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Date of Birth*
City and State
Please Indicate*
Authorize Deduction*
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  • I understand that the total amount I contribute to the retirement account may not exceed IRS Guideline limits.
  • I understand a withdrawal charge will be assessed by the carrier if more than 10% is withdrawn from the account per contract year.
  • I have received a copy of the prospectus.
  • I understand that in order to enroll, make a change in my percent of contribution or stop my participation all together, I must complete my request in writing via the Contribution Authorization Form.
  • I understand participation is not on a deal by deal basis.
  • I understand enrollments, changes or stops may take 30 days to process from the date the written request is received by MARC JACOBSON & ASSOCIATES. I further understand that contributions will be initiated or ceased on the earliest funding date following the 30-day processing period.
  • I understand that retirement accounts will fund on Tuesdays or the first funding date following said Tuesday, on a weekly basis.
  • I understand I may make future contribution changes and/or may stop contributions and they will be effective according to the above schedule.
  • I understand that my contribution percentage will remain the same if a deal closes and is changed after it closes, despite a downward or upward earnings adjustment.
  • I understand that this is already a tax-deferred product and want the additional benefits that are associated with a variable annuity.
  • I understand that the services and products offered by and through Marc Jacobson & Associates are offered solely by independent third-party providers. I further understand that NRT LLC and its parent, Realogy, are not affiliated with Marc Jacobson & Associates or any of the third-party providers and does not receive any payment from Marc Jacobson & Associates or any of the providers.
  • I understand that participation in any of the programs or services provided through Marc Jacobson & Associates is entirely voluntary on my part.
Digital Signature*
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