R E G I S T R A T I O N - Please Print or Type [landscape oriented
along left margin]
[Pioneer logo] Independence Plans
PIONEER Application
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/ Special pricing applicable? [] Yes [] No
/
/ Special Pricing Breakpoint (Dealer Use)
/ [____________________________]
/
New Account Number __________ / List all associated account numbers and
/ monthly amounts.
Monthly Unit $__________ /
/ _________________________ $__________
Total Plan Amount $__________ / _________________________ $__________
/ _________________________ $__________
Initial Investment $__________ / _________________________ $__________
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/REGISTER THIS PLAN AS FOLLOWS:
/
Individual /_________________________________________ ____-____-____
/First Name Middle Initial Last Name Social Security Number
Joint Tenant / (If joint tenants, use
with Right of /_________________________________________ Social Security Number
Survivorship /First Name Middle Initial Last Name of the first joint
/ tenant listed.)
Uniform /_________________________________________
Gifts/ /Custodian's Name
Transfers /
to Minors /_________________________________________ ____-____-____
/Minor's Name (only one permitted) Social Security Number
/ of Minor
/under the _____ [] Uniform [] Uniform
/ State Gifts to Transfers to ____-____-____
/ Minors Act Minors Act Birthdate of Minor
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Corporations, /_______________________________________ ____-_________
Trusts, or /Name of Corporation or Trustee(s) Taxpayer
other / Identification Number
Fiduciaries /_______________________________________ ____-____-____
/Name of Trust Date of Trust
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Address /__________________________ ______________ _________ ________
& /Street or P.O. Box City State ZIP
Citizenship /
/____-____-____ Citizen of U.S. [] Yes []No ___________________
/Telephone If no, citizen of
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TELEPHONE WITHDRAWAL FEATURE--Unless indicated below, I authorize BFDS to accept
instructions from any person to redeem up to 90% of the share value of my
account(s) by telephone, in accordance with the procedures and conditions set
forth in the Pioneer Independence Plans current prospectus.
[] I DO NOT want the Telephone Redemption Privilege.
Redemptions by telephone must be for an amount less than $100,000 and will be
sent by check via U.S. mail to the address of record. In the event that the
mailing address has been changed within 30 days of the redemption request, the
redemption request must be in writing if over $5,000.
Pioneering Services Corporation and BFDS will not be liable for any loss,
expense or cost arising out of any telephone redemption request effected in
accordance with the authorization(s) set forth in this application if they
reasonably believe such request to be genuine, but may in certain cases be
liable for losses due to unauthorized or fradulent transactions. Procedures for
verification of telephone transactions may include recordings of telephone
transactions and requests for conformation of the shareholder's Social Security
Number and current address. Mailings of confirmations occur promptly after the
transaction.
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The undersigned warrant(s) that I (we) have full authority and, if a natural
person, I (we) am (are) of legal age to purchase shares pursuant to this
application, and have received a current prospectus for the plans.
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WITHHOLDING INFORMATION (Substitute Form W-9)
UNDER THE INTEREST AND DIVIDEND TAX COMPLIANCE ACT OF 1983, WE ARE REQUIRED TO
HAVE THE FOLLOWING CERTIFICATION: UNDER THE PENALTIES OF PERJURY, I CERTIFY
THAT:
(1) The number shown above is my correct taxpayer identification number
(or I am waiting for a number to be issued to me); and
(2) I am not subject to backup withholding because (a) I am exempt from
backup withholding, or (b) I have not been notified by the Internal
Revenue Service that I am subject to backup withholding as a result
of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding.
You must cross out item 2 above if you have been notified by the IRS that you
are currently subject to backup withholding because of underreporting interest
or dividends on your tax return. For real estate transactions, item 2 does not
apply. For mortgage interest paid, the acquisition or abandonment of secured
property, contributions to an individual retirement arrangement (IRA), and
generally payments other than interest and dividends, you are not required to
sign the certification, but you must provide your correct taxpayer
identification number.
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SIGNATURE PROVISIONS
I/We, the undersigned Depositor(s), have read and understand the foregoing
application and the attached material included herein by reference. In
addition, I/We certify that the information which I/we have provided and the
information which is included within the application and the attached material
included herein by reference is accurate including but not limited to the
representations contained in the Withholding Information section of this
application above. [The Internal Revenue Service does not require your consent
to any provision of this document other than the certifications required to
avoid backup withholding.]
Signature of Owner* X ___________________________________ Date ________________
Signature of Joint Owner X ______________________________ Date ________________
*If a corporate or trust account, authorized signor should indicate title (e.g.,
President, Treasurer, or Trustee).
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A Bank Draft Authoriza- / MAIL APPLICATION United Services Planning
tion is attached [] Yes [] No / AND INITIAL Association, Inc.
/ INVESTMENT TO: P.O. Box XXXX
Check box for / Fort Worth, Texas 76113
Government Allotment [] /
/
MAKE ALL CHECKS [___________ /
PAYABLE TO: ______________ /
______] /
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Dealer Name ________________________ Authorized Signature X ____________________
Branch Office (Location) _______________________________________________________
Representative _________________________________________________________________
Name Number
Representative's Signature X ______________________________________
7XX (12/97)
[copyright symbol] 1997 United Services Planning Association, Inc. 12057