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APPLICATION FOR SINGLE PREMIUM DEFERRED ANNUITY * LIBERTY NATIONAL LIFE INSURANCE COMPANY ADMINISTRATIVE OFFICE: P.O. BOX 8080 * MCKINNEY, TX 750708080 Plan Code Annuitant Telephone No. PENNSYLVANIA
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PENNSYLVANIA Annuitant yyyy LANN TX MCKINNEY false Modal 1st debits materially VOIDED Rollover conceals contractual federally DEFERRED applicable ANNUITY fraudulent defraud thereto personalized herein premiums stipulated certify Taxpayer credited Applican

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