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By signing and completing the information below, the following parties hereby agree to this Unallocated Contract <br />Application, Acceptance, and New Business Agreement. <br />Dated at <br />on <br />APPLICANT/PROPOSED CONTRACTHOLDER/PLAN FIDUCIARY <br />Signature: <br />Printed Name: Nelson Fialho <br />Title: City Manager <br />Date: <br />TPA/PLAN ADMIMSTRATOR <br />Signature: <br />Printed Name: J. Wesley Compton, CPA. CEBS <br />Title: President <br />Date: <br />AUL RETIREMENT SERVICES OFFICER <br />Signature: <br />Printed Name: <br />Title: <br />Date: <br />SOLICITING PRODUCER <br />Signature: <br />Printed Name: <br />Title: <br />Date: <br />Florida License ID No. (for Florida Applications) <br />ID No. <br />For governmental employers applying for a fixed group annuity contract to be used with an HRA or a GASB 45 OPEB <br />Plan, by signing and completing the information below, the following parties hereby agree to the "Non -Registered Fixed <br />Annuity Offering Representation" above. <br />"EMPLOYER" (with respect to <br />Employer representations only) <br />Dated: <br />By: <br />TRUSTEE(S) (with respect to Trustee <br />representations only) <br />Dated: <br />By: <br />Name: <br />Dated: <br />By: <br />Name: <br />Dated: <br />By: <br />Name: <br />