Issuu

NameofReceivingCompany

ThisformcanbeusedtoaccomplishaFULLoraPARTIALExchangeofpoliciespursuanttoInternalRevenueCode(IRC)Section 1035.ThisformcanalsobeusedforTransfersofFundsandDirectRollovers.Completetherequestedinformationconcerning theexistingpolicyandcontract,checktheappropriateboxes,anddateandsignthisform.Refertotheapplication,andifapplicable, prospectusandanystaterequiredformsforadditionalimportantdisclosuresandinformation.Checkwithboththereceivingand surrenderingcompanyforformrequirementsspecifictothetransactionthatisbeinginitiated.

Ifyouareconsideringareplacementyouhavetherighttoreceiveinformationregardingyourexistingpolicyorcontractvalues including,ifavailable,aninforceillustration,policysummary,premiumpaymentamountsortheproductprospectus.Ifthe informationisrequestedyourexistingcompanywillreturntherequestedinformationtoyouwithinfivebusinessdays.Contactyour existingcarrierforadditionalinformation.

Completeoneformforeachsurrenderingcompanyandcontract.Pleaseapplyfundsto:

New/ExistingContractNumber:

Withoutthiscontractnumber,thefundswillbeappliedtoanewcontract.

Thereceivingcompanymaynotaccepttheexchange/rollover/transferifthefundsdonotmeetitsminimumpremiumrequirements.

1.SURRENDERINGCOMPANYPOLICY/ACCOUNT/CONTRACTINFORMATION

SurrenderingCompanyName(Completeoneformforeachsurrenderingcompany)

StreetAddressLine1

AddressLine2

FaxNumber

Pleaseconfirmtheavailabilityoftheseoptionswithboththesurrenderingandreceivingcompany.Notallreceivingcompanies providelifeinsuranceproducts.

FullExchange

IfpurchasingaLifeInsurancepolicy,selectanyofthefollowingthatapply:

LoanCarryForward(Notavailableforannuities)SpecifyLoanAmount:$

ModifiedEndowmentContract(MEC)

PartialExchange(ApplicabletoAnnuityContractsOnly)

Iwishtorequestapartial1035Exchangefromtheaforementionedannuitycontractintheamountof:

% or $

PenaltyFreeAmount

SeePage3,Section4V.

(Thisamountissubjecttochangebasedontheproductprovisions.Pleasecheckwiththesurrenderingcompanytoverifytheamount)

CertificateofDeposit(CD)

InvestmentDescription:

Iwishtoliquidateandtransfer:

Fund/AccountNumber: directlytothereceivingcompany.Specifyfundstoliquidate.

I.Transferredfrom:

BeneficialIRASpecifyType:

401(a)

Other: RothIRAfundscanbetransferredonlytoanotherRothIRA.

%oftheabovereferencedaccount

401(k)DesignatedRothAccount

*AllexistingTSAloansmustbereconciledwithyourcurrentcarrierpriortothetransfer. TSA/403(b)*

Pleaseconfirmthatthereceivingcompanywillacceptatransfer/exchangeoffundsintoaTSA/403(b).

Ifthereceivingcompanywillprocessatransfer/exchangeoffundsintoaTSA/403(b),theTSA/403(b)owner/participant'semployeroremployer's third-partyadministratormustauthorizeandsignthistransferrequestinSection6.

AuthorizationforaTSA/403(b)transfer/exchangetoaTSA/403(b):

Thisrequestisforthedirecttransfer/exchangeofnon-ERISAfundsfromtheTSA/403(b)(annuitycontract)or403(b)(7)(custodialaccount) identifiedinSection1ofthisformtoaTSA/403(b)(annuitycontract)establishedonmybehalfbythereceivingcompany.Iherebyagreeto surrendermyinterestasindicatedaboveandauthorizethereceivingcompanytotakewhateveractionnecessarytoeffectthistransfer/ exchange.Iacknowledgethatthetransferred/exchangedfundsshallbesubjecttothemorestringentrestrictionsondistributionsfoundineither thepredecessorannuitycontractorthereceivingannuitycontract.Iintendthistransactiontobea403(b)transfer/exchangeoffundspursuant toIRCsection403(b)andthefinalregulations.Thetransfer/exchangeistobeexecutedfromfinancialinstitutiontofinancialinstitutioninsucha mannerthatitwillnotplacemeinactualorconstructivereceiptofalloranypartofthetransferred/exchangedfunds.Becausethistransaction constitutesadirectrollover/transfer/exchangeoffundsandnotadistribution,withholdingdoesnotapply.(Providethereceivingcompanywith anyrecordsordocumentstheymayrequestwithrespecttothistransfer/exchange.)

II.CompleteforallTransfers:

Note:Employer/ThirdPartyAdministratormustacknowledgebysigninginSection6.

Iwishtoliquidateandtransferfrommypresentqualifiedaccounttothecontract/policyIhaveestablishedthroughthereceivingcompany: EntireValueor PartialValue,intheamountof:$ or %,or

PenaltyFreeAmount

(Thisamountissubjecttochangebasedontheproductprovisions. Pleasecheckwiththesurrenderingcompanytoverifytheamount)

3.SPECIALINSTRUCTIONSFORLIQUIDATINGEXISTINGCONTRACTORACCOUNT

Byexecutingthisform,Iauthorizethefullorpartialliquidationofmyexistingcontractoraccountinaccordancewiththesectionscompletedabove.I understandthatfeesandchargesmayapplyifthetransferisprocessedbeforethematuritydate.Iherebyinstructthepartiestoprocessthat liquidation:

Assoonaspossibleafterreceiptofallnecessaryforms

Onaspecificdate:

AtMaturityDate:

I/Wealsounderstanditismy/ourresponsibilitytoconfirmwiththesurrenderingcompanytheirprocessingguidelinestoselectingaspecific transferdate.

I.Ifullyassignandtransferallclaims,options,privileges,rights,titleandinteresttoeitherallofthelifeinsurancepolicy,alloftheannuitycontract orpartoftheannuitycontractvalueidentifiedintheContractInformationsectiononpage1tothereceivingcompany.Thesolepurposeofthis assignmentistoeffectatax-freeexchangeunderSection1035(a)oftheInternalRevenueCode.Allofthepowers,elections,appointments, optionsandrightsIhaveasownerofthecontract,includingtherighttosurrender,arenowexercisablebythereceivingcompany. Simultaneouswithafullassignment,IalsorevokeallexistingbeneficiarydesignationsundertheAssignedPolicy.Otherthantheabove mentionedowner,noperson,firm,orcorporationotherthanmyselfandtheinsurerthatissuedtheabovenumberedpolicy,hasaninterestin saidpolicy.Noproceedingsininsolvencyorbankruptcyhavebeeninstitutedbyoragainstme.Iunderstandthatthereceivingcompany intendstosurrenderthecontractforthecashvalue;orifthisisapartialexchange,theportionassigned,subjecttoitstermsandconditions, andtousetheproceedsasthepurchasepaymentforthenewcontracttobeissuedbythereceivingcompany.Iauthorizethesurrendering companytosendtheproceedsdirectlytothereceivingcompanyandunderstandthatfeesandsurrenderchargesmayapply.Thisexchangeis subjecttoacceptancebythereceivingcompany.Neitherthereceivingcompanynorthesurrenderingcompanyisliableorresponsiblefor changesinmarketvaluethatmayoccurafterthesurrenderingcompanyhasprocessedthetransactionandbeforetheproceedsarereceived bythereceivingcompanyingoodorderandallocatedtothenewcontract.Priortothedateofreceiptoftheproceedsbythereceiving company,novaluewillaccrueorbeearnedonthereceivingcompanycontract.

II.Ifthisisapartialexchange,IunderstandthatitissubjecttoRevenueRuling2003-76,whichdictateshowmuchoftheoriginalcontract'scost basismustbeallocatedtothenewcontract.Thecostbasisshouldbeallocatedratablybetweenthetwocontractsbasedonthepercentageof thevalueretainedintheoriginalcontractandthepercentageofthevaluetransferredtothenewcontract.Forexample,ifthecontractvalueis $100,000andbasisis$50,000,andIassign30%forapartialexchange,then$15,000(30%of$50,000)ofthebasiswouldbeappliedtothe newcontract.IunderstandthattheIRShasraisedconcernsaboutannuitycontractownersusingpartialexchangestoavoidincometax,andI certifythatIamnotenteringintothistransactionforthepurposeofreducingoravoidingincometaxorthe10%penaltytaxforearlywithdrawals.

Iexpresslyrepresentthatthesolepurposeistoaffectapartial1035exchangeofanannuitycontract.However,IacknowledgethatRevenue Procedure2011-38statesthatwithdrawalsfromannuitization,taxableownerorannuitantchanges,orsurrenders,otherthananamount receivedasanannuityforaperiodof10yearsormoreorduringoneormorelives,ofeithertheoriginalcontractorthenewcontractduringthe 180dayperiodfollowingthepartialexchange,mayaffectthetaxfreestatusofthepartialexchange.

Note:Otherexceptionsmayapplyandasubsequentdirecttransferofalloraportionofeithercontractinvolvedintheexchangecouldhavetax andtaxreportingconsequences.Pleaseconsultyourtaxadvisor.Pleaseconfirmwiththecarrieriftheywillsupportpartial1035exchanges. Iacknowledgethatthereceivingcompanyhasmadenorepresentationsconcerninganytaxtreatmentofthistransaction.Iunderstandthatthe receivingcompanyhasneitherresponsibilitynorliabilityforthevalidityofthistransactionorformytreatmentunderSection1035(a)ofthe InternalRevenueCodeorotherwise.Therefore,Iagreetoreleaseandholdharmlessthereceivingcompanyanditsagentsfromanyandall liabilityarisingfrom,relatingto,orinconnectionwith,thetaxationofapartialexchangeoftheabovelistedcontract.Iauthorizethereceiving companyandthesurrenderinginstitutiontoshareinformationnecessarytomaintainaccuraterecordsoftheannuitycostbasisandtoensure properwithholdingandtaxreporting.Ihavebeendirectedtoconsultmytaxorlegaladvisorbeforeproceeding.

III.Iauthorizethereceivingcompanytorelyuponthecostbasisinformationprovidedbythesurrenderingcompany,butagreethatthereceiving companywillassumenoresponsibilityfordeterminingorverifyingcostbasis.Ifcostbasisisnotprovided,Iacknowledgethatmorerestrictiveor lessbeneficialtaxrulesmayapplytotheamountstransferred.Iacknowledgethatthereceivingcompanyprovidesthisformandparticipatesin thistransactionasanaccommodationtome.Thereceivingcompanydoesnotgivetaxorlegaladviceonthetaxconsequencesforreplacing onecontractforanother,andassumesnoresponsibilityorliabilityforthevalidityofthisassignmentorforthetaxtreatmentofthisexchange underIRCSection1035(a)orotherlawsorregulations.

IV.Iagreethatifthereceivingcompany,initssolediscretion,determinesthatitisunlikelytoreceivetimelypaymentofthefullcontractcash surrendervalues,thereceivingcompanymayreassignownershipofthepolicy/contractbacktome.

V.LOANCARRYFORWARD-IFTHEBOXINSECTION2A.ISNOTCHECKED,THERECEIVINGCOMPANYWILLASSUMETHATTHE LOAN(S)IS/ARENOTTOBECARRIEDFORWARD.Ifthisboxischecked,Irequestthatthepolicytobeissuedbythereceivingcompanybe subjecttoindebtednessequaltotheloanontheexistingpolicy.Iacknowledgethatwhenissued,theprovisionsofthereceivingcompanypolicy willapplytotheindebtednessandthatthebenefitsandvaluesofthatpolicywillbereducedaccordinglyfortheamountloanedandinterest.I understandthatthereceivingcompanymaynotprocessthisrequestpriortoissuingapolicyunderthefollowingconditions:Surrendervalueis insufficientasdeterminedbythereceivingcompanypolicy'sspecificationsortheexistinginsurerdoesnotprovideconfirmationofcostbasiswith acknowledgementofloancarriedforward.

VI.RETURNOFLIFEINSURANCEPOLICYORANNUITYCONTRACT-Doesnotapplytopartial1035exchangesonannuitycontracts.Unless

thesurrenderingcompany'spolicyorcontractisattached,Iaffirmthatthepolicyorcontracthasbeendestroyedorlostandthatreasonable efforthasbeenmadetolocateit.Tothebestofmyknowledgenooneelsehasanyright,titleorinterestinthecontract,norhasitbeen assigned,pledgedorencumbered,unlessthisisalifeinsurancepolicywithaloantocarryforward.

VII.MAXIMUMISSUEAGEDISCLOSURE-Anannuitycontractmaynotbeissuedshouldthefundingrequirementsbereceivedafterreaching maximumissueagefortheannuitycontractappliedfor.Ifthefundsarereceivedafterthemaximumissueage,thecontractmayberejected andthefundsreturnedtotheiroriginalsource.Thesurrenderingcompanymayormaynottakethefundsback,whichcouldresultinataxable event.

VIII.

NON-QUALIFIEDTRANSFEROFFUNDS(NON1035EXCHANGE)-Thereceivingcompanywillapplyallsuchfundsreceivedtoanannuity

contractissuedtome.IunderstandthatthereceivingcompanyassumesnoresponsibilityfortaxtreatmentofthismatterandIshallbe responsibleforpaymentofallfederal,stateandlocaltaxesincurredwithrespecttotheliquidationofsuchaccount.Iacknowledgethatthe earningscreditedundertheannuitycontractwillbegintoaccruewhenthereceivingcompanyreceivestheseproceedsandallothernecessary paperworkingoodorder.Forindexannuities,fixedaccountinterestundertheannuitycontractwillbegintoaccrueonthenextIssueDay.

IX.TheIRShasprovidedlimitedguidanceonthetaxconsequencesoftransferringalifeinsurancepolicywithvalueslessthantheinvestmentinthe contracttoaneworexistingannuitycontract.Iftheownersurrendersthenewlyacquiredannuitycontract,it’snotclearwhethertheannuity lossesarefullydeductibleagainstordinaryincomeordeductibleasamiscellaneousdeductionsubjecttoalimitationof2%ofadjustedgross income(AGI).IftheIRSviewsthetwotransactionsasasingleintegratedtransaction,theycouldconsideritasteptransactionandsuccessfully disallowthelossesasataxdeduction.

5.TAXPAYERIDENTIFICATIONNUMBERCERTIFICATION

Underpenaltiesofperjury,Icertifythat:

Thenumberonthisformismycorrecttaxpayeridentificationnumber(orIamwaitingforanumbertobeissuedtome);and1.

2. IamaU.S.person(includingaU.S.residentalien).3.

Iamnotsubjecttobackupwithholdingbecause:(a)Iamexemptfrombackupwithholding,or(b)Ihavenotbeennotifiedbythe InternalRevenueService(IRS)thatIamsubjecttobackupwithholdingasaresultoffailuretoreportallinterestordividends,or(c) theIRShasnotifiedmethatIamnolongersubjecttobackupwithholding;and

CheckthisboxifyouhavebeennotifiedbytheIRSthatyouarecurrentlysubjecttobackupwithholdingbecauseyouhavefailed toreportallinterestanddividendsonyourtaxreturn.

4.IamexemptfromForeignAccountTaxComplianceAct(FATCA)reporting.

6.SIGNATURES

Thistransferrequestalsoauthorizesthereceivingandsurrenderingcompanytorequestinformationonthestatusofthistransferorexchangeby phoneorinwriting.Bysigningbelow,Irepresentthattheresponseshereinare,tothebestofmyknowledge,accurateandIhavereadthe DISCLOSURES/ACKNOWLEDGMENTSsectiononpage3theACORD1035Exchange/Rollover/TransferForm.

TheInternalRevenueServicedoesnotrequireyourconsenttoanyprovisionsofthisdocumentotherthanthecertificationsrequiredto avoidbackupwithholding.

ForyourprotectionCalifornialawrequiresthefollowingtoappearonthisform:Anypersonwhoknowinglypresentsfalseorfraudulent informationtoobtainoramendinsurancecoverageortomakeaclaimforthepaymentofalossisguiltyofacrimeandmaybesubjectto finesandconfinementinstateprison.

SignatureGuarantee(ifapplicable)

SignatureofOwner/PlanAdministrator/Trustee/Custodian

SignatureofJointOwner/Co-Trustee

SignatureofInsured/Annuitant(ifapplicable)

SignatureofSpouse(RequiredinAZ,CA,ID,LA,NV,NM,TX,WAandWIonly)

SignatureofIrrevocableBeneficiary(ifapplicable)

Date(mm/dd/yyyy)

FORTSA/403(b)TOTSA/403(b)TRANSFERS/EXCHANGESONLY-EMPLOYER/THIRDPARTYADMINISTRATORSIGNATURE

Bysigningbelow,IamacknowledgingthatIhavereviewedthisdirecttransfer/rollover/exchangerequestandthatitisauthorizedandapproved undertheemployer's403(b)planunderIRCsection403(b)andthefinalregulations.

a)Iamauthorizingthistransfer/rolloverrequest.

b)IamconfirmingthatthereisaninformationsharingagreementinplacewiththereceivingcompanyundertheIRCsection403(b)regulations.

c)Allinformationprovidedonthisformisaccurate.

PrintNameofEmployerorThirdPartyAdministrator

SignatureofEmployerorThird PartyAdministrator

TitleofEmployerorThirdPartyAdministrator

Date(mm/dd/yyyy)

Bysignatureofanauthorizedofficerbelow,thereceivingcompanyacceptsassignmentofall(oraportionoftheassetsifthisisapartialexchange) totheabovecontractforpurposesofcomplyingwiththeclient'sintentionofeffectinganontaxableexchangeunderIRCSection1035.Pleaseissue apaymentpayabletothereceivingcompany,theownerofthecontract,forthefullcashsurrendervalueofthecontractoraportionifitisapartial surrender.