Yes. The facts that must be collected from the senior consumer are:

1. Personal information, including the age and sex of the parties to the annuity and the ages and number of dependents;

2. tax status of the consumer;

3. investment objectives of the consumer;

4. source of funds being used to purchase the annuity;

5. the applicant's annual income;

6. intended use of the annuity;

7. the applicant's existing assets, including investment holdings;

8. the applicant's liquid net worth and liquidity needs;

9. the applicant's financial situation and needs;

10. the applicant's risk tolerance; and

11. such other information used or considered to be relevant by the insurance agent or insurer in making recommendations to the consumer regarding the purchase or exchange of an annuity contract.

This information must be collected on a form adopted by the Department and signed by the applicant and agent. If the senior consumer does not wish to provide all of this information, the agent must obtain from the senior consumer a signed verification form that he/she refuses to provide the requested information and may be limiting protections regarding the suitability of the sale.

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