EX-99.(4)(67) 2 c54195bexv99wx4yx67y.txt EX-99.(4)(67) . . . EXHIBIT 4.67 CONTRACT DATA Deferred Annuity Contract: RIVERSOURCE(R) SIGNATURE ONE SELECT Contract Number: 9920-SAMPLE Contract Date: October 1, 2009 Annuitant: John Doe Annuitization Start Date: October 1, 2069 Contract Owner: John Doe Age at Issue: 35
Application Signed State/Contract Delivery State: state State Insurance Department: 800-ZZZ-ZZZZ Initial Purchase Payment: $25,000 Contract Type: Non-Qualified Scheduled Purchase Payment: Annual Amount: NA Maximum Purchase Payments Permitted: 1st Contract Year and Total: - Under age 86: $1,000,000 - Age 86 or older and under age 91: $ 0 - Age 91 or older: $ 0 Each Contract Year thereafter: - Under age 86: $ 100,000 - Age 86 or older and under age 91: $ 0 - Age 91 or older: $ 0 Minimum Additional Purchase Payment: $ 100 Minimum Purchase Payment or Transfer Amount to any Guarantee Period Account: $ 1,000 Purchase Payment Credits: Crediting Method 1
Cumulative Net Purchase Payment* Amount Net Purchase Payment Credit Percentage --------------------------------------- -------------------------------------- $ 0 - $249,999.99 4% $250,000.00 + 5%
* Cumulative net purchase payments are total purchase payments less the total amount of partial surrenders. Upon issuance of this contract your purchase payments have been scheduled to be paid and applied to the Fixed Account, Guarantee Period Accounts and variable subaccounts investing in funds as shown below. You may change the amount, frequency and allocations as provided in this contract. Refer to the Purchase Payments provision.
Payment Allocation Allocation Percentage ---------- ---------- FIXED ACCOUNT Regular Fixed Account ___% 6-month Special DCA Fixed Account ___% 12-month Special DCA Fixed Account ___% GUARANTEE PERIOD ACCOUNTS (GPA) 1 Year Guarantee Period Account ___% 2 Year Guarantee Period Account ___% 3 Year Guarantee Period Account ___% 4 Year Guarantee Period Account ___% 5 Year Guarantee Period Account ___% 6 Year Guarantee Period Account ___% 7 Year Guarantee Period Account ___% 8 Year Guarantee Period Account ___% 9 Year Guarantee Period Account ___% 10 Year Guarantee Period Account ___%
Payment Allocation Allocation Percentage ---------- ---------- AIM V.I. Capital Appreciation Fund, Series II Shares ___% Capital Development Fund, Series II Shares ___% Global Health Care Fund, Series II Shares ___% International Growth Fund, Series II Shares ___% ALLIANCEBERNSTEIN VPS Global Thematic Growth Portfolio (Class B) ___% Growth and Income Portfolio (Class B) ___% International Value Portfolio (Class B) ___% AMERICAN CENTURY VP Mid Cap Value, Class II ___% Ultra(R), Class II ___% Value, Class II ___%
411265-DPSG1 Page 3.0 A(10/2009) CONTRACT DATA - Continued Contract Number: 9920-SAMPLE Contract Date: October 1, 2009
Payment Allocation Allocation Percentage ---------- ---------- COLUMBIA High Yield Fund, Variable Series, Class B ___% Marsico Growth Fund, Variable Series, Class A ___% Marsico International Opportunities Fund, Variable Series, Class B ___% Small Cap Value Fund, Variable Series, Class B ___% CREDIT SUISSE TRUST - Commodity Return Strategy Portfolio ___% DREYFUS VIF International Equity Portfolio, Service Shares ___% VIF International Value Portfolio, Service Shares ___% EATON VANCE VT Floating-Rate Income Fund ___% FIDELITY(R) VIP Contrafund(R) Portfolio Service Class 2 ___% Investment Grade Bond Portfolio Service Class 2 ___% Mid Cap Portfolio Service Class 2 ___% Overseas Portfolio Service Class 2 ___% FRANKLIN TEMPLETON VIP TRUST Franklin Income Securities Fund - Class 2 ___% Templeton Global Income Securities Fund - Class 2 ___% Templeton Growth Securities Fund - Class 2 ___% GOLDMAN SACHS VIT Mid Cap Value Fund - Institutional Shares ___% Structured U.S. Equity Fund - Institutional Shares ___% JANUS ASPEN SERIES Large Cap Growth Portfolio: Service Shares ___% LEGG MASON PARTNERS VARIABLE Small Cap Growth Portfolio, Class I ___% MFS(R) Total Return Series - Service Class ___% Utilities Series - Service Class ___%
Payment Allocation Allocation Percentage ---------- ---------- OPPENHEIMER Capital Appreciation Fund/VA, Service Shares ___% Global Securities Fund/VA, Service Shares ___% Main Street Small Cap Fund/VA, Service Shares ___% Strategic Bond Fund/VA, Service Shares ___% PIMCO VIT All Asset Portfolio, Advisor Share Class ___% RIVERSOURCE VARIABLE SERIES TRUST RIVERSOURCE PARTNERS VP Fundamental Value Fund ___% Select Value Fund ___% Small Cap Value Fund ___% RIVERSOURCE VP Cash Management Fund ___% Diversified Bond Fund ___% Diversified Equity Income Fund ___% Dynamic Equity Fund ___% Global Inflation Protected Securities Fund ___% High Yield Bond Fund ___% Income Opportunities Fund ___% Mid Cap Value Fund ___% S&P 500 Index Fund ___% Short Duration U.S. Government Fund ___% SELIGMAN VP Growth Fund ___% THREADNEEDLE VP Emerging Markets Fund ___% International Opportunity Fund ___% VAN KAMPEN LIT Comstock Portfolio Class II Shares ___% VAN KAMPEN UIF Global Real Estate Portfolio, Class II Shares ___% Mid Cap Growth Portfolio, Class II Shares ___% WANGER International ___% USA ___%
Asset Allocation Program Investment Selection: Portfolio Navigator Moderate Model 411265-DPSG1 Page 3.1 A(10/2009) CONTRACT DATA - Continued Contract Number: 9920-SAMPLE Contract Date: October 1, 2009 Fixed Account Minimum Interest Rate: X% Any purchase payments and purchase payment credits allocated to the Regular Fixed Account on the Contract Date will earn interest, for the first year, at the annual effective rate of 3.5%. New rates may be declared from time to time. Any purchase payments and purchase payment credits allocated to the 6-Month Special DCA fixed account on the Contract Date will earn interest at the annual effective rate of 3.5%. New rates may be declared from time to time. Any purchase payments and purchase payment credits allocated to the 12-Month Special DCA fixed account on the Contract Date will earn interest at the annual effective rate of 3.5%. New rates may be declared from time to time. MVA Risk Factor: 0.001 See Guarantee Period Accounts endorsement, MVA formula. CV Waiver Percentage: 10% See the definition of "total free amount" in the Surrender Charge provision. Hospitalization/Nursing Home Waiver Benefit Age: 75 See Waiver of Surrender Charges upon Hospital or Nursing Home Confinement provision. TI Waiver Benefit Age: 100 See Waiver of Surrender Charges upon Terminal Illness Disability Diagnosis provision. ROPP Benefit Age: 100* See Payments to Beneficiaries provision. * In the event of a "covered life change," then the ROPP Benefit Age is age 85. Schedule of Surrender Charges: If you surrender all or a portion of this contract, a surrender charge may apply. A surrender charge applies if all or part of the Contract Value surrendered is from payments received during the nine years before surrender.
Number of Completed Years from Surrender Charge Percentage Date of Each Purchase Payment Applied to Each Purchase Payment ------------------------------ -------------------------------- 0 8.0% 1 8.0% 2 8.0% 3 7.0% 4 6.0% 5 4.0% 6 3.0% 7 2.0% 8 1.0% 9+ 0.0%
You may surrender the greater of (1) your prior contract anniversary Contract Value multiplied by the CV Waiver Percentage shown above or (2) contract earnings each contract year without incurring a surrender charge. Refer to the Surrender Provisions. 411265-DPSG1 Page 3.2 A(10/2009) CONTRACT DATA - Continued Contract Number: 9920-SAMPLE Contract Date: October 1, 2009 Annual Mortality and Expense Risk Fee: Until 9th Contract Anniversary Base Fee + Optional Death Benefit Rider Fee = Total M&E Fee 1.60% + 0% = 1.60% of the daily net asset value 9th Contract Anniversary and after Base Fee + Optional Death Benefit Rider Fee = Total M&E Fee 1.30% + 0% = 1.30% of the daily net asset value Annual Variable Account Administrative Charge: 0.15% of the daily net asset value Contract Administrative Charge: Initial Annual Charge $40 We reserve the right to adjust this charge after the first contract anniversary, but the charge will never exceed $50. Initial Annual Charge if contract value equals or exceeds $50,000 $ 0 We reserve the right to charge up to $20 after the first contract anniversary. See Contract Administrative Charge provision. Regular Fixed Account Purchase Payment and Transfer Limits: 1. Payments to the Regular Fixed Account are limited to 100% of each payment. (There are no limits on payments to the Regular Fixed Account if the payment is used to establish automated transfers under a dollar cost averaging arrangement, unless this exception is terminated on a nondiscriminatory basis with notification.) 2. Transfers to the Regular Fixed Account are limited to transfer amounts which result in the Regular Fixed Account Contract Value (after the transfer) being no more than 100% of the total Contract Value. (There are no limits on transfers to the Regular Fixed Account if the transfer is used to establish automated transfers under a dollar cost averaging arrangement, unless this exception is terminated on a nondiscriminatory basis with notification.) 3. Transfers from the Regular Fixed Account (including automated transfers under a dollar cost averaging arrangement) are limited to the greater of: a. $10,000; or b. 30% of the Regular Fixed Account Contract Value at the beginning of the contract year. All purchase payments and any purchase payment credits received into the Regular Fixed Account prior to Your transfer request are considered Your beginning of contract year value during the first contract year. 411265-DPSG1 Page 3.3 A(10/2009)