REQUIRED MINIMUM DISTRIBUTION (RMD) REQUEST

Transcription

1 REQUIRED MINIMUM DISTRIBUTION (RMD) REQUEST Symetra Life Insurance Company First Symetra National Life Insurance Company of New York Mail to: PO Box Nashville, TN Overnight to: 100 Centerview Drive, Suite 100 Nashville, TN Phone Fax Important! Please read the supplemental information provided on pages 1-2 and retain for your records. Complete all applicable sections of this form and return pages 3-5 to us via the fax or mailing address listed above. You should consult your tax advisor if you have questions about your individual circumstances. Starting, Changing or Stopping RMDs Use this form if you want Symetra Life Insurance Company and First Symetra National Life Insurance Company of New York (collectively Symetra ) to automatically distribute the RMD each calendar year for your individual retirement annuity (IRA), 403(b) tax-sheltered annuity or annuity held as part of a 457 deferred-compensation plan. Also use this form if you want to make changes or stop the automatic RMD. We must receive this form at least 30 days prior to the date that you want to start, change or stop the automatic RMD. Please use a separate request form for each annuity contract. RMD Amount We provide the service of calculating and automatically distributing the RMD, if any, for this annuity contract each year. We will determine the RMD by dividing the prior December 31 balance, plus the actuarial present value, if any, by a life expectancy factor that the IRS publishes in the Uniform Lifetime Table. Distributions taken during the year, including any RMD, reduce the December 31 balance. For 403(b) tax-sheltered annuity contract holders: because the RMD rules apply to post-1986 contributions, but not to pre-1987 contributions made to your 403(b) tax-sheltered annuity, we will exclude the pre-1987 contributions from the RMD calculation until the calendar year following the year in which you turn 74. If you would like these monies included in the RMD calculation, please call us or send us your request in writing. Stopping RMDs If stopping automatic distributions, current and future RMDs must be satisfied from this annuity or another like-qualified contract. Starting or Changing RMDs Your request to receive automatic RMDs will apply, unless modified or revoked, until annuity distributions begin or through the year of your death. Electronic Funds Transfer (EFT) To receive automatic RMDs via EFT, you must provide a pre-printed voided check in the contract owner's name. If you do not have pre-printed checks, please ask your financial institution to write a letter on their letterhead. Please make sure the letter includes the account owner name(s), account type (e.g. checking or savings), account number, the bank's routing number, and the signature and title of an authorized officer. Income Tax Withholding Withdrawals may be subject to federal and state income tax, where applicable. If the federal withholding section is left blank, we are required to withhold income tax in an amount equal to 10% of the gain portion of each automatic RMD. If the state withholding section is left blank, we will follow state income tax withholding guidelines. You may waive, change, or revoke the income tax withholding elections at any time. Surrender Charge During the surrender charge period, we may assess surrender charges on any automatic RMDs in excess of your penalty-free amount per contract year. The amount of any surrender charges will also reduce the value of your contract, in addition to the reduction in value as a result of the automatic RMD. Refer to your annuity contract for details. Variable Annuity Accounts Automatic RMDs will be withdrawn proportionately from all variable sub-accounts. LP /18 Page 1 of 5

2 Signing Instructions For security purposes, we may request you obtain an original medallion signature guarantee or notary stamp or seal. Medallion Signature Guarantee The medallion signature guarantee, available at most financial institutions, must be in original form a photocopy or faxed copy is not acceptable. A medallion signature guarantee may be requested if: A check is being mailed to a residential address other than your address of record. Owner's name on banking information provided does not identically match the owner s name on contract (e.g. Betty instead of Elizabeth). Attorney-In-Fact Any acting Attorney-in-Fact (AIF) must indicate their capacity as AIF (e.g. John Doe, AIF). We require a copy of the entire power of attorney document, if not previously submitted, and we require a completed Affidavit of Attorney-in-Fact form (available at every two years. Guardian or Conservator Any guardian or conservator for the contract owner must indicate their capacity as guardian or conservator (e.g. John Doe, Guardian, or John Doe, Conservator) and provide a certified copy of the current guardianship or conservatorship documents, if not previously submitted. Fixed Indexed Annuities Only Interest Crediting If you take a withdrawal prior to the end of the Interest Term, we will not credit interest on the funds withdrawn. A withdrawal that causes the contract value to fall below $100,000 may result in lower indexed interest caps and fixed account rates. Please refer to your annuity contract for details. Market Value Adjustment (MVA) If applicable to your contract, we will apply an MVA to amounts withdrawn during the surrender charge period. The MVA can be a positive or negative adjustment. Guaranteed Lifetime Withdrawal Benefit (GLWB) Rider If your RMD is automatically distributed from this annuity contract, we will distribute any amount that exceeds the GLWB maximum interest term withdrawal amount on December 28 each year. If a payment date falls on a non-business day, we will process it on the next business day. Enhanced Death Benefit (EDB) Rider Withdrawals may have an impact on the calculation of the EDB amount and the EDB rollup basis. Please refer to your annuity contract for details. Fixed Indexed Annuity Accounts We will withdraw automatic RMDs proportionately from all fixed indexed annuity accounts. LP /18 Page 2 of 5

3 A. Owner Information Contract number SSN/TIN Date of Birth Owner name Address City State Zip Primary phone number Secondary phone number B. Automatic RMD Please choose one. Start or change automatic RMDs. I would like Symetra to calculate and automatically distribute the RMD each year for this annuity, in the manner provided in this form. (Proceed to sections C G, sign and return form to us.) Stop receiving automatic RMDs. I do not want Symetra to calculate and automatically distribute the RMD each year for this annuity. I understand that Symetra will not distribute the RMD for this annuity without my prior written instruction. (Proceed to section G, sign and return form to us.) C. Automatic RMD Start Date If no option is selected we will use a default date. Begin my RMDs: Month: Day of Month (1-28): Year: 20 FIXED INDEXED ANNUITIES ONLY I have a fixed indexed annuity and would like to maximize my potential index interest. Therefore, distribute the RMD annually at the end of my interest term. (Proceed to sections E G, sign and return form to us.) D. Automatic RMD Frequency Please choose one. If no option is selected we will default to annually. Monthly Quarterly Semi-annually Annually (default) E. Federal/State Withholding Election. Federal Withholding Elect Federal Income Tax Withholding: Withhold at a rate of % (not less than 10%) from each annuity payment. Waive Federal Income Tax Withholding: I elect to waive Federal Income Tax withholding. I understand I am liable for the payment of Federal Income Tax on the amount received. I also understand that I may be subject to Federal Income Tax penalties under the estimated tax payment rules if my payments of the estimated tax and withholding are insufficient. State Withholding Elect State Income Tax withholding? Yes No For tax reporting purposes, my resident state is. Withhold % of my taxable distribution or % of my Federal Income Tax. You will be subject to state income tax withholding if you elect Federal withholding and reside in a mandatory state. For NY only: Enter the whole dollar amount to be withheld from each annuity or pension payment: 1 State Income tax 1 2 New York City income tax (if a New York City resident) 2 3 Yonkers Income tax surcharge (if a Yonkers resident) 3 LP /18 Page 3 of 5

4 F. Automatic RMD Instructions If an option is not selected, we will send automatic RMDs by regular mail to the address of record. Mail a check to my address of record. Mail a check to the alternate address shown below. (Medallion Signature Guarantee may be required, see page 2.) Institution name Address City State Zip Attached is a pre-printed voided check; electronically transfer funds to my bank account. (After payment processes allow an additional 2-3 days for funds to be deposited into your bank account.) Attach Voided Check Here Please do not attach voided check below this line. LP /18 Page 4 of 5

5 G. Authorization, W-9 Certification, and Signature(s) I direct Symetra Life Insurance Company to make distributions from my annuity contract based on the information I have provided. I am aware of the Required Minimum Distribution rules, and I acknowledge that Symetra and its affiliates are not responsible for ensuring that I have complied with these rules. I certify that the above information is accurate, and I will notify Symetra of any changes. I agree to hold harmless Symetra and its affiliates for any claims, expenses or taxes (including penalties and interest) incurred due to distributions made in accordance with this form. Under penalties of perjury, I certify that the number shown on this form is my correct Social Security or Tax Identification Number, I am a U.S. citizen or other U.S. person, and I am not subject to backup withholding due to failure to report all interest or dividends. Check this box if you have received a notification from the IRS that you are subject to backup withholding. Check this box if you are claiming Non-U.S. status and submitting an appropriate withholding certificate (usually a signed IRS Form W-8 or IRS Form 8233) instead of agreeing to this certification. The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Owner s signature Title (if applicable) Date SIGN HERE H. Medallion Signature Guarantee (if required, see page 2.) This must be completed by an authorized officer of an eligible guarantor institution, such as a bank that is a member of the Federal Deposit Insurance Corporation (FDIC), a trust company, or a member of a domestic stock exchange. The guarantee must be in original form; a photocopy or faxed copy is not acceptable. Guarantor signature Place seal or stamp here Date Title / Name of Institution I. Notary Public (if requested, to be completed by a Notary Public.) On this day personally appeared before me the person(s) who executed this instrument, and acknowledged that he/she signed the same as his/her free voluntary act and deed for the uses and purposes therein mentioned. Given under my hand and official seal on the day of,. (month, year) State of County of Place seal or stamp here Notary public signature My appointment expires LP /18 Page 5 of 5 Symetra is a registered service mark of Symetra Life Insurance Company.