This disclosure document is mandated by the Business Regulation and Enforcement Division of the Office of the Mississippi Secretary of State. VIATICAL DISCLOSURE DOCUMENT (FORM VIAD PART II) To be completed by the issuer or sales agent You are purchasing a viatical settlement investment contract. A viatical settlement investment contract is an agreement for the purchase of the death benefit of a life insurance policy. The individual whose life insurance policy is being sold is called the viator. Right to Rescind 1. You have the right to rescind the purchase of this investment by giving written notice of your intention to rescind. To be effective, your written notice of rescission must be postmarked no later than 30 days following the later of: a. b. The date on which you paid for your investment; or, The date on which you received this disclosure document. It must be mailed, postage prepaid, to: Name: Address: What you are Purchasing 2. You are investing $ upon the death of the viator. and will receive $ The life expectancy of the viator in whose policy you are investing is months. 3. You are purchasing (check one): % ownership of a life insurance policy with a $ death benefit. The entire ownership of a life insurance policy with a $ death benefit. 1 American LegalNet, Inc. www.USCourtForms.com $ % ownership of the death benefit of a life insurance policy with a death benefit. The entire death benefit of a life insurance policy with a $ death benefit. The Insurance Policy 4. The life insurance policy was issued by: Company Name: Address: Telephone Number: 5. The policy number is: 6. The policy was issued on (date): 7. This policy is (check all that apply): A term policy. The term of the policy is: A group policy. Name of Group: Address: Telephone Number: Contestable. The policy is contestable until (date) Ownership 8. After you make your purchase, you will be (check one): An owner and beneficiary of a life insurance policy Other owners of the policy will be: (Attach a list of names and addresses of other owners) 2 American LegalNet, Inc. www.USCourtForms.com A beneficiary only of a life insurance policy. The owner(s) of the policy will be: (Attach a list of names, addresses and telephone numbers) Other beneficiaries of the policy will be: (Attach a list of names and addresses of other investors) Premiums 9. Premiums on the policy are (check one): Paid in full and no additional premium payments will ever be required. (If checked, go directly to item 12) Required to be paid periodically. Premiums are $ annually Payments of $ are due to be paid: Monthly Quarterly Semi-annually Annually 10. Term of premium payments (check one): If premium payments are made as required the policy will be fully paid up on . (date) Premium payments must be made until the death of the viator. 11. Funding of premium payments (check all that apply): A portion of your investment has been set aside to pay premiums. This amount will fund the payment of premiums until (date) . These funds have been placed in an escrow account. Name of Escrow Agent: Address: 3 American LegalNet, Inc. www.USCourtForms.com Telephone Number: Bank Name: Escrow Account Number: You will be obligated to pay additional money to fund premium payments after will be (date) . Payments of $ due to be paid: Monthly Quarterly Semi-annually Annually Before these additional payments are due, you will be notified of when and to whom to make your premium payments. Use of your investment funds 12. Of the amount you are investing: $ will be used to purchase the policy from the viator. $ will be set aside to pay premiums on the policy. $ the policy. will be used to pay a commission to the person who sold you $ transaction costs. will be used to pay administrative expenses and other The Business Regulation and Enforcement Division of the Mississippi Secretary of State is the agency of state government responsible for the registration of brokerage firms, investment advisers and their employees, the registration of investment products and enforcement of the State's securities laws. Anyone with questions or concerns about investments may call the Business Regulation and Enforcement Division of the Mississippi Secretary of State at 1-800-804-6364. 4 American LegalNet, Inc. www.USCourtForms.com