VIRGINIA: IN THE CIRCUIT COURT FOR THE COUNTY OF FAIRFAX AMERICO FINANCIAL LIFE AND 1 ANNUITY INSURANCE COMPANY, g5; '93 :2 Plaintiff, ~74 9493 f- (5?2 V. Case No.2 i ABIDA.AWAN 25!? 3548 and SAMINA ASHRAF GILANI, Defendants. COMPLAINT FOR IN TERPLEADER COMES NOW the plaintiff Americo Financial Life Annuity Insurance Company by counsel, and states the following for its Complaint for Interpleader brought pursuant to Virginia Code 8.01?364, Rule 3 :15 of the Rules of the Supreme Court of Virginia and/or Virginia common law. firm 1. Plaintiff AF is a corporation duly organized and incorporated under the laws of the State of Texas, with its principal place of business in the State of Missouri, and it is licensed to do business in the Commonwealth of Virginia. 2. Defendant Abid A. Awan upon information and belief, is the son of the insured Muhammad Ashraf Shah ("Shah") and resides at 7110 Falcon Street, Annandale, Virginia 22003. 3. Defendant Samina Ashraf Gilani ("Gilani"), upon information and belief, is the wife of the insured Shah, and resides at 6834 Kenyon Drive, Alexandria, VA 22307. Jurisdiction and Venue 4. This Court has subject matter jurisdiction over this matter pursuant to Virginia Code 17.1-513. 5. This Court has personal jurisdiction over the defendants pursuant to Virginia Code because the subject matter of this action involves the contracting to insure the life of a person, Shah, who lived in the Commonwealth of Virginia at the time of contracting and at the time of his death. 6. Venue is properly laid in this Court pursuant to Virginia Code 8.01 -262(4) because the subject matter of this action arose in Fairfax County, Virginia. EM 7. On or about May 19, 2012, proposed insured Shah completed and signed an Application for Simpli?ed Issue individual Life Insurance ("Application") applying to AF for a life insurance policy with a face amount of $50,000.00. 8. Based upon the information that Shah disclosed in his Application, AFL issued a Flexible Premium Adjustable Life Insurance Policy insuring the life of Shah bearing policy number with a face amount of $50,000.00, a policy date of May 18, 2012, and an issue date of June 11, 2012 ("Policy"). (A redacted copy of the Policy with the Application is attached hereto and marked as Exhibit 1.) 9. The Policy states that the bene?ciary is the person named in the Application or later changed in writing by the owner. See Policy (Exhibit 1) at page 9. 10. On the Application, Shah listed his wife Gilani as the primary bene?ciary with a 100% share. Shah also listed his daughter, Adeela Ashraf, as both a primary bene?ciary and as a contingent bene?ciary with a 50% share and his son Awan as a contingent bene?ciary with a 50% share. 11. To clarify the Application as to who was the primary bene?ciary and the contingent bene?ciary, by letter to the insured Shah dated June 12, 2012, AF forwarded the Policy (Exhibit 1). In that letter, AF explained to Shah that the enclosed Amendment of Application must be completed and returned to AFL in the enclosed postage paid envelope. (Copies of AF L's letter to the insured Shah and its enclosed Amendment of Application are collectively attached hereto and marked as Exhibit 2.) 12. AF subsequently perceived the Amendment of Application completed and signed by Shah on June 13, 2012. (A copy of this signed Amendment of Application dated June 13, 2012, is attached hereto and marked as Exhibit 3). 13. AF received an Ownership Change Request form signed by Shah on or about November 16, 2016, requesting that the owner of the Policy be changed to his son Awan. (A modi?ed redacted copy of the Ownership Change Request form signed by Shah is attached hereto and marked as Exhibit 4.) 14. AF accepted the Ownership Change Request form (Exhibit 4) and updated ownership of the Policy to re?ect Awan as the new owner of the Policy. 15. The Policy states that the owner may exercise all rights granted in the Policy while the insured is living. See Policy (Exhibit 1) at page 9. 16. Subsequent to the change of ownership, AF received a Bene?ciary Change Request form signed by Awan, the new owner of the Policy, on or about December 16, 2016, requesting that the primary bene?ciary of the Policy be changed to Awan. (A copy of this Bene?ciary Change Request form is attached hereto and marked as Exhibit 5.) 17. By letter dated January 11, 2017, AF wrote to Awan acknowledging receipt of the Bene?ciary Change Request form (Exhibit 5), and requesting a new Bene?ciary Change Request form with the owner's notarized signature. (A copy of AF L's letter to Awan dated January 11, 2017, after Awan had ?lled in the requested owner address and telephone information, is attached hereto and marked as Exhibit 6.) 18. AF received another Bene?ciary Change Request form signed by Awan which was notarized dated January 17, 2017, and another copy of letter dated January 11, 2017, this time with the owner Awan's current address and telephone number handwritten in. (Exhibit 6.) (A copy of this Bene?ciary Change Request form dated January 17, 2017, is attached hereto and marked as Exhibit 7.) 19. On January 16, 2017, Shah died in Fairfax County, Virginia. 20. On or about February 2, 2017, AF received a completed Claimant's Statement that Awan signed before a notary public on February 2, 2017, to which was attached a copy of Shah's Certi?cate of Death. (A redacted cepy of the Claimant's Statement dated February 2, 2016, is attached hereto and marked as Exhibit 8.) 21. On or about February 9, 2017, AF received by telecopier correspondence from Gilani bearing the same date making various accusations against her husband Shah?s children related to the Policy. (A copy of Gilani?s signed correspondence to AF dated February 9, 2017, is attached hereto and marked as Exhibit 9.) 22. On or about February 9, 2017, AF received correspondence ?orn Robert L. Segal on behalf of Shah?s wife, Gilani, stating that Gilani claimed, among other things, that the recent ownership and bene?ciary changes to the Policy were procured through fraud. (A redacted copy of Segal's correspondence to AFL on behalf of Gilani is attached hereto and marked as Exhibit 10.) 23. On February 13, 2017, AF spoke with Awan by telephone and advised him that AF had competing claims on the Policy. Awan stated that his father anticipated problems, that they recorded by Videotape the signing of the ownership change, and that he would send AF a copy of that recording. AF subsequently received a copy of the videotaped recording of the ownership change. 24. On February 27, 2017, AF received an email from S. Ahmed in which he made accusations of ?aud related to the Policy on Gilani's behalf. (A copy of this email dated February 27, 2017, with its attached prior email by Ahmed dated February 23, 2017, is attached hereto and marked as Exhibit 11.) 25. AF received a copy of an Incident/Investigation Report for the Fairfax County Police Department dated February 23, 2017, which stated that Gilani called after her stepchildren denied her access to her husband, Shah, who was hospitalized. (A redacted copy of this Fairfax County Police Department Incident/Investigation Report dated February 23, 2017, is attached hereto and marked as Exhibit 12.) 26. For the reasons outlined above, there is a dispute as to the proper bene?ciary of the Policy and AFL is in great doubt and cannot safely determine who is rightfully entitled to the Policy proceeds without subjecting itself to inconsistent obligations and potentially multiple liabilities. See Virginia Code 382-321. 27. AF is ready, willing and able to pay the proceeds of the Policy into the registry of this Court. 28. AF seeks to deposit the aforementioned Policy proceeds into the registry of this Court to permit resolution bythe Court of the competing claims to those proceeds and to shield itself ?om the risk of potential liability to any of the defendants in this interpleader action. AFL is filing the instant Complaint For Interpleader and seeking an Order requiring the Clerk to deposit into the registry of this Court payment of the proceeds of the Policy (plus any accrued interest) representing the total bene?ts paid under the Policy. 29. AF L, as a mere stakeholder, has no interest (except to recover out of the proceeds of the Policy its attorneys' fees and costs of this interpleader action) in the total bene?ts payable and respect?illy requests that this Court determine to whom said Policy proceeds should be paid 30. AF has not brought this Complaint For Interpleader at the request of any of the defendant claimants; there is no fraud or collusion between AF and any of the defendant claimants; and AF brings this interpleader action of its own free will and to avoid being vexed and harassed by con?icting and multiple claims. WHEREFORE, the plaintiff Americo Financial Life and Annuity Insurance Company by counsel, respectfully prays that this Honorable Court enter an Order or series of Orders granting the following relief: A. Granting AF leave to deposit its admitted liability for the proceeds under the Policy with the Clerk of this Court in an interest bearing account, or, at the Court?s direction, said sum to abide there pending further Order of this Court; B. Requiring the defendants Awan and Gilani to each interplead their respective claims to the Policy proceeds; C. Enjoining and restraining, preliminarily and permanently, the defendants Awan and Gilani, during the pendency of this action and thereafter, permanently and perpetually from prosecuting any proceeding or claim against AF in any state or federal court or any other forum with respect to the proceeds payable under the Policy andon account of the death of Shah and that said injunction issue without bond or security; D. Releasing and forever discharging from all liability under the Policy by virtue of the depositing into the registry of this Court the Policy proceeds, plus any accrued interest, pending further Order of this Court as to which of the defendants is entitled to receive these proceeds; E. Excusing AF from further attendance in this cause and ordering each of the defendants, Awan and Gilani, to litigate their respectively claims to the proceeds of the Policy without further involving American, its agents, employees and/or attorneys; F. Awarding out of the Policy proceeds AF L's attorneys' fees and costs incurred in connection with the prosecution of this Complaint for Interpleader; G. Dismissing AF with prejudice in its entirety without ?irther costs, attendance or participation in this proceeding; H. Determining the person to whom these Policy proceeds are payable; and I. Granting AP such further and other relief as this Court may deem appropriate. AMERICO FINANCIAL LIFE ANNUITY INSURANCE COMPANY By Counsel Robert B. Delano, Jr. (VSB No. 2061296 SANDS ANDERSON PC Bank of America Center, Ste. 2400 1 11 1 East Main Street (23219) P. O. Box 1998 Richmond, VA 23218-1998 Telephone: 804?648-1636 Telefax: 804-783-7291 cdelano@sandsanderson.com Counsel for Plainti??Americo Financial Life Annuity Insurance Company Application for Simpli?ed . I Individual Life Insurance ?means-rm - . 1. PROPOSED INSURED INFORMATION . . . . a. Proposed lnsured's Name (Last, First, Mt) b. Married ??/A?Fa?vpmw . 6. 13 Male Female d. Address (Include City State, and ZIP. If mai?rrg address is a PO Box, a street address- is also required.) 4/3 9/ 25:3, ?f/W?x?r?ze 1/4. 2-Home Phone 1. Work Phone - g. Email Address - i??vi?w??fb g?myu%?wy%3v?v? (awe h. Howtong at current agrees? . tiless-thans years atcunentaddress, prioradol'essis required. A r. Soctal Security Number; j. K. .Age 1. Place Sfate,Country) 7 33 A #44237 . 4g.? n. Occupation - .. 0. Annual Salary - m- ls the Proposed lnsured currentlyemplqed? DYes Kc?c??dq? 7 my - p. Provide description ofjob duties: . . . Wave; 'mew ?ame/V ?4?7 ?35245 2 . PRODUCT INFORMATION (Verify that the product is available in the state Mere the application-is being Signed.) . - I -f HMS with A05 ?J'selectect 'secrrons'zb'r 2c.) 3? [3125 125 (:80 - I Base Face Amount $1 000 100 . . [j 100 CBC [Egg-.61.: ADB Rlder $mq Mortgage Series UL=Unlversal Life Death Bene?t h. Guarantee Periods (Laue: Pariodffwarantee Period; ro. 8. Effective Dat? (tfnat checked Will be [31525 20/20 Des/25 Dmrso . ?Issue Date?. Date cannotbetheZg?, F389 Am? Lama 30%, were or'the month.) - 15/5 20/5 25/5 3015 . 4. Mode Premltu'n :5 [3 Issue Date WE Mode: El Bank Draft - El Save Age of . - IMPORTANT NOTE: {Wear Guarantee Harrods are NOT amiable . . with UL products. Annually Speci?c Date Elf/ 6 5 212/2? 3. RIDERS {Veri?/ rider availatx??ty Optional rtders are not available with HMS WADE.) a. Additional lnsured Term lnswance* d; [3 Disability lncomef Primary Insured [:11 Year ZYears 5 Additional lnsued?s Occupation lnsued?s Annual Salary: . Additional insured D1 Year 2Years - b. Temt?_$ .a Duran-ereemtml c. [j Crt?cal Accekareted Bene?tTi t. Other "Complete section 4 at this apptiqxttort Tarpplemen?tel recurred. ?Critfcal Illness Accelerated Bene?t and Waiver of Premium on the same policy. . . ll. ADDITIONAL PROPOSED (To inciurte Additiorkal Insured end Childrenis- Term rider. riders cannot be issued out?) {Willa sex We sew DFemale . DMale DFemale m__h TDMale DFemale I [:lMale Elf-"amale i DMale DFemate 5. BENEFICIARY INFORMATION (Include percentage she-res. If shares are not given, they'nlrirl be equal.,l' 'tfnotspectfted, . - . ?/onSlIat?8 attbeno?cterlm- Name 1 beer: Date at Birth {Mustt'otal wrr/be anaiy. I . . 5? - r0093 - I .. '15" Mme-2% . 2533 4-, Administrative WKZSIPOBDX 410235. 414102.33 . wimamancmm Ear Use in 't?rrginle 3.9mm? 1 547w w; ?ragaa??arw @rt?rtgent Ell?2367514 41W Dmm?l?ammem 3&9 -- America Lrte and Annui-ry ln-mra?ce Company 4 Heme-Office- Danae! Term: 1) P3991 0? 6. LIFE INSURANCE IN FORCE AND REPLACEMENT INFORMATION Yes No a. Bass any Proposed insured have ?fe Insurance or amuity applicafrons pending with Usher canpanies? i3 . b. Is ?iers any existing life Insurance orannuity coverage on the life of any Propnsed insured? {If Yes, provide informaiion below and complete the applicable replacement incurs) and submi: with application. Appisa?cn and repiscemenr fann{s) musr? be dated on ?re same dais.) o. lhe life insurance applied for replace oroiherwise reduce in value, any existing life insuranze or annuity now in force? (El d. Is dris an internal rnplaoemenl? {Ir Yes, inciude a Surrender form orAbsquz?e Assignment form forms file insurance orannuiry being redacsd) a. II current lira Insurance or annuity is being replaced. indirete ?re amounl oi sunander charges that will tn assessed. -u insared?s Name 7 Accidental Policy Date {Last Firsi, Mil ?mpg? owne? Death Bene?l (MM/09mm 7. OWNER (If di?erenr from the Pmposed Oumer's Name (Lnsr. Firs; M8 in. Relationship i0 Proposed Insured 0. SSN or Taxpayer ID d. Address {Include City 3121's, and ZIP. If warring addr 's a PO Box, a street address isalsn required) a. How long al current address? If iass fhan 5 years at curk?sddress prioradnress is required. Elf?dare Ir. Place of arm (City. Stare, Country} i. Home Phana I 9. Work Phone 8. PAYOR INFORMATION {If different dam the Pmposad Insured and Owner.) Pam?s Name (L855, First. MU b. Rnlalionship to Proposed insured c. SSN or Taxpayer ID d. Address (Include Ciiy. Sieie. and ZIP. If mailing addressis a. a sneez?addrass is aiso requirsd.) a. How long at current address? megs than 5 years at current address, Endgames? is required. 9. SPECIAL REQUESTS Additional PERSONAL HISTORY (Home details afar? ?Yes" answers a the Persona! rrsrory Detaiis section beiow.) inns? $333210. Has any Proposed insured ever been declined. rated. or modi?ed for life or health insurance? Ina past two [2}.yeazs. has any Proposed insured: a made any ?ighls as a pilot, student pilot or member of a light crass? {If Yes, compilers satiation quealomaire.) E1 n: engaged ?n the folloni?g hazardous Spods: bungee or base jumping. parachu?ng, hang glic?ng; onmpa?tive (such as hell?skiing orskijumping}; diving activities (sum as scuba. cave diving, or underwater photography): canyoning, kayaking. orwhita waier rafting; organized racing (such as automobies, drag racers. or mommy/tries); rock or mcunrarn arming, rodeo riding. er any char hasn't-rare spodlnotivity? complete spans .. . Ci i: 12. WrIl'rin the pasI seven years. has any Proposed lr?iswed been mmided ul. pleaded guiliy In, orenlered a plea of no contest in any felony?? 13. is any Proposed Insurad currently on proba?an or been plamd on probation within the lasl hveive {12) monzhs? 14. Within ihe near two years, does any :3ropassd Insured intend to mark. trat'ei, or reside outside Of the United Stem for more man thirty (30) days? {If Yes. where? Prow'de details below.) [j 15. Within inc- past ?ve years. has any Proposed Insured- a. pleaded guilty to or been nonuicien oithree (3) or more moving neuronsdriver's Iioense suspended cr remked. crare you curan?y under license arspension or revocation? [3 El a bean conviclad of realises driving or driving underlne in?uence nr alcohol or drugs? . 16. Driver?s License Nmnbeds! during ihe past five (5) years: Name of Proposed lnsurac?s} on Driver?s License Driver?s License Number State Issued (5 V/Wr/Irn? PERSONAL HISTORY Queslion Proposed -nsured?s Name Dates Delails i i Hanna Mica: Dallas, Tens - Admirislr?ve Orrin-a P0 30): 510288, Kansas City. MO [34141-0288 . umvamericnoznm For Use in Virginia Amman ?nancial Life and Annu'ro/ Insurance (Mpary avasrso {on-n 1; - Page 2 nI-i 90/127 AVAEIED MEDICAL HISTORY (Provide dermis of at? ?Yes? answers in the Marina! History Details section boron-gt 17- a. Proposed Insured?s Height b. Proposed lnsured?s Weight . lbs. Additional liyou are applying tor HMS answers provided to questions 18-26 will NOT be ounsiderod. Proposed Proposed Please no NOT answer questions 18-25101' Hills ft?: Juli": 95 18. Has any Proposed Insured used cigarettes cigars pipes chewing tobacco. nicotine patches snuff nicotine nhewingm gum or other products containing nicotine within the Iast?Melve [12) months? .. E: 19. Within the past seven years, has any Proposed insured: or been treated tor or been advised or diagnosed by a medical professional to seek treatment for the use oiatomoi or El Ci prescription . .. b. been advised to redone or ?disconiinue the intake of aloe-hot" or drugs?" DE (If Yes, complete the alcohol usage and/ornmsorip?on medication and drug use questionnaire. I 20. Within the past sentient?) years, has any Proposed Insured used. exoept as presumed by a physician: heroin. morphine, ecstasy. opium derivatives, marijuana woeine crack barbiturates amphetamines methamphetamine, haliudnogens, any other illega restricted or controlled substances bean treotod for or been advised by a medical to seek heathentlor the intake of ofany drug?i. (if Yes, complete the prescription medication and drug use questionnaire)" .. .. 21. Within the past we (5) years. has any Proposed Insured been diagnosed with or been advised to have or had treetrnentior. a. hypertension heart disease or disorder valve disorders. engine. cardiac heart surgery including bypass. angioplasty or stent placement circulatory disorder, blooc vessel or blood disorders? b. lung or respiratory disorder chronic obstructive pulmonary disease (COPD) cunont use of oxvgen shortness of breath, Orsteep a .. c. anccr in an? form? - d. diabetes: or pancreatic cisorders'2?t. e. digestive disorder. kidney or Ever disease to include heparin; Crohn' 3 disease or uloe'a?iro coitie. gasbointestlnel bleeding,? bladdordisorders, of unexplained weight 1055?. "a i. Alzheimer's disease dementia, nervous system: deorder, emotional or disorder. paralysis sexually disease. systemic lupus. and,I blood disorders or birth defedsrheumatoida arthritis. any disease ordisordoroi the bones or 22. Withi 5iyears Proposed Insured oonsuiteda icion hadtests pedomod (ouoh'. as ar?l??w) mardiogram?- blood a )orboon hospitalized or had urge orany reason? 23. Has any Proposed Insured ever been diagnosed as having, been told by a medical professional that you have or been treated by a medical prordesronai for Acquired Immune De?ciency AIDS-Related Complex (ARC). or my immune de?ciency related disorderor tested positive for antibcdioe to the Human Vinrs 24. t'lntbin the last twelve (12) months, has any Proposed Insured had tests, surgery. treatmert or hospitalization" reocrnmended, but not completed or con suited any health care providertsl not already identi?ed for any reason??. . Do any of the Proposed Insured(s EL currently use medicines? (If Yes list each medication and describe mereason for its use.) mm I). currently have a personal physio am? {If Yes. list name, address, and telephone number along wig?! to, reason and results of lasf consultation) ?gs. ..li??S?fL??mnfn RS. E. 13 .7. .. ANSWER QUESTION #26 BELOW IF ANY PROPOSED INSURED IS AGE 65 OR OLDER: 28 Within the past ?ve (5) years has anv Proposed Insured been diagnosed with or been advised to have or had treatment for: stroke transianr lechemio attacks (TIA) prostate disorders. any disease or disorders oithe boot or pints memory loss or htaldng anyp esoription medication ld-Aizneirners disease ordemerr w. El [3 MEDICAL HISTORY DETAIL Fieass provide details of all "Yes? answers in the area below {Attach a separate streetr'.? more space is needed, additional sheetMUSTbe signed and dated by applicable Proposed insured/OW to avoid amendments ,i Date of Onsetr? DetailsiResutts Name, Address, and Telephone Number of Attending Physician Cit] Bi QUSBUUFI it Insured 5 Name Treatment Morgan?:2- Fr? 21" gray/re?? ?snezgao? WM 2?3? Wired? I?m/r ?41 {A7?7w?szyr4 703'? 3-13? . 5" Awe?xi Mama? - . or a? Age??4.26! ?ycw?m irre- or!) no do 703 ifioye Mo 14/ armor? wit-J- or}: a 1- America- Financial Lite and Annuity Insuranrt. Company - Home Of?ce: Dallas. Torres - Administration Or?ltco: PO BOX 415283, Karim: City, MO 1 028.5 Whom-adds corn A?v?A?t 20 (dd/1t} Page 3 at 4 For Use in Virginia 92/127 Avnotzo roan i AUTHORIZATION AND ACKNOWLEDGMENT authorize any insurance or reinsurance company, employer, licensed medical physician, medical professional, hospital. pharmacy or phannacy bene?t manager, records custodians. other medical or medically related facility, cleanng house, consumer reporting agenm, andior the- Medical information Bureau (MIB, inc.) that has any record information about meius or myiour minor children utho are to be insured, to give Anterior) Financial Life and Annuity Insurance Company (herein called ?Finance" or the ?Companyii, or its reinsurers. information about other insurance coverage, employment, age, generai character, motor vehide records, habits, court records. pharmacy records, foreign travel, ?nances, participation in hazardous activities, medical care or advice about any physical or mental condition, including information about past medical history, drugs and aisohoiism. criminal activity. mutations. and test results required by Amends to determine insurabnity andr'or claims eligr'uility for the duration of the Claim America may release information obtained by this Authorization To its reinsurers, to the IrtlB, inc, to outer insurers With whom liwe have policies or to whom iivvs may apply or submit a claim, in connection with an insurance transaction for rnetus, indudtng paramed companies, labs, andior inspection points-antes, or as may otherwise be lawfully required. Although federal regulations require that Americo inform You of the potentiai that information disclosed pursuant to this Authorization may be subject to redisstosure by the recipient and no longer be protected by such regulation. alt information received by Americo pursuant-to this Authorization will be protected by tederai and state privacy laws and regulations. ir'Wc have received a copy of the Notice of insurance Information Practices. iiWe, or myiour authorized representative, may obtain a copy of this Authorization on request. This Authorization wilt be valid for thirty (3d) months from the date signed and no longer than the duration of the claim it used for claims purposes. it is America?s practice to prohibit third parties who lawfully receive nonpublic health intent-ration from redisciosing or reusing the disclosed inionnation. A photographic copy shall he as valid as the enginai. This Authorization be revoked; however, it may not be revoked during the period of the policy or to the extent America has taken action in reliance on this Authorization. Notice of revocation may be sent, in ranting, to Amerlso at its Administrative Ollise address. IN ACCORDANCE WITH STATE LAW, WE MUST PROVIDE YOU THE FOLLOWING FRAUD NOTICE: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or ?les a claim containing a raise or deceptive statement may have violated the state law. The USA PATRIOT ACT requires all ?nancial institutions, inctudihg insurance companies. to verity the identity of their customers. Providing your name, address, date of birth and teameyer identi?cation number allows us to verify your identity. Our veri?cation process may induce the use of third, porn: sources to verify the information provided. REQUEST FOR TAXPAYER NUMBER. AND CERTIFICATION: Under penalties of perjury. tea the Owner, certify that the number shown on this icon is my correcttaxpayer identi?cation number {or I am waiting for a hammer to be issued to me}. Any policy issued on this application will be deemed to be dethroned in and governed by the laws of the jurisdiction in which this application urea signed. Notwithstanding the foregoing, it this application is not solicited face to face or is chested through any electronic means. any policy issued on this application will be deemed to be delivered in and governed by the laws of the jurisdiction oftho Gunter, and said jurisdiction will also be the ?Signed at {City and State)" inserted beiow. No agent or medical emminer can waive the answer to any question in this appiiwtion nor decide on nor waive any of the company?s undemriting requirements her make or change any contract. The company shall have no imowiedge ofstetements made by or to the Agent or medical examiner unless such statements are shown on the applice?cn. Wile have read this application and represent to America that the statements made on this application are true, complete and oorreclty recorded to the best of my/cur knOn'iedge and belief. ?We agree that Function can rely on these statonents. ?We agree that this application andior any medical exam form and any supplemental appication or amendment to the application will be the basis tor any policy issued on this application or any antendment to the applintion. it'lr'liE AGREE THAT ALL ANSWERS TO THE PERSONAL HISTORY QUESTIONS ON PAGE 2 AND TO MEDICAL HISTORY QUESTIONS ON PAGE 3 OF THIS APPLICATION, SIGNED AND DATED BELOW, ARE COMPLETE AND ACCURATE. Signed attCity and State) 5?g/N57??z?s on (MonddDay/?I?eari 2455/ y} .. of Pro coed insure require?r" Signature of Owner (if di?'erent than the Proposodlnsured) Mar-9w Signature of Additional Proposed Insured Signatore oiWitnessing Agent1?reriuir'co?) America Financial Lite and Annuity Inarrenca Company - Home Cit-tics: Dallas, Texas - Administrative Office; PO BOX #0286. Kansas City, MO 84141-0285 - 20 (06/11) Page at of at For Lise in Virginia 94/127 June11,2012 America Financial Life and Annuity Insurance Company Proposed Insured Muhammad Aehraf Shah Policy Number - AMDDOID1E5 requesi thel ihe application dated May 9. 2012 be amended as follows: The primary insured lull}:r recovered frem collarbene surgery completed in 2MB. Contingenl Bene?ciary: Adeela Ashraf, Daughter of the insured, 50% and Mohhamad Abid Irfran. Son of the insured; 50%. To The heel of my knowledge and belief, The enewers recorded in the original applica?lion remain irue and carreci at this time. II is agreed than this amendment shall form a part of the original application and any policy issued there under and i1 shall be binding on every person who shall have or claim any ir'rlereal under said policy. cg??mf? 1/6? . Dated at 531: 3 iffy-lie 5.3 day of W?nessVM?/ lnaured 1 . (Purchaser if Proposed insured is under age 15) Witnesseg?lwz 3422?.3.a?- OwnerJMiE; 45' Millia?inrr??d Ashraf?sl?iah CA8161 9/127 Nov 19 2016 Home Fax 732566754 page I I I Americqi Financial Life and Annuity Insurance Company Home Of?ce: Daliasj?i?axas . Administrative Of?ce: P. 0. Box 410288. Kansas City, MO 64141-0285 I I: OWNERSHIP CHANGE REQUEST Policy Insuredt-i?u??om mg a/ {Lagowner of the above designated policy. (request that all bene?ts, rights and pnwl?eges moldent to ownership of the {30!th gasteo? in the new owner named below, or to such new owner?s Executors, Administrators and nasty r'Successors_ and Assigns. NEW PRIMARY owwg? Name: 743;? if: (Print full ha' . 24* h, lndividuai or lrusL} lip. Date of Birth: .83 Relationship to Insu'redor?at of Trust {if applicable): 40h. . f7! fwc?t?b/K 1/05. 2?;003 1 NEW PRIMARY CHI-NE . ionnrua?fw Print Title Or Truslafe If Ap Limelight-?34: Social Security 1 Certification Under ,clens?y of perjury, I certify tharrhe Social Security number provided on this form is true. correct. and complete. I understand that failure to fumish number could subject me to backup withholding. certify that Jam not new subject to backup Withholding. NEW CONTINGENT OWNER: I Name: I rim full narrje or individual or trust.) Social Security #2 Dateof Birth: I. i (OrTrust ID Relationship to lnsrired or Date or Trust (if applicable]: Address: I i NEW CONTINGENIT SIGNATURE: AUTOMATIC TRANSFER: In the event the owner predleceases the insuradfann uitant. ownership of said policy shaII vest in the insured. . I . Signedat (Ai?nlnolion 1% .,dany ?Oi/?274 557? ,10 Day . Month Year 3?7: f/Ji as! 1873? X: . . 'Sligriatdr?ro'lLF? Signature of Spousefall/6L ?9-58 spo 186 Signatuig?l 611151ng 1 I Print name of Witness of Abid YOU RESIDE IN ONE OF THE COMMUNITY PROPERTY STATES LISTED. YOUR SIGNATURE IS YOU ARE DIVORCED. A COPY QF THE DIVORCE DEGREE SHOWING ALL RIGHTS GIVEN UP BY YOUR REQUIRED. IF YOUR SPOUSE IS DECEASED, A COPY OF THE DEATH CERTIFICATE IS REQUIRED. YOUR RF CANNOT BE PROCESSED WITHOUT THIS COMMUNITY PROPERI STATES: ARIZONA. GUAM. IDAHO, LOUISIANA. NEW MEXICO. TEXAS. WASHINGTON. WISCONSIN. i . EXHIBIT i 06-195-5 3 I 39/127 Americo Financial Life and Annuity insurance Company Home Office: Dallas, Texas - Administrative Of?ce: P. O. Box 410288, Kansas City, MD 64141-0288 BENEFICIARY CHANGE REQUEST Policy Number: j'M? 0 0 f0 5 insured: Ma?amme?f Iii-f6 Aggy ?552 A, PoiicyOwner. 27. Alix/4 Subject to the provisions of the Policy and the rights of any Assignee of Record with the Company, it is requested that the Bene?ciary be change as follows: PRIMARY BENEFICIARIES: Name: I4 5 a! )4 1/0" :2 Relationship: 0 fL (Print 'full name of Individual or trust) (Or Date of Trust, if appiimbie) Address: 14/0 f7? V4 3205;? Name: Relationship: (Print full name of Individual or trust) (Or Date of Trust. if app?mhie) Address: Name: Relationship: (Print full name of individual or trust) (0r Date of Trust, if applicable) Address: CONTINGENT BENEFICIARIES: Name: Relationship: (Print full name of individual or trust) (Or Date of Trust if applicable) Address: Name: Relationship: (Print full name of individual or trust) (0r Date of Trust. if applicable) Address: If this request shall make any provision for children of any person as a class. the phrase shall include only lawful chiidren of that person. including any legally adopted child. except as the term ?child" or ?children? shall be otherwise speci?cally de?ned in the request. It is understood and agreed that, unless otherwise directed, proceeds will be paid in equal shares to any primary bene?ciaries who survive the insured. but if none survives, proceeds will be paid in equal shares to any contingent bene?ciaries who survive the insured. Signedat Jthis .dayof .M Day City/State Month ?Year Si of ray Owner Signature of Policy Owner (if Applicable) Signature of ess Print name of Witness *For Additional Designations, please use the next page?Both Pages must be signed and dated by the policy owner and a Witness 5? 08-1954 2 19/127 K3. Bow-1025.12- 5511:1115. C. 2.1110 8?41 {11-92-133 January-11. ?-3131? A819 .11 0111101 HEB 17.11.001.151 111-1110110105. 11.11 22.3003- P011051 Number: 33 185 Re: 11111081111030 AS11101 Shah Come 1101111011136 Number: 031331393; .Amefrico Financial 1.111213. 1511111111111 "113111311100 0001133211151 - 335. 0001111011.! .15. 11.11.1311: 10111 10111100.: raga1d?ngthe 1391191131013103131130011110 81210110113100 1301101. 1135 013311. 1009111001. 110111011121. ..11 0100110 praseas the 18011031 we. 1equ_1re the 1013' -0w?r13 1111011111211 1011 51111131010011 1951115101 13993 not appear ("31011 Gar 111.03 <11. tines. ?101 30.119813. C1111 mespimner's 1101:. 1120.1: 5101101111315 reau?sed IX) P108351 complete and 10111111 1119 01101000010101. may 01.2119; 35.0181 1101-1 please 0101.100 1:01.11 current. 201111039200 105-3111110119 11111111001.- This 1.1.4111 rims; 00 1.111111 K00 ?011111.11 your 10011121 10121111151003 110511110121. .1 .1 .11 3.41.12? 1/ 1 .121?1?1 *1 1:1" (P011051 0111211131": Currenthd?ress and Telephane 81111112101T112111: you 1 1:11:91 01213011011111? :0 be 0120030101109 for 51.0111 11100121100. needs'. 11011. 110110 further questions 01' cameras. 0108.512 00111301001 131101011131 Se =00 Dwariment at 1110 1011.16.13 18100113110110mher' Eisted' above and 11.10 heap}: to be of assistance. 3111:: 8101}, claims Department ?.ene??ciary Change Form-41110111011131 Rethzn'Envelope. ?10101011 Ens-5mm:- 1.011051- 133E {.?nmpuw 01 11:01:11?) - {312311 391.1011 1.111: 31'11111'01101. Cu 1 Ohiri 5.3131112]. 11211110111.? Ca. 1 15111131 Fatzt?lni 1.601115115111ch me?x 2 mm ?2'th 11:31:11 Riff. 1 11:10:11.1. {1110211110 . tnvm-re 1.11: 1151:: 0310. f. 111011-11? $11111 ?m?miuuztmim .131: :unciiw (3:111:11 111151211102: 111111111111: 1101111011 (111102: .11: .1115. '1 11:50:31. .11: 5113- 11mm- 1111;. Cc 1:01:13ch 1111'ch 511mm? 1-1111 and. 3.123.111: Lih- ?ank Immune <41; uammlx 161.31? Lik- (10.3 1011: Lifu Sm. <1 .K. 11.111111 hum occ- (2011th of "and: 1' ?111-111 1111-11111 1-111: d?Ornaha). niNY- 11101111T'zr11'1.? 01.1113 1111151111111 Lin (cf: J'm 4 Oman?) 1'30 {ML-mite Cr: Grmni 1.11:. 110011111: ziintn?a1mxgnu5mmzru of math 4111;211:111 Aibmr. Aimni?. a. 041 Nov.- gammy. {fut-111211;; hurt-561m 1.11m) Kn) 18/127 any contingent bene?ciaries who survive the insuredNOTARY {Ame In .this Lina?? .day of I wa?w?tur?om: Current Policy Owners lig?? MY EMISSION ?r a Wmm?aiilg?dr -. BENEFICIARY CHANGE REQUEST Policy Number: Insured: Ashraf Shah, Muhammad Current Policy Ovmer: Awan?bld A Owner's Current Mailing Address: 7110 Falcon St Annandale. VA 22003 Subject to the provisions of the Policy and the rights of any Assignee of Record with the Company. it is requested that the Bene?ciary be change as follows: PRIMARY BENEFICIARIES: Name: ?51? if? i Relationship: (Print full name 01 or trust) [0r Date ct Trust. if upp?cahlc) Address: 77/0 f7! 22003 Name: Relationship: {Print full name of individual or trust) (01' Date of Trust, if appll cable) Address: Name: Relationship: (Print full name of or trust) (Or Detect Trust. If applicable) Address: CONTINGENT BENEFICIARIES: Name: Relationship: (Print full name of lndeual or [mail {Or Dale of Trust. if applicable) Address: Name: Relationship: {Print name 01 Indiuduai or trust; (Or Date of Trust. if aoolicablei If this request shall make any provision for children of any person as a class. the phrase shall include only,r lawful children of that person, including any legally adopted child. except as the term ?child? or?ohitdreh= shall be otherwise Specifically de?ned in the request. it is understood and agreed that, unless otherwise directed, proceeds will be paid in equal shares to any primary bene?ciaries who survive the Insured, but if none survives. proceeds will be paid in equal shares I ClIyISIate 1 Month Yea rrent PolloyW/? 45027 f/ image/? ya .2 2 a print name of?Mtness 7" ?For Additional Declgnatlons. please use the next page?Both Pages must he signed and dated by the owner and 3 Witness. 903 17/127 STATEMENT 8: SETTLEMENT OPTIONS STATEMENT must be completed by the personts) to whom the insurance is payable. bene?ciary, you may make cepies of this form as needed. When a policy is payable to the Estate, the Claimant?s Statement must submitted along with the Letters issued by the Court appointing that individual. When a policy is payable to a company or corporation, the Claimant?s Statementmust be signed by two of?cers and include each of?cer's title. When a policy is payable to a named bene?ciary who is the age of majority or older, the statement must be made and signed by such bene?ciary. if a policy has been cotiaterally assigned by the owner prior to the death of the decedent, a Statement of interest is also required. This document provides a statement of the assignee's interest and may be obtained by contacting our of?ce. When an of?ciai inquiry as to the cause of death has been made, a certi?ed copy of the medical report, verdict. or ?nding, must be furnished with this statement. SETTLEMENT OPTIONS: To hetp you through this dif?cult time, we have created a settlement option, calied a Financial Access Account (FAA), to give you the time you need in order to determine the section of the enclosed claim forms, you will have the opportunity to select this easy to access and bene?cial settlement option. We believe that the Financiat Access Account allows you many options that more traditional settlement options, such as a lump sum payment, do not offer. We would encourage you to read the exciting features of the Financial Access Account that are described beiow and make the decision that is best for you. Please remember, if any other settlement option is selected, you cannot receive the bene?ts of the Financial Access Accoun . A Financiat Access Account allows you many bene?ts that the other settlement options do not offer. From the day your ?nancial Access Account is established, you witl begin earning interest at 25%, a basis. You have FULL access to your funds from the date the Financial Access Account is opened. You can access the funds by writing a draft on your personalized draft book or by conta no limit to the number of withdraws or drafts that are written each mont transaction fees. Further information on the Financial Access Accounts can be found towards the end of the claim packet. if we can answer any additional features about the Financial Access Accoun WENT-WED be completed by the Executorts} how you woutd like to use your insurance proceeds. in with the interest being compounded daily and credited on our ot?ce during normal business hours. There is h. In addition, there are no maintenance or I, please contact us at 1?800-231?080t. The undersigned claimant hereby states as follows: STATEMENT Part A - ABOUT THE DECEASED) t?e?TiFt??"' COPY Name of Deceased (State all names used by the deceased during their tite including maiden name, nickname. aiias, or other name) Nuhecmtza/rtr fen/t. i 33% AW 0570 (a my ?g Policy Numberts) pct/? A. List alt policy numbers with this company: CO 14?040-6 3 ll 5%5 ill 26/127 Oeceased?s Daj of Birth ?3 Sociat Security Number Date of Death .. .-- -. f2 73f fan. a 0/7 Decea ed?s Place of Birth ?Cause of Death lit/e y?aft?a we: i 1 if cause of death was other than natural: ]Suicide [jHomicide ]Accident at I Part - (INFORMATION ABOUT THE BENEFICIARY) (335-AM00010165) Bene?ciary Name 1% ad I4 Z4 150? 703 33/ - 9 7519f First Middle Last Telephone Number Mailing Address 71005 Street City State Zip Code Bene?ciary's Social Security Numberfiaxl.D.#: 3f: 6 5 6 Date of Birth 9 3 Relationship to the Deceased 170/1 0 Day Year Part - (Policleeath Certi?cate) Please check the appropriate statements: Enclosed is a certi?ed copy of the death certificate of the insured. have enclosed the original policy(ies). After a diligent search, the original policy(ies), or copies, cannot be located if bene?ciary is a trust, have enclosed trust documents, which shows successor trustee. It bene?ciary is a trust, certify that the trust is still in full force and effect. Please select one of the two foltowing statements: Under penalty of perjury, certify that i am subject to backup withholding. {vi Under penalty of perjury, I certify that i am not subject to backup withholding because (choose one): am exempt jt/t?l have not been noti?ed by the lnternai Revenue Service that am subject to backup withholdings Part - Settlement Options You may elect to receive your policy bene?ts in any of the below~listed ways. To select one of the fotlowing, check the box and initial your setectlon. By selecting the option for the Financial Access Account, your poticy proceeds wiil be immediately deposited into a Financial Access Account. This account acorues interest at a competitive rate, white altowing you fult access to the funds from the date the account is opened. A book of personalized drafts allows you the opportunity to access the funds at any given time. In addition to these features. severat other descriptions and features of the Financial Access Account can be found within the ctaims packet. Make proceeds immediatety available through a Financial Access Account [m Maize proceeds payable in the form of a bank check i am interested in the Special Payment Options (eg. Deposit. installment or Life income Options). FRAUD NOTICE Several States require that a notice be provided to each claimant to protect against Fraud. The undersigned acknowledge the Fraud Notice document has been received, read and is incorporated by reference if the state in which the undersigned resides in is listed on that notice. it is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may inctude imprisonment, fines or deniai of insurance benefits. t4-D40-6 27/127 SIGNATURE The undersigned agree that this Ctaiinantis Statement constitutes their ctaim for proceeds. poticies as such were contractually in force at the time of the Deceased?s death an that tumi waive an 1/ contract pro visions. . . Disinterested Witness Date tetamnaiure LEASE AS YOU WOULD A CHECK) 1?80" wf?qom kg, . #30! Hit/Lea?? M4, Witness Address and Phone Number BE SIGNED BY A 14-040-5 Bot . it a under each of the above-listed ?ig of this Statement does not 05cm RENE mummy: moouussmagpmes magma monument ?ij name! 702/?7? Egg/fr!) 9:2 0 28/1227 Date 40?? . . Tc: ATTN: Claims Page 2 of 5 2017?02?10 1 6:38:14 (GMT) From: February 09, 201? Samina Ashraf Gilani do solemniy state the foilowing. During his Visit to Pakistan Mr Ashraf got sick in Pakistan and got admitted in a hospital in October. Due to his severe health conditions he was brought back to USA and was taken to the local hospital the same day of our arrival in it was ?rst week of October) . During his illness (while MrAshraf was in hospital) his children barred me from seeing MrAshraf many times. Last time I was taken to Mr Ashraf was 12-31-2016 . Between 12-31?2016 and 01?16?2017 was compietely denied by Mr Ashrafs children to visit him in hospital. Meanwhile all relevant papers and 2 lap top computers were also taken from my house illegally without my permission and knowiedge. Now some more details about the behaviour of Mr Ashraf?s chiidren, during MrAshraf?s illness while he was admitted in hospitai my teiephone conversations were taped and some other recording devices were also installed/planted in my house at 6314 Thomas Drive, Springfield, VA. was directed by Mr Ashrat?s children not to go out or visit MrAshraf without the children's permission, only the children will decide when to see Mr Ashraf. 5 91 at Some times between 12?31?2016 and 01?16-2017 (believed to be on January 6201?) I called the local police to ?nd out the where abouts of my husband Mr Ashraf since i was compieteiy blacked out about my husband. 1 had no Knowledge of my husband nor of his health conditions. i did inform this situation to the police over the phone and in person when the police arrived at my house. At that time one of Mr Ashraf's son Abid Awan showed up and spoke to the poiice and painted a picture of family matter to the 124/127 :tobert Segal To: ATTN: Ciaims Page 3 of 5 2017-02-10 16:38:14 (GMT) From: police. Right after the police left Mr Ashraf?s another son Shahid tmran Awan showed up and threatened me for me calitng the police. Mr Shahid imreo Awan threatened that he is very powerfui and if i ever" cell the police again Mr Shehid lrnrah Aswan wilt do harm to me and my famiiy members back in Pakistan and one of my cousins here in Battimore. Mr Shehid iroran Awen threatened that he has power to kidnap my family members back in Pakistan. Mr Shehid imran Await did admit to me that my phone is taped and the-re are devices installed in the house to iisterr my all conversations and that he wilt remove all these devices. Next day of the police catiing Mr Shahid lmren Awan came back to my house at 6314 Thomas drive and removed something from under the kitchen counter and living room from behind the printer), after he left i checked under kitchen counter and found some marks and took pictures of that place pictures are sent to you Worth mentioning here that Shehid lmren Aswan introduces himself someone from US congress or someone from Federal Agencies. Mr Shahtd ire-ran Awe-1o also demanded me to sign a power of Attorney for my Pakistani matte-rs and was forcing me over the phone and through other people to sign power of attorney. was put under tremendous pressure to sign the power of attorney to Mr Shehid lmr?eo Awao for Pakistani properties and at point i was going to sign ,but then i decided to leave my house and requested my sisters to arrange my departure from that location. My cousin was also tacttutty informed and threatened that MrAshret's children are very resourceful and powerful and that he shoutd protect him, his wife and his children from theses people. He was told that they are Dons badmaash log hein). in Pakistan Mr Shahid ire-ran Awan manages to have police mobite based on his position in US congress or Federal Agencies to escort him during his visit to Pakistan. There are many peopte who have this knowledge that my phone conversations were taped and my conversations in side my house were being listened. 393-bit 3] 5k? 1t A 125/127 Qobert Segal To: AWN: Claims Page 4 of 5 2017-02?10 16:38:14 (GMT) From: FE it was very unusual and strange that even ather friends and relatives were aiso denied access :0 Aghraf during his Illnessi My cousin?s caiis were turned down many times and he was aiways told th at Mr Ashraf was asiee-p due to his pain medicaiidns and that Mr- AShraf cauldrt't talk. My cousin never had a chance to speak to Mr Ashraf sometimes after mid November 2016:. There is a whole iot to tail which I can't put in one 9?mail. reaiiy appreciate your help and e?mds Little bit 0f the behavidur of these children in the past . On August 25, 200? in a feial read accident in Pakistan Mr Ashraf?s ?rst wife Tahira and the driver Mr Shah-Ber were kilied and MrAshraf nearly missed, Mr A-shrai was badiy injured in that accident . Mr Ash raf resei?red same Cdmpensaiion amount because of this tragic accident. From where insurances and gavemment benefits. As per MrAshraf his son Shahid lmrari Awan took Mr Ashrafs all money fraudulentiy by signing legai documents with Phony 1 Fake Signatures, Pretending to be MrAshi?af. As Mr Ashraf had stated in his lifeg MrAshraf?s. Son Shahid imran Awan and Abid Awan both together performed this fraud. Aft-er taking his money Sha'hid imran Awan purchased real state properties with that money, The houses in whiah both brothers are living new! believed to be purchased from that money. it is not confirmed but MrAshra?i reported this fraud to the locai Police and than withdrew his report at that time. However MrAshraf did mention this gory personaily to me many times. Aiso he had mentioned this story to many other people in the community. . 126/127 obert Segal To: ATTN: Ciajms Page 5 of 5 2017-02-10 76:38:14 (GMT) Your hair.) be very much appreciated in this matter. i also authorize Syed Ahmed as my legal attorney is deal with my legai matters an my behaff . He can and wit! receive informatian and can and win execute any steps mace-33am, Signed Dated Sam-ma A$hraf Giiani wife of Muhammad Ashraf Shah 127/127 From: ~\?obert Sega!