Fill and Sign the Private Annuity Agreement with Payments to Last for Life of Annuitant Form

Private Annuity Agreement with Payments to Last for Life of Annuitant Annuity Agreement made on the ________________ (date) , between ____________________ (Name of Annuitant) , of ___________________________ ______________________________________________ (street address, city, state, zip code) , referred to herein as Annuitant , and ____________________ (Name of Grantor) , a corporation organized and existing under the laws of the state of __________________, with its principal office located at _______________________ ___________________________________________________ (street address, city, state, zip code) , referred to herein as Grantor . For and in consideration of the covenants contained in this Agreement, and the execution by Grantor of a good and sufficient bond to secure the performance of Grantor under this Agreement, Grantor agree to pay to Annuitant, for the remainder of Annuitant’s life, an annual sum of ________________ (dollar amount) , in equal monthly installments of _______________ (dollar amount) each, beginning on ___________________ (date) and continuing on the first day of each month for the duration of this Agreement. Payments under this Agreement shall cease on the death of Annuitant. WITNESS our signatures as of the day and date first above stated. ________________________ (Name of Grantor) ________________________ By:______________________________ (P rinted Name of Annuitant) _________________________ ________________________ (P rinted Name & Office in Corporation) (Signature of Annuitant) _________________________ (Signature of Officer) (Acknowledgment form may vary by state) STATE OF _____________ COUNTY OF ____________ Personally appeared before me, the undersigned authority in and for the said county and state, on this ______ day of ________________, 20______, within my jurisdiction, the within named ____________________ (Name of Officer of Grantor) , who acknowledged that he is _______________ (Name of Office) of __________________________ (Name of Corporation) , a ________________ (name of state) corporation, and that for and on behalf of the said corporation, and as its act and deed he executed the above and foregoing instrument, after first having been duly authorized by said corporation so to do. _______________________________ NOTARY PUBLIC My Commission Expires: ____________________ State of _____________________ County of ___________________ Personally appeared before me, the undersigned authority in and for the said County and State, on this ________________ (date) , within my jurisdic tion, the within-named ___________________ (Name of Annuitant) , who acknowledged that he executed the above and foregoing instrument. _____________________________ NOTARY PUBLIC My Commission Expires: ____________________