Form 5305-RB                                                                                                       Do not file 
(Rev. April 2017)             Roth Individual Retirement Annuity Endorsement                                       with the Internal 
Department of the Treasury            (Under section 408A of the Internal Revenue Code)                            Revenue Service 
Internal Revenue Service 
Name of issuer                                                                 Check if this endorsement supersedes a prior Roth IRA 
                                                                               endorsement .    . . . .  . .  .  .       . . .   ▶
This endorsement is made a part of the annuity contract to which it is attached, and the following provisions apply in lieu of any 
provisions in the contract to the contrary. 
The annuitant is establishing a Roth individual retirement annuity (Roth IRA) under section 408A to provide for his or her retirement 
and for the support of his or her beneficiaries after death. 

                                                               Article I 
Except in the case of a qualified rollover contribution described in section 408A(e) or a recharacterized contribution described in 
section 408A(d)(6), the issuer will accept only cash contributions up to $5,500 per year for 2013 through 2017. For individuals who 
have reached the age of 50 by the end of the year, the contribution limit is increased to $6,500 per year for 2013 through 2017. For 
years after 2017, these limits will be increased to reflect a cost-of-living adjustment, if any.

                                                               Article II 
1. The annual contribution limit described in Article I is gradually reduced to $0 for higher income levels. For an annuitant who is 
single or treated as single, the annual contribution is phased out between adjusted gross income (AGI) of $118,000 and $133,000; for 
a married annuitant filing jointly, between AGI of $186,000 and $196,000; and for a married annuitant filing separately, between AGI of 
$0 and $10,000. These phase-out ranges are for 2017. For years after 2017, the phase-out ranges, except for the $0 to $10,000 range, 
will be increased to reflect a cost-of-living adjustment, if any. Adjusted gross income is defined in section 408A(c)(3).
2. In the case of a joint return, the AGI limits in the preceding paragraph apply to the combined AGI of the annuitant and his or her 
spouse. 

                                                               Article III 
The annuitant’s interest in the contract is nonforfeitable and nontransferable. 

                                                               Article IV 
1. The contract does not require fixed contributions. 
2. Any dividends (refund of contributions other than those attributable to excess contributions) arising under the contract will be 
applied (before the close of the calendar year following the year of the dividend) as contributions toward the contract. 

                                                               Article V 
1. If the annuitant dies before his or her entire interest in the contract is distributed to him or her and the annuitant’s surviving  
spouse is not the designated beneficiary, the remaining interest in the contract will be distributed in accordance with paragraph (a) 
below or, if elected or there is no designated beneficiary, in accordance with paragraph (b) below. 
(a) The remaining interest in the contract will be distributed, starting by the end of the calendar year following the year of the  
annuitant’s death, over the designated beneficiary’s remaining life expectancy, or a period no longer than such remaining life  
expectancy, as determined in the year following the death of the annuitant. Life expectancy is determined using the single life table in 
Regulations section 1.401(a)(9)-9. 
(b) The remaining interest in the contract will be distributed by the end of the calendar year containing the fifth anniversary of the 
annuitant’s death. 
2. If the annuitant’s surviving spouse is the designated beneficiary, such spouse will then be treated as the annuitant. 

                                                               Article VI 
1. The annuitant agrees to provide the issuer with all information necessary to prepare any reports required by sections 408(i) and 
408A(d)(3)(E), Regulations sections 1.408-5 and 1.408-6, or other guidance published by the Internal Revenue Service (IRS). 
2. The issuer agrees to submit to the IRS and annuitant the reports prescribed by the IRS. 

                                                               Article VII 
Notwithstanding any other articles which may be added or incorporated, the provisions of Articles I through IV and this sentence will 
be controlling. Any additional articles inconsistent with section 408A, the related regulations, or other published guidance will be 
invalid. 

                                               Cat. No. 25871H                                             Form  5305-RB  (Rev. 4-2017) 

Form 5305-RB (Rev. 4-2017)                                                                                                     Page  2 

                                                         Article VIII 
This endorsement will be amended as necessary to comply with the provisions of the Code, the related regulations, and other  
published guidance. Other amendments may be made with the consent of the persons whose signatures appear on the contract. 

                                                         Article IX 
Article IX may be used for any additional provisions. If no other provisions will be added, draw a line through this space. If 
provisions are added, they must comply with applicable requirements of state law and the Internal Revenue Code and may not imply 
that they have been reviewed or pre-approved by the IRS. 

General Instructions                       not includible in gross income. For more    Article V. This article describes how  
                                           information on Roth IRAs, including the     distributions will be made from the Roth  
Section references are to the Internal     required disclosures the issuer must give   IRA after the annuitant’s death. Elections 
Revenue Code unless otherwise noted.       the annuitant, see Pub. 590-A,              made pursuant to this article should be  
                                           Contributions to Individual Retirement      reviewed periodically to ensure they  
Purpose of Form                            Arrangements (IRAs), and Pub. 590-B,        correspond to the annuitant’s intent.  
Form 5305-RB is a model annuity            Distributions from Individual Retirement    Under paragraph 2 of Article V, the  
endorsement that meets the                 Arrangements (IRAs).                        annuitant’s spouse is treated as the  
requirements of section 408A. However,                                                 owner of the Roth IRA upon the death of  
only Articles I through VIII have been     Definitions                                 the annuitant, rather than as the  
reviewed by the IRS. A Roth individual     Issuer. The issuer is the insurance         beneficiary. If the spouse is to be treated 
retirement annuity (Roth IRA) is           company providing the annuity contract.     as the beneficiary, and not the owner, an 
established after the contract, which      The insurance company may use other         overriding provision should be added to  
includes this endorsement, is fully        terms besides “issuer” to refer to itself,  Article IX. 
executed by both the individual            such as, “company,” “insurer,” or “us.”     Article IX. Article IX and any that follow  
(annuitant) and the issuer. To make a      Annuitant. The annuitant is the person      it may incorporate additional provisions  
regular contribution to a Roth IRA for a   who establishes the annuity contract.       that are agreed to by the annuitant and  
year, the IRA must be established no       The insurance company may use other         issuer to complete the contract. They  
later than the due date (excluding         terms besides “annuitant” to refer to the   may include, for example, definitions,  
extensions) of the individual’s income tax person who establishes the annuity          investment powers, voting rights,  
return for the year. The contract must be  contract, such as, “owner,” “applicant,”    exculpatory provisions, amendment and  
for the exclusive benefit of the annuitant “insured,” or “you.”                        termination, removal of the issuer,  
and his or her beneficiaries.                                                          issuer’s fees, state law requirements,  
                                                                                       beginning date of distributions,  
Do not file Form 5305-RB with the          Specific Instructions                       accepting only cash, treatment of  
IRS. Instead, keep it with your records.                                               excess contributions, prohibited  
                                           Article I. The annuitant may be subject  
Unlike contributions to traditional        to a 6% tax on excess contributions if      transactions with the annuitant, etc.  
individual retirement arrangements,        (1) contributions to other individual       Attach additional pages if necessary. 
contributions to a Roth IRA are not        retirement arrangements of the annuitant 
deductible from the annuitant’s gross      have been made for the same tax year,  
income; and distributions after 5 years    (2) the annuitant’s adjusted gross  
that are made when the annuitant is        income exceeds the applicable limits in  
591/2 years of age or older or on          Article II for the tax year, or (3) the  
account of death, disability, or the       annuitant’s and spouse’s compensation  
purchase of a  home by a first-time        is less than the amount contributed by  
homebuyer (limited to $10,000), are        or on behalf of them for the tax year. 
                                                                                                   Form  5305-RB  (Rev. 4-2017)