Participant s Name (Last, First, Middle) S.S.N. (last 4 digits only) Daytime Phone Number

Transcription

1 EQUI-VEST Strategies TSA Loan Request Form for use with the Independent Benefits Council (IBC) Program Express Mail: AXA Equitable EQUI-VEST Processing Office 100 Madison St., Suite 1000 Syracuse, N.Y Regular Mail: AXA-Equitable EQUI-VEST Processing Office P.O Box 4956 Syracuse, N.Y Fax Number: (201) For Assistance: Call (800) Monday Thursday 8:00 a.m. 7:00 p.m. EST Friday 8:00 a.m. 5:00 p.m. EST 1. PARTICIPANT INFORMATION (Certificate number must be provided to process this request) AXA Equitable may not be able to process your loan request if you cannot secure your employer s signature. Refer to the Authorization section starting on page 3 prior to completing this form with respect to employment status and employer signature requirements. Certificate Number Unit Number (if known) Participant s Name (Last, First, Middle) S.S.N. (last 4 digits only) Daytime Phone Number Address Number and Street Apt/Suite/Floor City State Zip Name of Employer/ Plan Name Financial Professional Please check if this is an Address Change. 2. LOAN AMOUNT REQUESTED (See Item 9 in Terms and Conditions for more information) The minimum loan amount with respect to this certificate is $500. Except as otherwise explained below, the maximum loan amount is $50,000. The amount that you may borrow is based upon your Certificate s account value on the loan Effective Date, as defined in Item 2 in Terms and Conditions. If the account value is at least $1,000 but less than $12,500, the maximum loan amount with respect to the certificate is 80% of the account value subject to a remaining minimum account value of $500; if the account value is at least $12,500, but less than $20,000, the maximum loan amount with respect to the certificate is $10,000; if the account value is $20,000 or more, the maximum loan amount with respect to the certificate is 50% of the account value, but not more than $50,000 Please CHECK and COMPLETE either A, B or C below for desired action: A. I request the maximum loan amount to be established proportionately from all Investment Options. I represent that this is the only certificate I have under all plans of my employer. B. I request a loan amount of $ to be established proportionately from all Investment Options. C. I request a loan amount of $ to be established from my Investment Options as indicated in the Loan Funding Schedule in Section LOAN TERM (See Item 3 in Terms and Conditions for more information) (Check one) 5 years 10 years. I represent that these loan funds will be used to acquire a dwelling unit that will, within a reasonable time, be used as my principal residence. Page 1 of 6

2 4. LOAN FUNDING SCHEDULE You have the options to request that your loan be established, and the Loan Reserve Account be funded, from specific Investment Options rather than proportionately from all Investment Options in which you participate. If you wish to specify a manner in which the loan is to be established, you must complete the information on page 2. However, before proceeding, please take note of the following: 1. Any Investment Option transfers you may request after completion of this schedule and before we process your loan application may impact your instructions. 2. If you specify dollar amounts for the establishment of the loan, keep in mind that the Loan Reserve Account must be funded with 110% of the amount you indicate. 3. The dollar value of your participation in the Variable Investment Options fluctuates daily and may increase or decrease; therefore an adequate margin should be allowed for such fluctuations. I request that my loan be established as follows: (Place a check mark next to those Investment Options to be used if you want the loan to be funded from one, or proportionately from two or more Investment Options; show a dollar amount in the space provided if you want the loan funded by a specific dollar amount from specified Investment Options.) Structured Investment Option Segment Small/Mid Cap Stocks $ S&P 500 1year -10% Buffer (V2*) Asset Allocation AXA Allocation $ AXA Aggressive Allocation (18*) $ AXA Moderate Allocation (T4*) $ AXA Moderate-Plus Allocation (17*) $ AXA Conservative Allocation (15*) $ AXA Conservative-Plus Allocation (16*) Target Allocation $ Target 2015 Allocation (6G*) $ Target 2025 Allocation (6H*) $ Target 2035 Allocation (6I*) $ Target 2045 Allocation (6J*) Large Cap Stocks $ AXA Tactical Manager 500 (7M*) $ EQ/BlackRock Basic Value Equity (81*) $ EQ/Boston Advisors Equity Income (33*) $ EQ/Common Stock Index (T1*) $ EQ/Equity 500 Index (TE*) $ EQ/Equity Growth PLUS (94*) $ EQ/Large Cap Core PLUS (85*) $ EQ/Large Cap Growth Index (82*) $ EQ/Large Cap Growth PLUS (77*) $ EQ/Large Cap Value Index (49*) $ EQ/Large Cap Value PLUS (89*) $ EQ/UBS Growth and Income (35*) $ Fidelity VIP Contrafund (7R*) $ MFS Investors Growth Stock (8I*) $ MFS Investors Trust (7P*) $ Multimanager Aggressive Equity (T2*) * The number in parenthesis is shown for data input only. $ AXA Tactical Manager 400 (7L*) $ AXA Tactical Manager 2000 (7K*) $ EQ/AllianceBernstein Small Cap Growth (TP*) $ EQ/GAMCO Small Company Value (37*) $ EQ/Mid Cap Index (55*) $ EQ/Morgan Stanley Mid Cap Growth (08*) $ EQ/Small Company Index (97*) $ Multimanager Mid Cap Value (61*) International Stocks/Global $ AXA Tactical Manager International (7N*) $ EQ/Global Multi-Sector Equity (78*) $ EQ/International Core PLUS (88*) $ EQ/International Equity Index (TN*) $ EQ/International Value PLUS (73*) Bonds $ EQ/Core Bond Index (96*) $ EQ/Intermediate Government Bond (T1*) $ EQ/PIMCO Ultra Short Bond (28*) $ EQ/Quality Bond PLUS (TQ*) $ Ivy Funds VIP High Income (8G*) $ Multimanager Multi-Sector Bond (TH*) Cash Equivalents $ EQ/Money Market (T3*) Sector/Specialty $ Invesco V.I. Global Real Estate (8C*) $ MFS Utilities (8K*) Guaranteed-Fixed $ Guaranteed Interest Option (A1*) $ Total (Must be 100%) If my selection cannot be satisfied exactly as specified because of insufficient funds in one or more of the Investment Options named, I authorize AXA Equitable to bring the specified Investment Option balance(s) to zero and fund the remainder from the other nonspecified Investment Options. I further authorize AXA Equitable to prorate the additional amount required proportionately among the nonspecified Investment Options based upon their values as of the Loan Effective Date, subject to minimum Investment Option transfer rules. IF YOU DO NOT WISH AXA EQUITABLE TO PRORATE AS DESCRIBED ABOVE PLEASE CHECK THIS BOX. I HEREBY AUTHORIZE AXA EQUITABLE TO LIMIT MY LOAN AMOUNT IF SELECTED INVESTMENT OPTIONS ARE INSUFFICIENT. NOTE: AXA EQUITABLE WILL PROCESS THE LOAN AMOUNT BASED ON SUFFICIENT INVESTMENT OPTIONS AVAILABLE. Page 2 of 6

3 5. Delivery Options Unless otherwise instructed, checks are mailed via First Class Mail. Expedited delivery is available for a fee of $35 for Express Mail and $90 for a Wire Transfer after your request has been processed. AXA Equitable has 5 business days to process your request. Please select one option below if you want to expedite delivery. 1. Please expedite delivery by using Express Mail for a Fee of $35 (Cannot be a P.O. Box), or 2. Please expedite delivery by using a Wire Transfer for a fee of $90. Only available for net wire amounts of $10,000 or more to a Personal Bank Account. You must attach a voided personal check for Wire Transfer requests. We cannot process your request without it. Select Account Type: 1 Bank Checking Bank Money Market Credit Union Checking Name as it appears on account Name of Bank / Financial Institution Bank Address Bank City, State & Zip Code Bank ABA / Routing Number Account Number 6. AUTHORIZATION By signing this form, I indicate that I have not defaulted on any loans from this or any other plan of my employer. If I have defaulted on such a loan, I have included the sum of the unpaid balance and continually accruing interest on the loan in my calculation of outstanding loan balance; see Item 9, (B) Maximum Loan Amount in Terms and Conditions. Further, I represent that this loan is within the maximum loan amount permitted under Internal Revenue Code as described in Item 9 in Terms and Conditions. The total of the loan amount requested in Section 2, when aggregated with loans (principal plus interest) from all qualified plans of my Employer, including governmental employer for example any other Internal Revenue Code 403(b) arrangements funded by my Employer and Internal Revenue Code Section 457(b) governmental employer plans, does not exceed the greater of $10,000 or 50% of the value of nonforfeitable accrued benefits under all of my Employer s qualified plans, including this 403(b) plan, other 403(b) plans and 457(b) governmental employer plans. (For my EQUI-VEST Contract funding this 403(b) plan, my nonforfeitable accrued benefit includes my Annuity Account Value. For other plans of my Employer, it is my vested benefit.) In no event can the loan exceed $50,000, reduced by the excess of the highest outstanding balance of all loans from my Employer s qualified plans as well as other 403(b) and/or 457(b) governmental employer plans that I may participate in during the one-year period ending on the day before the date the loan is made, less the outstanding balance of all loans from all such plans on the date the loan is made. I understand that you may require me to elect not to have income tax withholding apply with respect to any interest and/or loan principal that would otherwise be subject to withholding. Check the boxes which apply: A. I am currently employed with the employer which sponsored my EQUI-VEST TSA 403(b) contract. B. I am retired from, or have terminated employment with, the employer which sponsored my EQUI-VEST TSA 403(b) contract. Do you have assets under any other plans of the employer which sponsored your EQUI-VEST TSA 403(b) contract? No (skip to acknowledgements) Yes, in addition to my EQUI-VEST TSA 403(b) contract, I also have one or more 403(b) contracts with other carriers. Please indicate the names of these carriers,,, Yes, a 457(b) governmental employer plan: Where are your assets in this plan (names of carriers or plan contact) Yes, a 401 qualified plan: Where are your assets in this plan (names of carriers or plan contact) Page 3 of 6

4 6. AUTHORIZATION (cont d) Have you ever taken a loan from any 403(b) contract, 401 plan or Governmental 457(b) plan of the employer which sponsored your EQUI-VEST TSA 403(b) contract? Yes No ACKNOWLEDGEMENTS: Recently, the IRS issued final regulations that affect 403(b) plans. These tax law changes may result in your loan being treated as a taxable distribution under certain circumstances noted below. For this reason, AXA Equitable will process your completed loan request, regardless of your employment status (employed, retired, or terminated) provided that your employer (or former employer) signs the loan request form. A. If you are currently employed with the employer which sponsored your EQUI-VEST TSA 403(b) contract: AXA Equitable will process your completed loan request even if there is no signature from your employer if (i) AXA Equitable is a current provider for your employer s 403(b) plan, (ii) your employer has not prohibited us from processing loan requests; and (iii) your employer has provided AXA Equitable with a list of approved 403(b) plan providers/carriers which have agreed to share information so that AXA Equitable can verify account and loan information with those approved carriers. If AXA Equitable has received a list of approved 403(b) plan providers/ carriers from your employer, AXA Equitable will attempt to contact those plan providers/carriers to secure account and loan information. If those plan providers/carriers do not respond or share the information within a reasonable time, AXA Equitable will not be able to process the loan request and will return the loan request form to you. If your employer has prohibited AXA Equitable from processing loan requests, AXA Equitable will not be able to process your loan request unless your employer specifically permits loan transactions at a later time. If your employer has not provided AXA Equitable with a list of approved providers/carriers we will not be able to process your loan request. AXA Equitable will return the loan request form and you may attempt to secure the approval and signature of your employer or other authorized person. B. If you are retired or have terminated employment: AXA Equitable will process loans without your former employer s signature only if (i) AXA Equitable is a current provider for your employer s 403(b) plan, (ii) your employer has confirmed to AXA Equitable that 403(b) contracts for retired and terminated employees will continue to be under the employer s 403(b) plan and has not prohibited processing loan requests, and (iii) your former employer has provided AXA Equitable with a list of approved 403(b) plan providers/carriers which have agreed to share information so that AXA Equitable can verify account and loan information with those approved carriers. If AXA Equitable has received a list of approved 403(b) plan providers/ carriers from your former employer, AXA Equitable will attempt to contact those plan providers/carriers to secure account and loan information. If those plan providers/carriers do not respond or share the information within a reasonable time, AXA Equitable will not be able to process the loan request and will return the loan request form to you. If your former employer has not signed the loan request form and has not met the conditions noted above for processing a request without an employer signature, AXA Equitable will not be able to process the loan request and will return the loan request form so that you may attempt to secure the approval and signature of your former employer or authorized person. If you cannot secure your former employer s approval, AXA Equitable cannot process the loan. If restrictions do not apply to contract amounts, you may be able to take a withdrawal by submitting a Request for Disbursement form (Cat # ) that will be treated as a taxable distribution and will be reported on an IRS Form 1099-R. I have read and do understand the terms of this TSA Loan Request Form including those on subsequent pages of this form and the formula for computing the maximum loan amount. I acknowledge that any loan not in accordance with the requirements outlined herein may be considered as taxable income to me. I am returning the original and making a copy for my records, as this TSA Loan Request Form together with the TSA Loan Confirmation Notice comprises the Loan Agreement. X Signature of Participant Date X Employer s/trustee s Signature Print Name and Title Date Page 4 of 6

5 TERMS AND CONDITIONS AXA Equitable Life Insurance Company ( AXA Equitable ) requires the following information in order to process a loan against your EQUI-VEST Contract indicated on this form. Before you complete this form, you should review the entire form, including the information following the signature. You may need to check your records or request information from your Employer to confirm the information needed to process your loan request. You should also consult your own attorney, accountant or tax advisor for tax information relating to your own particular situation. Please note: All references on this form to Participant also include Annuitant. All references to Contract also include Certificate. 1. LOAN RESERVE ACCOUNT: On the Loan Effective Date (defined in Item 2 below), we will hold in reserve an amount equal to the loan amount, which will earn interest at the Loan Reserve Account Rate (defined in Item 5 below) during the loan term, plus 10% of the loan amount, which will earn interest at the Guaranteed Interest Rate, as defined in the Contract. This loan reserve will remain in your Contract and will be reported on all financial confirmation notices sent to you. You may not make any partial withdrawals or transfers from the Loan Reserve Account until after repayment. You may specify on your TSA Loan Request Form from which Investment Option(s) the Loan Reserve Account will be funded (see Section 4, Loan Funding Schedule). 2. LOAN EFFECTIVE DATE: If the loan request form is received prior to the 27th day of the month, this transaction will be effective on the day on which the loan request form, properly completed, signed and in good order, is approved at our Processing Office (see addresses shown on cover). If the loan request form is received on the 27th day of the month or later, this transaction will be effective on the first business day of the month following the date on which the loan form, properly completed, signed and in good order, is approved at our Processing Office. A separate Confirmation Notice is issued for loans. If you do not receive a Confirmation Notice or check within 10 days, please notify the EQUI-VEST Processing Office immediately. A loan does not affect future contributions. 3. LOAN TERM: The repayment period is 5 years. The only exception is if you use the loan funds to acquire a dwelling unit which, within a reasonable time, is to be used as your principal residence. In that case, the loan repayment period is 10 years. In requesting a 10-year loan term, you specifically represent that you will use the loan funds for this purpose. 4. LOAN INTEREST RATE: Loan interest is calculated at an effective annual rate of 6%. Your Loan Interest Rate will be on your Loan Confirmation Notice. 5. LOAN RESERVE ACCOUNT RATE: The Loan Interest Rate in Item 4 above minus 2%. 6. REPAYMENT: Your initial Loan Confirmation Notice will indicate the amount of principal you have borrowed and the interest you must repay quarterly over the specified loan term. It will also specify the repayment dates. Upon request, we will send you an amortization schedule. Your first payment is due 3 months from the date following the Loan Effective Date. Approximately 30 days before each payment due date, we will send you a TSA Loan Payment Notice which will indicate the amount due and the remaining unpaid principal balance. Payment must be made by money order or bank check for full loan repayment, or personal check for ongoing quarterly payments only. All payments made by check must be drawn on a bank in the U.S., in U.S. dollars and made payable to AXA Equitable. All checks are accepted subject to collection. Any payments will first be applied by us to interest due, with the balance applied towards repayment of the loan principal. We send a Confirmation Notice after we receive your loan payment. Your loan may be repaid in full (bank check or money order only) at any time, including interest due. After any repayment is made, including full repayment of the loan, the principal amount repaid will be transferred from the Loan Reserve Account to the Guaranteed Interest Option and may be withdrawn (if otherwise permitted), transferred to another Investment Option, or applied to a Benefit payment as described in the Contract. Required repayment of the loan may be accelerated and full repayment of unpaid principal and interest will be required when your Contract terminates. The following transactions will terminate your Contract: 1) death, 2) commencement of Benefits under the contract, and 3) other termination of the Contract (for example, a surrender). Please note we reserve the right to limit transfers of Cash Value, up to the amount remaining in your Loan Reserve Account under your Contract, to another 403(b) arrangement while you have an outstanding loan. We also have the right to accelerate the repayment of this loan if we determine that such acceleration is necessary to preserve the federal income tax status of your TSA Contract. Mail quarterly and full loan payments to: Regular Mail Express Mail AXA EQUITABLE EQUI-VEST Loan Payment Lockbox JPMorgan Chase PO Box EQUI-VEST Lockbox #13496 Newark, NJ Chase Metrotech Center (7th Floor) Brooklyn, NY The number to be listed on Express Mail Packages is: Attn: Extraction Supervisor (718) Page 5 of 6

6 TERMS AND CONDITIONS (cont d) 7. DEFAULTS: By each due date, if the amount of the loan payment is less than the amount then due or the loan payment is not received at the EQUI-VEST Processing Office, we will treat the unpaid balance of the loan at that time, including interest due but not paid, as a deemed distribution for Federal income tax purposes. In determining the due date, we will apply the applicable IRS rules for a grace period. We will withdraw the amount of such entire unpaid balance from your Loan Reserve Account. Even if a loan has been defaulted for tax purposes as described in this section, AXA Equitable has the right to foreclose on the defaulted unpaid balance, plus interest to the date of foreclosure, after the time that amounts under this Contract are no longer subject to any withdrawal restrictions which may apply under the Plan or Internal Revenue Code. 8. NUMBER OF LOANS: Only one loan is permitted on your Contract at one time. Should you require additional funds while any portion of a prior loan remains outstanding, the existing first loan must be fully repaid, including all interest due. After full repayment is confirmed, you may request a new loan in the desired amount but the new loan will be subject to the limitations discussed on the front of this form with respect to the maximum loan amount, including the limitation with respect to prior outstanding loan balances during the one-year period ending the day before the new loan is made. We reserve the right not to permit new loans if a previous loan was defaulted and not repaid when due. 9. MAXIMUM LOAN AMOUNT: The maximum loan amount you are permitted is calculated as follows: (A) Is the loan amount you have indicated in Section 2. (B) Is the outstanding loan balance on all other loans you have not yet repaid from all other qualified plans, funded by the Employer who has provided the funds for this contract, including for example other Internal Revenue Code Section 403(b) TSA plans and contracts or Internal Revenue Code Section 457 governmental employer EDC plans. (C) Is the amount of your highest outstanding balance for the one year period ending on the date before the date this loan is made for all loans from this Employer s plans, including those you have repaid. (D) Is (C) minus (B). (E) If (D) is positive, then subtract (D) from $50,000 to calculate the value of (E). If (D) is negative or equal to zero, then (E) is equal to $50,000. (F) Determine the present value of your nonforfeitable accrued benefits under all of your Employer s qualified plans, including this Contract. For this Contract the benefit is equal to the Annuity Account Value. Under all of your Employer s qualified plans, it is equal to your vested benefit. Divide this number by 2. (G) Is the greater of (F) and $10,000. (H) Is the lesser of (E) and (G). (I) Is (A) plus (B). (J) Your maximum loan amount is the lesser of (H) and (I). Page 6 of 6