optional)” columns. Both allocations must total 100%.

  Page 6

Use section 10B only if you have elected the ING LifePay Plus or ING Joint LifePay Plus living benefit options.

Please note, contracts that elect the ING LifePay Plus or ING Joint LifePay Plus living benefit options must comply with the fund allocation requirements as described on Page 6 of this application (see Options 1-3) and in your prospectus. These requirements apply to both initial and DCA allocations. Please see the next page for examples.

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.

After contract issue, ING USA Annuity and Life Insurance Company may periodically rebalance the contract value to remain in compliance with the ING LifePay Plus and ING Joint LifePay Plus allocation requirements. Please see your prospectus for additional information.

To elect an optional DCA transfer program, allocate money to either ING Liquid Assets or 6-Month DCA, and indicate the funds the DCA is to go to by writing percentages in the “DCA Allocation % (Optional)” columns. Both allocations must total 100%.

 

Page 7

Provide any additional remarks in section 12 (e.g. additional beneficiaries).

Page 8

The owner has signed and dated section 13, including the city and state where this application was signed. If this is different from the owner’s resident state, an explanation is provided at the top of page 1 and a “Nexus Information Worksheet” is submitted with this application.

If this form is signed by a power of attorney, legal guardian, etc, a copy of the appropriate supporting documentation is provided confirming the signer’s ability to act on behalf of the owner.

  Page 9

The name, Social Security number, phone number, broker/dealer branch, and signature for each agent is provided. If more than one agent is listed, the agent commission split is entered and totals 100%.

MAILING INSTRUCTIONS         
Send completed and signed documents to:         
For Regular Mail:    ING ANNUITIES    For Overnight Delivery:    ING ANNUITIES 
    Attn: New Business        Attn: New Business 
    PO Box 9271        909 Locust Street 
    Des Moines, IA 50306-9271        Des Moines, IA 50309-2899 

  To contact our Licensing Department please call 800-235-5965.
To contact our Client Services Department please call 800-366-0066.

To contact our Sales Desk please call:     
INDEPENDENT DIVISION    NYSE/REGIONAL DIVISION 
800-344-6860    800-243-3706 
 

EXAMPLES OF ING LIFEPAY PLUS AND ING JOINT LIFEPAY PLUS FUND ALLOCATIONS

If you elect ING LifePay Plus or ING Joint LifePay Plus, there are allocation guidelines that must be followed.
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 30% 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 30%
of the account value not invested in Accepted Funds must be invested in the LifePay Plus Fixed Allocation Fund(s).

Option 1 - Allocate entirely among Accepted Funds.

• $100,000 Total Investment
• 100% ($100,000) in Accepted Funds


Option 2 - Elect not to allocate any account value
to Accepted Funds and allocate entirely among the
LifePay Plus Fixed Allocation Fund(s) and Other Funds
(30% of your total investment must be in the LifePay
Plus Fixed Allocation Fund(s)).

• $100,000 Total Investment
• 30% ($30,000) in LifePay Plus Fixed Allocation Fund(s)
• 70% ($70,000) in Other Funds


Option 3 - Allocate among a combination of Accepted
Funds, the ING LifePay Plus Fixed Allocation Fund, and
Other Funds (30% of the money not in Accepted Funds
must be in the ING LifePay Plus Fixed Allocation Fund).

  • $100,000 Total Investment
  • $50,000 in Accepted Funds (50% of total)
  • $15,000 in ING LifePay Plus Fixed Allocation Fund
  • $35,000 in Other Funds
  • ING LifePay Plus Fixed Allocation Fund is 30% of the account value not invested in Accepted Funds

Here are some common allocation percentage combinations you might want to use:

Accepted    Fixed Allocation Fund    Other    Accepted    Fixed Allocation Fund    Other 
 
 
 
 
 
0%    30%    70%    55%    14%    31% 
 
 
 
 
 
5%    29%    66%    60%    12%    28% 
 
 
 
 
 
10%    27%    63%    65%    11%    24% 
 
 
 
 
 
15%    26%    59%    70%    9%    21% 
 
 
 
 
 
20%    24%    56%    75%    8%    17% 
 
 
 
 
 
25%    23%    52%    80%    6%    14% 
 
 
 
 
 
30%    21%    49%    85%    5%    10% 
 
 
 
 
 
35%    20%    45%    90%    3%    7% 
 
 
 
 
 
40%    18%    42%    95%    2%    3% 
 
 
 
 
 
45%    17%    38%    100%    0%    0% 
 
 
 
 
 
50%    15%    35%             
 
 
 
 
 

IMPORTANT INFORMATION ABOUT THE ING JOINT LIFEPAY PLUS LIVING BENEFIT RIDER

There are certain issue requirements that must be met to successfully elect the ING Joint LifePay Plus living benefit rider. Applications
that do not comply with these issue requirements will be deemed not in good order, and the contract will not be issued.

The ING USA Annuity and Life Insurance Company Joint LifePay Plus living benefit rider can only be issued if there are two
individuals who are married at the time of issue and meet the ownership, annuitant and beneficiary issue requirements listed
in the table below. ING USA Annuity and Life Insurance Company will comply with the then current definition of marriage under
federal tax law and regulations and federal tax publications issued by the Internal Revenue Service (IRS). The IRS has interpreted
marriage to mean a legal union between a man and a woman as husband and wife. Please consult your financial advisor to
determine whether you meet the requirements.

ING Joint LifePay Plus Living Benefit Issue Requirements
            Annuitant(s)    Primary Beneficiary 
Type of Plan    Owner1    Ownership Requirements    Requirements    Requirements 
 
 
 
 
Non-Qualified    Joint owners    The two owners must be the    Must be a spouse.    None 
        two spouses.         
   
 
 
 
    Single owner    The owner must be a spouse.    Must be a spouse.    Sole primary beneficiary 
                must be the owner’s spouse. 
 
 
 
 
Qualified-IRA    Single owner2    The owner must be a spouse.    Must be the owner.    Sole primary beneficiary 
                must be the owner’s spouse.3 
 
 
 
 

1 Non-natural owners are not allowed. Neither joint owners nor non-natural owners are allowed under qualified plans.
2 Includes custodial accounts. The beneficial owner of the custodial account must be one of the spouses.
3 If a custodial account, this requirement applies to the beneficiary information on record with the custodian.

Changes in ownership, annuitant and/or beneficiary designations, and changes in marital status may affect the terms and conditions
of the ING Joint LifePay Plus living benefit option. Please refer to your prospectus for complete details to determine if this living
benefit option is consistent with your needs and objectives in purchasing an annuity contract.

If you decide to elect the ING Joint LifePay Plus living benefit option, please be sure to provide names, birth dates and Social Security
numbers wherever requested on the application. Please follow the instructions listed on the “Important Information and Reminders”
page at the beginning of this document.

Annuities

ING GOLDENSELECT
DEFERRED VARIABLE ANNUITY APPLICATION

ING USA Annuity and Life Insurance Company (the “Company”)
PO Box 9271 Des Moines, IA 50306-9271 Phone: (800) 366-0066

Overnight Delivery: ING Annuities 909 Locust Street Des Moines, IA 50309-2899

For Agent Use Only: Client’s Account Number:
If this application 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 (Please provide supporting documentation for all non-natural owners.)     
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                         E-mail Address         
   
 
     
 
Country of Citizenship                     
 
 
 
 
 
1(B). JOINT OWNER    (Standard Death Benefit option only.)         
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                         E-mail Address         
   
 
     
 
Country of Citizenship                     
 
 
 
 
 
2(A). ANNUITANT                     
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 
   
     
       
Street Address                     
   
 
 
 
 
    (No P.O. Box addresses.)                                 City    State    ZIP 
Country of Citizenship                     
 
 
 
 
 
2(B). CONTINGENT ANNUITANT (Optional.)             
Name                Relationship to Owner     
   
 
 
     
SSN        Birth Date        Male       Female 
   
     
       
Street Address                     
   
 
 
 
 
    (No P.O. Box addresses.)                                   City    State    ZIP 
Country of Citizenship                     
 
 
 
 
 
138187(04/08)            Page 1 of 9    Order # 138311 01/12/2009 

3(A). BENEFICIARY(S) (All fields for each beneficiary must be completed. Complete Section 3B for custodially owned contracts.)

       Restricted Beneficiary. (If selected, complete a “Restricted Beneficiary” form and submit with this application.)     
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             
   
 
 
Please use the space in Section 12 if you need to list additional beneficiaries.         
 
 

3(B). CUSTODIAL BENEFICIARY (Required if Joint LifePay Plus is selected on a custodially owned contract. This sole beneficiary
must be the spouse of the annuitant. All fields must be completed.)

Name    Birth Date    Percent    100        % 
           
       
SSN/TIN    Is this sole beneficiary the spouse of the annuitant?    Yes    No 
Address                     
 
 
 
 
 

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 to             
    Name    Owner    Birth Date    SSN/TIN    Percent 
 
 
 
 
 
 
One Primary Beneficiary    Mary M. Doe    Sister    03/31/1950    123-45-6789    100% 
 
 
 
 
 
 
 
Two Primary Beneficiaries    Jane J. Doe    Mother    04/01/1940    ###-##-####    50% 
    John J. Doe    Father    05/01/1935    ###-##-####    50% 
 
 
 
 
 
 
One Primary Beneficiary    Jane J. Doe    Wife    11/30/1921    ###-##-####    100% 
One Contingent    John J. Doe    Son    06/18/1951    ###-##-####    100% 
 
 
 
 
 
 
Estate    Estate of John Doe    Estate    N/A    67-981239    100% 
 
 
 
 
 
 
    ABC Trust                 
Trust        Trust    N/A    44-234567    100% 
    Dated 1/1/85                 
 
 
 
 
 
Testamentary Trust1    Trust created by the                 
(Trust established within the    Last Will and Testament    Testamentary Trust    N/A    38-078602    100% 
owner’s will)    of John Doe                 
 
 
 
 
 

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.

138187(04/08)

Page 2 of 9

Order # 138311 01/12/2009

4. INITIAL INVESTMENT

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
 

ING Architect

Surrender Charge Option (Standard Surrender Charge Period is 7 Years.)

4-Year Surrender Charge Period

Optional Premium Bonus

ING Premium Credit Rider

(4% Bonus on the Standard 7-Year Surrender Charge Period and 2% Bonus on the Optional 4-Year Surrender Charge Period. )

Death Benefit Option (Select One. If a death benefit is not chosen, the death benefit will be the Standard Death Benefit.)

Standard Death Benefit (This is the only death benefit option available to Joint Owners. )

Annual Ratchet Death Benefit 1 MAX 7% Solution Death Benefit 1

1 Only available for owner and annuitant ages 0-75, unless LifePay Plus or Joint LifePay Plus is elected. If LifePay Plus or Joint LifePay Plus is elected, owner ages 0-79
are permitted. Please consider the additional cost of these options (0.85% of MGWB Base for LifePay Plus and 1.05% of MGWB Base for Joint LifePay Plus) as well
as their interaction with the death benefit elected to determine if this combination is appropriate considering your investment objectives.

Optional Living Benefit (May select one.)

Minimum Guaranteed Income Benefit (MGIB) (Only available for owner and annuitant ages 0 - 75 years. )

ING LifePay Plus Minimum Guaranteed Withdrawal Benefit (2008. v2) (“LifePay Plus”)2

ING Joint LifePay Plus Minimum Guaranteed Withdrawal Benefit (2008. v2) (“Joint LifePay Plus”)2

There are specific ownership and beneficiary requirements for election of the Joint LifePay Plus benefit option.

2Funds must be allocated per the LifePay Plus and Joint LifePay Plus requirements detailed on page 6. Read your prospectus carefully regarding details about the
LifePay Plus and Joint LifePay Plus options. 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.

6. TELEPHONE/ELECTRONIC TRANSMISSION AUTHORIZATION

I authorize ING USA Annuity and Life Insurance Company to act upon instructions given by electronic means or voice command
from the agent that signs in section 15 and/or the following individuals listed below upon furnishing their Social Security Number
or alternative identification number.

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

Name    SSN/TIN 
Name    SSN/TIN 

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 affiliated with the broker/dealer under which
my contract was purchased or until such time as I notify the Company in writing of a change in instructions.

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

138187(04/08)

Page 3 of 9

Order # 138311 01/12/2009

7. ELECTRONIC INFORMATION CONSENT

(Both owners must consent for jointly owned contracts.)
I consent to electronic delivery by ING USA, when available, of:
(Owner Initials) (Owner Initials)

  • Legal disclosure materials (prospectuses and prospectus supplements for the variable annuity and the underlying funds and annual and semi-annual reports for the underlying funds).
  • Account documents (quarterly statements and immediate confirmations).
  • Related correspondence (privacy notice and other notices to customers).

I confirm that I have ready access to a computer with the hardware and software necessary (a CD-ROM drive and Adobe® Acrobat®,
and Internet access and an active e-mail account) to receive this information electronically – in the form of a compact disc, by e-mail
or by notice to me of this information being made available on ING’s website – and to be able to read and retain it.
I understand that:

  • There is no charge for electronic delivery, although I may incur the costs of Internet access and computer usage.
  • I may always request a paper copy of this information at any time for no charge, even though I consented to electronic delivery or if I decide to revoke my consent.
  • ING is not required to deliver this information electronically and may discontinue electronic delivery in whole or part at any time.

This consent is effective until further notice by ING or I revoke it.
Please call 800-366-0066 if you would like to revoke your consent, wish to receive a paper copy of any of the information above, or
need to update your e-mail address indicated on page 1 of this application.

8. PLAN TYPE

         Non-Qualified    1035 Exchange 
 
Qualified     
         IRA    IRA Rollover from Qualified Plan 
         SEP-IRA    IRA Transfer (e.g., Trustee to Trustee transfer) 
       Qualified Other     
   

Indicate contribution amount and appropriate tax year

  Roth IRA. If transfer, provide original conversion/establishment date and amount
 
9.      REPLACEMENT
 

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

Will this contract replace any life insurance policy or annuity contract in this or any other company?    Yes    No 
If “Yes”, 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.

138187(04/08)

Page 4 of 9

Order # 138311 01/12/2009

10A. ALLOCATION SELECTION - USE IF YOU HAVE NOT ELECTED THE LIFEPAY PLUS OR JOINT LIFEPAY PLUS BENEFIT OPTION
Complete page 6, Section 10B if you have elected the LifePay Plus or Joint LifePay Plus benefit option.
To elect an optional DCA transfer program, allocate money to either ING Liquid Assets3 or 6-Month DCA3, 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%.    Variable Investments1         
Initial        DCA3    Initial        DCA3 
Allocation %        Allocation %    Allocation %        Allocation % 
(Required)        (Optional)     (Required)        (Optional) 
_______ % BlackRock Global Allocation V.I.    _______ %    _______ % ING Marsico Growth    _______ % 
_______ % Fidelity® VIP Contrafund    _______ %    _______ % ING Marsico International Opportunities    _______ % 
_______ % ING AllianceBernstein Mid Cap Growth    _______ %    _______ % ING MFS Total Return    _______ % 
_______ % ING American Funds Asset Allocation    _______ %    _______ % ING MFS Utilities    _______ % 
_______ % ING American Funds Bond    _______ %    _______ % ING Multi-Manager International Small Cap Equity                    ______ % 
_______ % ING American Funds Growth    _______ %    _______ % ING Oppenheimer Active Asset Allocation    _______ % 
_______ % ING American Funds Growth-Income    _______ %    _______ % ING Oppenheimer Global    _______ % 
_______ % ING American Funds International    _______ %    _______ % ING Oppenheimer Main Street    _______ % 
_______ % ING American Funds World Allocation    _______ %    _______ % ING PIMCO Core Bond    _______ % 
_______ % ING Baron Small Cap Growth    _______ %    _______ % ING Pioneer Mid Cap Value    _______ % 
_______ % ING BlackRock Global Science and Technology    _______ %    _______ % ING Russell Global Large Cap Index 85%    _______ % 
_______ %  ING BlackRock Large Cap Growth    _______ %    _______ % ING Russell Large Cap Index    _______ % 
_______ % ING Columbia Small Cap Value II    _______ %    _______ % ING Russell Mid Cap Index    _______ % 
_______ % ING Davis New York Venture    _______ %    _______ % ING Russell Small Cap Index    _______ % 
_______ % ING Evergreen Health Sciences    _______ %    _______ % ING T. Rowe Price Capital Appreciation    _______ % 
_______ % ING Evergreen Omega    _______ %    _______ % ING T. Rowe Price Equity Income    _______ % 
_______ % ING FMR(SM) Diversified Mid Cap    _______ %    _______ % ING T. Rowe Price Growth Equity    _______ % 
_______ % ING Focus 5    _______ %    _______ % ING Templeton Foreign Equity    _______ % 
_______ % ING Franklin Income    _______ %    _______ % ING Templeton Global Growth    _______ % 
_______ % ING Franklin Mutual Shares    _______ %    _______ % ING Van Kampen Capital Growth    _______ % 
_______ % ING Franklin Templeton Founding Strategy    _______ %    _______ % ING Van Kampen Comstock    _______ % 
_______ % ING Global Equity Option    _______ %    _______ % ING Van Kampen Equity & Income    _______ % 
_______ % ING Global Real Estate    _______ %    _______ % ING Van Kampen Global Franchise    _______ % 
_______ % ING Global Resources    _______ %    _______ % ING Van Kampen Global Tactical Asset Allocation    _______ % 
_______ % ING International Index    _______ %    _______ % ING Van Kampen Growth and Income    _______ % 
_______ % ING Janus Contrarian    _______ %    _______ % ING VP Growth and Income    _______ % 
_______ % ING JPMorgan Emerging Markets Equity    _______ %    _______ % ING VP Intermediate Bond    _______ % 
_______ % ING JPMorgan Mid Cap Value    _______ %    _______ % ING VP MidCap Opportunities    _______ % 
_______ % ING Julius Baer Foreign    _______ %    _______ % ING VP Small Company    _______ % 
_______ % ING Lehman Brothers U.S. Aggregate Bond Index        _______ %    _______ % ING WisdomTree(SM) Global High Yielding Equity Index           _______ % 
_______ % ING Liquid Assets2    _______ %             
 
 
 
 
ING Lifestyle Portfolios1
_______ % ING Lifestyle Aggressive Growth    _______ %
   		   _______ % ING Lifestyle Moderate    _______ % 
_______ % ING Lifestyle Conservative    _______ %     _______ % ING Lifestyle Moderate Growth    _______ % 
_______ % ING Lifestyle Growth    _______ %             
 
 
 
 
        Fixed Investments2         
Enter the allocation percentage and the fixed interest period. Check availability prior to selection.
_______ %    6 Month DCA        _______ %    Year Fixed     
_______ %
   		       Year Fixed        _______ %    Year Fixed     
_______ %         Year Fixed        _______ %    Year Fixed     
 
 
 
 
 
    100 % Allocation Total (Initial and DCA (if elected) allocations must each total 100%.)     
 
 

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 The minimum DCA Allocation amount is $250.00.

138187(04/08)

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Order # 138311 01/12/2009

10B. ALLOCATION SELECTION – USE IF YOU HAVE ELECTED THE LIFEPAY PLUS OR JOINT LIFEPAY PLUS BENEFIT OPTION
Complete page 5, Section 10A if you did not elect the LifePay Plus or Joint LifePay Plus benefit option.
Enter allocations in whole percentages according to the following options. DCA allocations also must follow the option limitations.
To elect an optional DCA transfer program, allocate money to either ING Liquid Assets3 or 6-Month DCA3, 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%.
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 30% 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 30% of the account value not invested in Accepted Funds must be invested in the LifePay Plus Fixed

  Allocation Fund(s).

Accepted Funds                 
Initial        DCA3    Initial        DCA3 
Allocation %    Variable Investments1    Allocation %           Allocation %        Allocation % 
(Required)        (Optional)          (Required)             (Optional) 
_______ % BlackRock Global Allocation V.I.    _______ %    _______ % ING Russell Global Large Cap Index 85%     _______ % 
_______ % ING American Funds Asset Allocation    _______ %    _______ % ING T. Rowe Price Capital Appreciation     _______ % 
_______ % ING American Funds World Allocation    _______ %    _______ % ING Van Kampen Equity & Income     _______ % 
_______ % ING LifeStyle Conservative    _______ %    _______ % ING Van Kampen Global Tactical Asset Allocation     _______ % 
_______ % ING Lifestyle Growth    _______ %              
_______ % ING Lifestyle Moderate    _______ %        Fixed Investments2     
_______ % ING Lifestyle Moderate Growth    _______ %    _______ %                 6 Month DCA     ___NA___% 
_______ % ING Liquid Assets2    _______ %    _______ %    Year Fixed     ___NA___% 
_______ % ING MFS Total Return    _______ %    _______ %    Year Fixed     ___NA___% 
_______ % ING Oppenheimer Active Asset Allocation    _______ %    _______ %    Year Fixed     ___NA___% 
 
 
 
 
 
LifePay Plus Fixed Allocation Fund(s)1                 
            If you have chosen to allocate according to Option 2 or 3 
_______ % ING American Funds Bond    _______ %    above, at least 30% of the account value not invested in 
_______ % ING Lehman Brothers U.S. Aggregate Bond Index    _______ %    Accepted Funds must be invested in the LifePay Plus Fixed 
_______ % ING PIMCO Core Bond    _______ %    Allocation Fund(s).     
_______ % ING VP Intermediate Bond    _______ %             
 
 
 
 
 
 
Other Funds1                 
_______ % Fidelity® VIP Contrafund    _______ %    _______ % ING Julius Baer Foreign     _______ % 
_______ % ING AllianceBernstein Mid Cap Growth    _______ %    _______ % ING Lifestyle Aggressive Growth     _______ % 
_______ % ING American Funds Growth    _______ %    _______ % ING Marsico Growth     _______ % 
_______ % ING American Funds Growth-Income    _______ %    _______ % ING Marsico International Opportunities     _______ % 
_______ % ING American Funds International    _______ %    _______ % ING MFS Utilities     _______ % 
_______ % ING Baron Small Cap Growth    _______ %    _______ % ING Multi-Manager International Small Cap Equity            _______ % 
_______ % ING BlackRock Global Science and Technology    _______ %    _______ % ING Oppenheimer Global     _______ % 
_______ % ING BlackRock Large Cap Growth    _______ %    _______ % ING Oppenheimer Main Street     _______ % 
_______ % ING Columbia Small Cap Value II    _______ %    _______ % ING Pioneer Mid Cap Value     _______ % 
_______ % ING Davis New York Venture    _______ %    _______ % ING Russell Large Cap Index     _______ % 
_______ % ING Evergreen Health Sciences    _______ %    _______ % ING Russell Mid Cap Index     _______ % 
_______ % ING Evergreen Omega    _______ %    _______ % ING Russell Small Cap Index     _______ % 
_______ % ING FMR(SM) Diversified Mid Cap    _______ %    _______ % ING T. Rowe Price Equity Income     _______ % 
_______ % ING Focus 5    _______ %    _______ % ING T. Rowe Price Growth Equity     _______ % 
_______ % ING Franklin Income    _______ %    _______ % ING Templeton Foreign Equity     _______ % 
_______ % ING Franklin Mutual Shares    _______ %    _______ % ING Templeton Global Growth     _______ % 
_______ % ING Franklin Templeton Founding Strategy    _______ %    _______ % ING Van Kampen Capital Growth     _______ % 
_______ % ING Global Equity Option    _______ %    _______ % ING Van Kampen Comstock     _______ % 
_______ % ING Global Real Estate    _______ %    _______ % ING Van Kampen Global Franchise     _______ % 
_______ % ING Global Resources    _______ %    _______ % ING Van Kampen Growth and Income     _______ % 
_______ % ING International Index    _______ %    _______ % ING VP Growth and Income     _______ % 
_______ % ING Janus Contrarian    _______ %    _______ % ING VP MidCap Opportunities     _______ % 
_______ % ING JPMorgan Emerging Markets Equity    _______ %    _______ % ING VP Small Company     _______ % 
_______  % ING JPMorgan Mid Cap Value    _______ %    _______ % ING WisdomTree(SM) Global High Yielding Equity Index     _______ % 
 
 
____100___% Allocation Total (Initial and DCA (if elected) allocations must each total 100%.)

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 The minimum DCA Allocation amount is $250.00.

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Order # 138311 01/12/2009

11. OPTIONAL ACCOUNT REBALANCING PROGRAM (May not use with Dollar Cost Averaging.)
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 a
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

12. SPECIAL REMARKS

13. 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. 
 
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14. SIGNATURES AND ACKNOWLEDGEMENTS (Please read carefully and sign below.)

Important Information: To help the government fight the funding for terrorism and money laundering activities, federal
law requires all financial institutions to obtain, verify, and record information that identifies 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 LifePay Plus
or 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     
 
 
 
138187(04/08)    Page 8 of 9        Order # 138311 01/12/2009 

15. AGENT INFORMATION

Check here if the applicant is on active duty with the U. S. Armed Forces or is a dependent of any active duty service member of the U. S. Armed Forces. Complete the Military Personnel Financial Services Disclosure Regarding Insurance Products and return it with this application.

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 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 specific 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 9 or in this Section 15 are answered “Yes,” you must provide a replacement notice. )

Complete any required state specific 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 (Select one. Please verify with your broker/dealer that the option you select is available.):

A B C D E

Check here if there are multiple agents on this contract.

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

Please Note: Compensation will be split equally if no percentage is indicated. Partial percentages will be rounded up. Percentages
must total 100%. 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 SSN

Broker/Dealer Branch

Agent #2

Print Name SSN

Broker/Dealer Branch

Agent #3

Print Name SSN

Broker/Dealer Branch

Signature Agent Phone

Broker Code

Signature Agent Phone

Broker Code

Signature Agent Phone

Broker Code

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Order # 138311 01/12/2009

138187(04/08)
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01/12/2009