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 Tenants / (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 up to and including $100,000
and will be sent by check via U.S. mail to the address of record.
The Plans, the Fund, Pioneering Services Corporation and BFDS and their
affiliated companies, directors, trustees and employees 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 prospectuses for the Plans and the
Fund.
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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 I/we have provided, the information 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 signer 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: State Street Bank/
and Trust Company/
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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
P l e a s e P r i n t o r T y p e [landscape oriented
along left margin]
[Pioneer logo] Independence Plans
PIONEER IRA 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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Account /REGISTER THIS PLAN AS FOLLOWS:
Registration /
/_________________________________________ ____-____-____
/First Name Middle Initial Last Name Social Security Number
/
/_________________________________________ ______________
/Address Date of Birth
/
/_________________________________________
/City State ZIP
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Type of /[] Traditional [] Roth Contributory [] Roth Conversion
/ [] Rollover [] SEP []SARSEP
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Initial / AMOUNT
Investment /[] Contribution for tax year 19__ $________________
/[] Direct transfer from another IRA
/ (attach completed IRA Transfer/
/ Conversion Form) $________________
/[] Rollover from another IRA $________________
/[] Rollover from an employer-sponsored
/ retirement plan or 403(b) plan $________________
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SEP /This is a SEP or SARSEP contribution
Instructions /on my behalf from:
/
/__________________________________________ ___________________
/Name of Employer Contact Person
/
/__________________________________________ ___________________
/Address of Employer Telephone Number
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Your /PRIMARY BENEFICIARIES: Upon my death, pay the PERCENTAGES
Beneficiary /value of my IRA to: MUST TOTAL
/ 100%
If you have /_____________________ ____________ ________________
additional /Name Birthdate Social Security
beneficiaries,/ (mo/day/yr) Number
attach a sep- /
arate sheet /__________________________________ ________________ ____________%
and include /Address Relationship Share
all informa- /
tion requested/_____________________ ____________ ________________
here. Please /Name Birthdate Social Security
sign and date / (mo/day/yr) Number
any sheets you/
attach. /__________________________________ ________________ ____________%
/Address Relationship Share
If you are not/
survived by /SECONDARY BENEFICIARIES: If no beneficiary survives
any designated/me (or if I have checked option 2 below and no
beneficiary, /primary beneficiary or heirs survive me), pay the PERCENTAGES
your benefici-/value of my IRA to: MUST TOTAL
ary will be / 100%
your estate. /_____________________ ____________ ________________
/Name Birthdate Social Security
/ (mo/day/yr) Number
/
/__________________________________ ________________ ____________%
/Address Relationship Share
/
/_____________________ ____________ ________________
/Name Birthdate Social Security
/ (mo/day/yr) Number
/
/__________________________________ ________________ ____________%
/Address Relationship Share
/
/CHECK ONE: If any primary (or secondary) beneficiary dies before
/me, pay that person's share to:
/
If neither box/1. [] the other primary ( or secondary ) beneficiaries in
is checked, / proportion to the shares indicated (per capita), or
option 1 /2. [] the heirs at law of the deceased beneficiary in shares
will apply. / determined by right of representation (per stirpes).
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I hereby adopt the Pioneer Independence Plans Individual Retirement Account
appointing The Pioneer Group, Inc. as custodian. I certify that: (1) I have
received and read the current prospectus of Pioneer Independence Plans including
the prospectus of Pioneer Independence Fund, and have read and understand the
IRA custodial agreement and disclosure statement and consent to the custodial
fees as specified herein; (2) any contribution designated as a rollover
qualifies for rollover treatment and constitutes an irrevocable election to have
such amount treated as a rollover contribution for federal income tax purposes;
(3) under penalties of perjury, my social security number shown on this
application is correct; and (4) I must specify whether federal income tax is to
be withheld from any distribution I request from this account - otherwise my
request will not be in good order. I further understand that the $10.00 annual
IRA fee is paid by redemption of Pioneer Independence Fund shares unless paid
separately. The undersigned warrants that I have full authority and, if a
natural person, I am of legal age to purchase shares pursuant to this
application.
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SIGNATURE PROVISIONS
I, the undersigned Depositor, have read and understand the foregoing
application and the attached material included herein by reference. In addition,
I certify that the information which I have provided and the information which
is included within the application and the attached material included herein by
reference is accurate.
Dated __________, 19__ At ______________________________________________________
City State ZIP
Signature of Shareholder X _____________________________________________________
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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: [State Street Bank/
and Trust Company]/
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Dealer Name ________________________ Authorized Signature X ____________________
Branch Office (Location) _______________________________________________________
Representative _________________________________________________________________
Name Number
Representative's Signature X ______________________________________
7XX (1/98)
[copyright symbol] 1997 United Services Planning Association, Inc. 01196