We, GBU Financial Life (GBU), have received and approved an application for an annuity contract ofthe type indicated above. You may consider this a Letter of Acceptance by GBU. We do hereby agree to serve as the new Custodian/Trustee for the account of the following individual, and as the Custodian/Trustee agree to accept the funds being transferred. make the check payable to: GBU-FBO (owner's name as listed above) and send it to the following addresses only: GBU Financial Life Attention: New Business PO Box Pittsburgh,645949PA15264-5257
Partial Liquidation in the amount of $ . Securities May Require A Medallion Stamp. Money Market Account Liquidate Entire Account (Attach copy of recent statement.)
Signature of Officer Date GBU Financial Life Attention: New Business 4254 Saw Mill Run Blvd. Pittsburgh, PA 15227-3394 mail:
Questions The undersigned hereby requests and directs that the following action be taken in order to transfer the account/policy funds identified above: Certificate of Deposit Liquidate Certificate of Deposit: Upon receipt of this request, I am aware of any penalty that may be imposed from an early withdrawal. Liquidate Certificate of Deposit on the maturity date of Mutual Funds (Signature guarantee is required.) Liquidate Entire Account (Attach copy of recent statement.)
NON-QUALIFIEDTRANSFERPLAN
Owner’sDate Signature (Signature Guarantee is required for mutual fund liquidations, please consult current custodian.)
Completed by GBU Home Office Letter of Acceptance
newbusiness@gbu.org
Owner’s Legal Name (First, Middle Initial, Last) Social Security Number Maturity Date (if applicable)
Overnight
Partial Liquidation in the amount of $ I am aware of any surrender/withdrawal penalties and income tax consequences which may apply to this transaction, and the transfer of the net liquidation proceeds. I am aware that GBU will apply the check on the date GBU receives it to the annuity contract for which I have applied. I understand that the date of receipt will be the date on which annuity coverage first becomes effective. GBU Policy Number Signed at (City, State)
Officer’s Legal Name Title GBU FINANCIAL LIFE PO Box 645949, Pittsburgh, PA 15264-5257 800-765-4428
412-884-5100
GBU-NQT 0422 (Use for Certificate of Deposit, Mutual Funds or Money Market Transfer to GBU) Funds Coming From Financial Institution Address (Street, City, State, Zip) Phone Account/Contract Number
