DOC0106113729 RverSource Lfe Insurance Company 70129 Amerprse Fnancal Center Mnneapols, MN 55474-9900 Annutzaton Request for Death Clams Part 1 Use ths form to annutze a deferred annuty contract due to death. Annuty payments must begn wthn one year of the decedent's date of death. To begn payments, all documents must be receved by RverSource Lfe Insurance Company n good order. You may want to contact a tax professonal to assess your personal stuaton. For all requests read the "Annutzaton Acknowledgements of Understandng", at the end of ths form. The orgnal s for the clent to retan, do not submt to the corporate offce. All RverSource non-qualfed annutes allow for assgnablty and, therefore, are not ntended for medcal assstance plannng purposes. For annutzaton payments, RverSource Lfe does not allow Tax Qualfed to Tax Qualfed transfers. If requested, the automatc default s to send a check to the benefcary at the address of record. Benefcary Informaton Account Number For RverSource annutes held nsde a brokerage account, enter 141 for the admnstraton code. For all other products, enter 004. Benefcary/Annutant Name Trust or Entty Name Benefcary/Annutant Taxpayer ID Benefcary/Annutant Date of Brth (MMDDYYYY) Trust or Entty EIN Part 2 Annutzaton Instructons The frst payment date must be at least 30 days, but no more than 60 days, from the date RverSource Lfe Insurance Company receves proof of death (the date all requrements are receved by RverSource Lfe Insurance Company). If Remanng Beneft Amount Payout Opton s selected n Part 4, the Type of Payout must be 100 fxed wth no annual ncrease. Fxed Index Annutes only (Select one) For fxed ndex annutes, annutzatons can occur at any tme; however, md-term annutzatons wll not receve nterest. Indcate below when you want ths request to process. Important: The frst payment must be wthn one year of the decedent's date of death. Process on next contract annversary (ths form, the death clam statement, and other requred documents must be receved no more than seven calendar days before the contract annversary) Process mmedately Note: You must also complete the Payment Frequency, Payment Date, and Type of Payout below. All Annutes Payment Frequency (Select One) Monthly Quarterly Sem Annually Annually Payment Date (Select One) Earlest possble start date: 30 days from the date all requrements are receved by RverSource Lfe Insurance Company. For fxed ndex annutes, annutes, ths ths 30 s days 30 days from from the the nexnext contract annversary f 'Process on next contract annversary' was selected above. On the day of the month (the 31st s not avalable). The frst payment month wll be determned by the date the request s completed and wll be wthn 30 to 60 days of the date the request s n good order. Sgn on Page(s) 6, 7, 8, 9 Annutzaton Instructons contnued on next page.. 2017-2018 RverSource Lfe Insurance Co. All rghts reserved. 113729 Page 1 of 6
DOC0206113729 Annutzaton Instructons contnued Type of Payout (Select One) 100 Fxed Annuty Payout (From Any Product) (Select One) The value of my annuty s to be appled to provde a 100 fxed payout wth: (Annual ncrease not avalable on IRA or TSA accounts.) No annual ncrease 2 annual ncrease 3 annual ncrease 4 annual ncrease In order to fund the fxed payout, all varable values wll be transferred to the fxed account as of the date we receve your request. Varable or Combnaton Payouts 3.5 Assumed Interest Rate (AIR) 5.0 Assumed Interest Rate (AIR) FOR VARIABLE OR COMBINATION PAYOUTS: You may use up to fve varable funds, plus the Fxed Account. Choose only from the varable fund(s) currently avalable for your contract. Lfe wth cash refund and jont and reduced (annutant death only) optons are not avalable on varable or combnaton payouts. Name of Fund Fxed Account Allocaton Percentages must total 100.00 Part 3 Account Profle Informaton Basc defntons for Investment Tme Frame, Rsk Tolerance, Investment Objectves and Lqudty Needs are provded below. More detaled descrptons and examples of some of the selectons can be found on your Sutablty Confrmaton. Complete the followng account nformaton for each new account. Complete all of the followng nformaton for a new Annuty account. Investment Tme Frame (Select only one) A. Less than 1 Year B. 1-3 Years C. 4-7 Years D. 8-10 Years Rsk Tolerance (Select only one) B. Conservatve/Moderate C. Moderate D. Moderate/Aggressve E. 11+ Years E. Aggressve Lqudty Needs (Select only one) A. Less than 1 Year B. 1-7 Years C. 8+ Years Investment Objectves (Select at least one per order of mportance) 1st 2nd 3rd A. Conservatve A. Captal Preservaton B. Income C. Tax Consderatons D. Protecton E. Educaton F. Estate Plannng G. Speculaton H. Growth I. Growth wth Income "B. Captal Apprecaton" s no longer an opton. Account Profle Informaton contnued on next page.. 113729 Page 2 of 6
Account Profle Informaton contnued Investment Tme Frame Defnton Investment The expected perod of tme you plan to nvest to acheve your current fnancal goal(s). Tme Frame Rsk Tolerance Defntons Conservatve Conservatve / Moderate DOC0306113729 You accept the lowest return potental, lowest return varablty, and the lowest fluctuaton n account value, n exchange for lower rsk. You accept a relatvely low return potental, relatvely low return varablty, and relatvely low fluctuaton n account value, n exchange for a below average amount of rsk. Moderate Moderate / Aggressve You accept an average amount of rsk n exchange for average return potental, average return varablty, and average fluctuaton n account value. You accept an above average amount of rsk n exchange for a relatvely hgh return potental, relatvely hgh return varablty, and relatvely hgh fluctuaton n account value. Aggressve You accept the hghest amount of rsk n exchange for the hghest return potental, the hghest return varablty, and the hghest fluctuaton n account value. Investment Objectve Defntons Captal Preservaton The prmary goal s preservaton of captal over growth or ncome. Income Tax Consderatons Protecton Educaton Estate Plannng Speculaton The prmary goal s ncome provded by the nvestment (e.g., dvdends) rather than potental growth. The prmary goal s nvestments that mtgate federal, state and/or local taxes. The prmary goal s leavng a monetary beneft at death to loved ones or charty. The prmary goal s provdng/payng for educaton related expenses. The prmary goal s transferrng assets to loved ones and/or provdng a legacy at one's death. To take a hgher than average rsk n hopes of makng a hgher than average return. Growth Growth wth Income Lqudty Needs Defnton Lqudty Needs The prmary goal s an ncrease n the captal or market value of the nvestment rather than ncome that may be receved from the nvestment. The prmary goal s to provde both growth and ncome, often by choosng nvestments whch have earnngs growth as well as dvdends. Perod of tme from the present untl you antcpate you may need access to some of the nvestment dollars. Part 4 Settlement Mode Electon Refer to a tax professonal regardng possble tax consequences as a result of ths transacton. For annuty payout optons 1-4 below, documentaton of date of brth s requred for ALL annutants. To submt documentaton of date of brth, attach a photocopy of one of the followng to your request: brth certfcate, drver s lcense, or passport. Unless otherwse specfcally requested, the owner wll be named the annutant for Guaranteed Perod payout optons, unless the owner s not an ndvdual person. For documentaton of date of brth questons, contact 1.800.862.7919. Select one of the 7 annuty payout optons below 1) Sngle Lfe 2) Jont and Full to Survvor (Complete the jont annutant nformaton below) 3) Jont and Two Thrds to Survvor (Complete the jont annutant nformaton below) 4) Jont and One-Half to Survvor (Complete the jont annutant nformaton below) 5) Guaranteed Perod wth years. 5 to 30 years, guaranteed perod cannot exceed lfe expectancy of benefcary/annutant. 6) Lfe Insurance Death Benefts Only - Hold at Interest 7) Remanng Beneft Amount (RBA) Payout Opton* or Prncpal Back Guarantee (PBG)** *The RBA Payout Opton s only avalable on accounts wth the Guaranteed Mnmum Wthdrawal Beneft (GMWB), Enhanced Wthdrawal Beneft (EWB), Guarantor Wthdrawal Beneft for Lfe (GWB for Lfe), SecureSource or SecureSource Flex rder. **The PBG s only avalable on accounts wth the SecureSource Stages, SecureSource Stages 2, SecureSource 3, SecureSource 4, SecureSource 4 Plus, SecureSource Core SM, or SecureSource Core Plus SM beneft. Settlement Mode Electon contnued on next page.. 113729 Page 3 of 6
DOC0406113729 Settlement Mode Electon contnued For annuty payout optons 1-4 above, you must select one of the followng : Lfe Income* Lfe Income wth 5-year guaranteed perod Lfe Income wth 10-year guaranteed perod Lfe Income wth 15-year guaranteed perod Lfe Income wth 20-year guaranteed perod Lfe Income wth Installment Refund (Only avalable wth opton 1 and 2 above) Lfe Income wth Cash Refund (Only avalable for 100 Fxed Annutzatons that choose opton 1 or 2 above) *There wll be no death beneft pad to any her or estate, ether lump sum or perodc nstallment, under the Lfe Income payout opton. The guaranteed perod cannot exceed lfe expectancy of benefcary/annutant. For annuty payout optons 2-4 above, you must complete the jont annutant nformaton below: Date of Brth Socal Securty Jont Annutant Name (MMDDYYYY) Number Clent ID For annuty payout optons 3-4 above, you must select one of the followng: Annuty payment reduces at the death of ether the Annutant or Jont Annutant. Annuty payment reduces at the death of the Annutant (shown n Part 1). Payment does not reduce at the death of the Jont Annutant named above. (Not avalable for contracts that choose a varable annutzaton * ) Optng out of the commutablty or payment acceleraton feature s an rrevocable decson and cannot be reversed or modfed. Do you wsh to opt out of the commutaton feature of your contract (f avalable)? If left blank, you attest to acceptng the commutaton feature. Do you wsh to opt out of the payment acceleraton feature of your contract (f avalable)? If left blank, you attest to acceptng the payment acceleraton feature. Explanaton and Purpose of Electon (Check all that apply) Retrement Income Tax Plannng Partal Wthdrawals Dsclosed Gftng Mnmum Dstrbuton Requrements Other; please explan (Tax Qualfed accounts only) Annuty Illustraton Provded? Yes No If yes, submt a copy of the llustraton Payment Amount Quoted $ (Actual payment may vary. Quotes are not guaranteed; used for llustraton purpose only) Yes Yes No No Part 5 Payment Arrangements Checks and bank deposts wll be avalable approxmately seven days from the payment date. For outgong ACHs on varable payouts, the frst payment wll be sent by check and all subsequent payments wll be sent by ACH. Select one opton Outgong ACH to Your Bank. (Complete Part 6 Bank Detals) Transfer to Amerprse Fnancal account number Mal check to Address of Record Mal check to alternate Payee or Address lsted below Make check payable to: Note: The frst payment wll be check maled to your address of record. * Transfer must be to a non-qualfed account only. Mal check to: Address Cty State ZIP code 113729 Page 4 of 6
DOC0506113729 Part 6 Bank Detals Provde fnancal nsttuton account nformaton and type. Money Market accounts may ether be checkng or savngs. Check wth your fnancal nsttuton. ACH to exstng bank If ths bank nstructon s not already authorzed for use, addtonal steps must be taken. Benefcares: Go to the Secure Ste on amerprse.com to authorze the use of the bank nstructon or contact the servce center for the Add Bank Instructons form. Advsors: Go to the Money Movement System to authorze the bank nstructon. The bank account must be authorzed and approved pror to submttng ths request. If we receve ths form pror to the bank beng authorzed, the wthdrawal request wll be consdered not n good order and rejected. To request a wthdrawal whle a bank authorzaton s pendng, please consder requestng a check to the address of record. Bank account type (Select one) Checkng Savngs Provde Name, Routng Number and Bank Account Number of the exstng bank to receve ACH payments Name of Fnancal Insttuton Bank Routng Number / RTN (Always 9 dgts n length) Bank Account Number RTNs must start wth 0, 1, 2, or 3. Part 7 Tax Wthholdng Federal Wthholdng: You are lable for federal ncome tax on the taxable porton of your dstrbuton. If total wthholdng s not adequate, you may be subject to estmated tax payments and/or penaltes. State Wthholdng: Wthholdng rules vary by state. Clents may have the opton to: (1) opt-out of wthholdng, (2) elect default state tax wthholdng, or (3) ncrease the rate of wthholdng. Dependng on the state, state tax wthholdng could be mandatory, optonal, unavalable, or the clent may need to complete a state-specfc form. For state tax wthholdng rules, go to rversource.com/statetax. Connectcut resdents only: Complete the most current verson of Form CT-W4P located on Connectcut's Offcal State Webste (ct.gov) to determne the amount that s requred to be wthheld for state taxes. If ths form s not receved pror to your frst payment, Connectcut requres that we wthhold at the hghest rate for state taxes from the taxable porton of each annuty payment. Please note that taxes wthheld per your electons or n accordance wth state rules wll not be refunded. For all tax-qualfed annutes: Wthholdng s taken from the total amount dstrbuted. For non-qualfed annutes: Wthholdng s taken from the taxable amount dstrbuted. Dfferent wthholdng rules apply n certan stuatons: If we do not have a vald Taxpayer Identfcaton Number on the account, f the payment s delvered outsde the Unted States or f you are a non-resdent alen. Please consult your tax professonal for addtonal nformaton regardng federal and/or state wthholdng. Federal Wthholdng Federal ncome tax wll be wthheld from the taxable amount dstrbuted based on the wage tables for a marred ndvdual wth three exemptons unless you make a dfferent wthholdng electon below (certan exceptons apply). Select One Do NOT have federal ncome tax wthheld from my payments. Wthhold $ Wthhold from each payment. of each payment (fxed payouts only). Have federal tax wthheld from my payments calculated usng the number of exemptons and martal status entered below: Number of exemptons Martal Status Marred Sngle If ths calculaton ndcates no wthholdng, please wthhold $ or per payment State Wthholdng If you do not ndcate an electon, we wll generally follow your choce for federal electon unless your state does not allow. No state tax wthholdng wll be taken for states where wthholdng s not avalable. The taxpayer's resdent state on fle s the state we use for state tax wthholdng. Do not wthhold state tax Wthhold default state tax Wthhold $ Wthhold 113729 Page 5 of 6
DOC0606113729 Part 8 Sgnatures (For Nonqualfed and IRA annutes) If an outgong ACH payment arrangement was selected, I (we) release RverSource Lfe Insurance Company and agree to hold t harmless from all lablty for or n connecton wth payments pad through the Automated Clearng House or any smlar system to credt payments to the bank shown above. Ths agreement also shall be bndng to my (our) personal representatves, hers, legatees and assgnees. For RAVA 5 annutes sold on or after Aprl 29, 2013: If you choose a varable annutzaton n the frst ten years of your contract, your Mortalty & Expense fee wll not decrease on the tenth contract annversary. For fxed ndex annutes, any money wthdrawn from an ndexed account before ts maturty date wll not receve nterest. Ths ncludes Requred Mnmum Dstrbutons, death clams, and annutzatons. My sgnature below certfes that I have receved, read and understand the 'Annutzaton Acknowledgements of Understandng', and that the acknowledgement statements contaned theren are accurate. I affrm that the nformaton provded n ths request form s truthful and correct as appled to me and may be ncluded n any requred reports to tax or regulatory authortes. I understand that n order to annutze my qualfed plan annuty contract I must frst drectly roll over the contract to an IRA. I understand that any annuty payments ssued after my death, but not due to me or my estate, wll be subject to rembursement from my estate. In certan crcumstances, we may contact you n an effort to valdate the request before the transacton can be processed. Benefcary Name Benefcary Sgnature X If sgnng as a Fducary, n what capacty are you actng? Power of Attorney Conservator/Guardan Date (MMDDYYYY) Advsor's Report Other I have explaned the varous settlement modes and the other dstrbuton optons to the clent and have told the clent to consult a tax advsor. To the best of my knowledge and belef, the clent understands the electons made on ths settlement form. I beleve the electon of the settlement opton under the clent's annuty to be sutable. Servcng Advsor Informaton Name Advsor ID Advsor Sgnature Date (MMDDYYYY) X Team ID Comp Phone Number Ext Area Offce Number Co-Advsor Informaton Name Advsor ID Advsor Sgnature Date (MMDDYYYY) X Team ID Comp Phone Number Ext Area Offce Number 113729 Page 6 of 6
Annutzaton Acknowledgements of Understandng Gve to clent, do not submt to corporate offce. All Annutes The varous settlement modes and other dstrbutons avalable to me are governed by the terms of my contract. The electon of a settlement s fnal upon recept of the request form n the corporate offce and the settlement mode cannot be changed or reversed after that date. Certan settlement mode electons for my annuty payments may mpact my ablty to obtan medcal assstance n the future or mpact your personal tax stuaton. I understand that I should consult my professonal tax and legal advsor(s) to consder all relevant fnancal nformaton before makng any decsons regardng ths dstrbuton method. There wll be no death beneft pad to any her or my estate, ether lump sum or perodc nstallment, under the Lfe Income Non-Refund payout mode. I understand that nether I, nor my benefcary can surrender or wthdraw n full or n part any porton of the contracts guaranteed payments once the contract s n payout, unless I have the commutablty feature approved by my state. If payments to my benefcary are under $20.00 per payment and the total of remanng guaranteed payments s $1,000.00 or less, we wll send your benefcary a lump sum check. Upon recept of my request and acceptance by RverSource Lfe Insurance Company, I wll receve confrmaton of the terms of my annutzaton plan. 100 Fxed Annutes - Apples to All Annutes The Installment Refund opton provdes guaranteed payments for a specfed perod of tme. When no annual ncrease s selected, the number of guaranteed payments s determned by dvdng the nvestment amount by the frst payment amount. For Installment Refunds wth an annual ncrease, the number of guaranteed payments s determned to reflect the annual ncrease percentage selected. The Cash Refund opton provdes a death beneft equal to the amount appled to the settlement, less any payments already made. If the total payments (ncludng any non-dscounted commutaton amounts) exceed the amount appled to the settlement, the death beneft wll be zero. The clent can opt out of commutaton at ssue or after ssue. Once a clent opts out of commutaton t s rrevocable and apples to all subsequent owners/benefcares. Payment acceleraton may be avalable for monthly, fxed annuty payment plans. A $20 admnstratve fee wll apply. Informaton wll be provded wth your confrmaton letter. After a watng perod, Payment Acceleraton provdes the ablty to receve a lump sum for a specfc 6 months annuty payments n advance. It s avalable on monthly payouts and on guaranteed payments only. Ths opton may be used 2 tmes through the guaranteed payout perod. Partal or full commutaton may be avalable. Informaton wll be provded wth your confrmaton letter. After a watng perod, Partal Commutatons wll receve a percentage of the present value of the remanng guaranteed payments n a lump sum, less any applcable surrender charge. The remanng guaranteed payments wll be reduced through the end of the guaranteed perod. Ths opton may be used 2 tmes through the guaranteed payout perod. After a watng perod, Full Commutatons wll receve the present value of the remanng guaranteed payments n a lump sum, less any applcable surrender charge. If a lfe contngent settlement opton s selected, payments wll resume at the end of the guarantee perod, f the annutant s stll lvng. Ths opton may only be used once durng the guaranteed payout perod. The Cash Refund opton provdes a lump sum death beneft, whch s equal to the amount appled to your settlement, less any/all payments already made. If the payments exceed the amount appled to your settlement, the death beneft wll be zero. Combnaton Varable/Fxed Allocatons - Apples to All Annutes The annutzaton value and future payments wll be valued seven days pror to the payment date. When allocated to a varable account, my annuty payment amounts wll vary, and can go both up and down based on the nvestment experence of the varable account(s) to whch my annuty s allocated. I understand the net nvestment experence for the account(s) must equal or exceed the A.I.R. (Assumed Interest Rate) that I have selected n order for my payment to not decrease. If my annuty has more than one varable account and I have allocated some porton to at least one account, I may reallocate values once per contract year among the other varable accounts, but I cannot change to or from the Fxed Account. Term certan annuty payout plans that contan a varable allocaton, may be fully surrendered for a lump sum of the commuted value of any remanng guaranteed payments. A dscount rate wll be used to calculate the commuted value. A commute s not avalable f the account s beng annutzed due to a Pre-Electon of Death Beneft benefcary desgnaton. The Installment Refund opton provdes guaranteed payments for a specfed perod of tme, determned by dvdng the nvestment amount by the frst payment amount. Wth a varable payout allocaton, total payments wth ths mode may be more or less than the total amount nvested. 113729