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 - -------------------------------------------------------------------------------- / 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 $__________ / _________________________ $__________ - -------------------------------------------------------------------------------- /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 - -------------------------------------------------------------------------------- Corporations, /_______________________________________ ____-_________ Trusts, or /Name of Corporation or Trustee(s) Taxpayer other / Identification Number Fiduciaries /_______________________________________ ____-____-____ /Name of Trust Date of Trust - -------------------------------------------------------------------------------- Address /__________________________ ______________ _________ ________ & /Street or P.O. Box City State ZIP Citizenship / /____-____-____ Citizen of U.S. [] Yes []No ___________________ /Telephone If no, citizen of - -------------------------------------------------------------------------------- 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. - -------------------------------------------------------------------------------- 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. - -------------------------------------------------------------------------------- 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. - -------------------------------------------------------------------------------- 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). - -------------------------------------------------------------------------------- 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: ______________ / ______] / - -------------------------------------------------------------------------------- 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