At Family Integrity Corporation, I believe that my Customers deserve the best possible service
that can be provided in order to help them achieve their goals and provide for their future.

I strongly advocate completing a proper needs analysis with all clients or potential clients, so that
my customer is aware of the products available to meet the various situations that may occur
during their lifetime. I also strongly suggest that I meet with the Client at least annually to review
their portfolio to ensure that the products they have chosen continue to meet their goals and
objectives. This will be evident on the “Investor Policy Statement” that will be prepared for all
new clients that I have chosen to work with.

While it is my responsibility as a financial professional to provide information and
recommendations based on your needs and objectives, the power of choice as to whether or not
recommendations are acted upon lies with you the client or potential client.

This document has been created to acknowledge that I have advised you of the products and
services that I can provide (shown below), and have discussed and explained the products with
you, including the features and benefits of those products.

       Basic Life Insurance                                  Health & Disability Insurance
       Mortgage Insurance                                    Critical Illness
       Investment Funds (Segregated funds)                   Long Term Care
       Registered Retirement Savings Plans                   Travel Insurance
       Registered Educational Savings Plans                  Investment Funds

       An “Annual Review” of your portfolio                  Tax & Estate Planning Services
       ________________________________                      Retirement Planning Service


While I/we do acknowledge the importance and benefit of the various products and services
offered by ____________________, it is my/our decision to decline pursuing action with respect
to any of the above products or services offered other than those accepted as indicated above.
I/we also acknowledge that it is my/our responsibility to initiate any action regarding the purchase
of any of the additional products or services shown above in the future, should I/we change this

Name: ____________________________                   Signature: ___________________________

Name: ____________________________                   Signature: ___________________________

Representative’s Name: _______________________ Signature: ______________________

Dated at: ____________________ this _____day of ________________ Year_____________

                                  Family Integrity Corporation

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