Required Minimum Distribution (Rmd) Form Ira Owner/plan Participant Form Page 2
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3REQUIRED MINIMUM DISTRIBUTION (RMD) FORM
IRA OWNER/PLAN PARTICIPANT
INSURER: FIDELITY & GUARANTY LIFE INSURANCE COMPANY
Tax- If you do not have enough Federal Income Tax withheld from your payments, you may be responsible for the payment of estimated taxes. You
may incur tax penalties if you elect not to have withholding apply and do not pay sufficient taxes.
State Income Tax Withholding – Some states allow us to follow your federal income tax withholding instructions, but others require us to withhold.
In states where withholding is not required or voluntary we do not withhold State Income Taxes. You are required to furnish your states withholding
form where applicable.
Please Check Election
Do not Withhold Federal or State Income Taxes
Withhold State Income Tax ____% or $______________
The percent or dollar amount cannot be less than the minimum required by your state of residence. If you do not enter a percent or dollar amount
we will withhold the required default amount.
This election will remain in effect until you revoke it. If you want to revoke your previously filed exemption from withholding, file a Form W-4P with
the Company and check the appropriate box on the form.
SECTION 5 – PAYMENT INSTRUCTIONS
I hereby authorize Fidelity & Guaranty Life Insurance Company to make all payments due to me under this election by direct deposit to the bank
account designated below. This authorization shall be effective until Fidelity & Guaranty Life Insurance Company receives written notice from me to
the contrary, in a form satisfactory to Fidelity & Guaranty Life Insurance Company.
I elect NOT to receive electronic payments. I am electing to receive payment in the form of a check.
Please attach below a voided check for
Bank Name
Telephone Number
checking accounts or
Deposit slip for savings – Type of account
Joint Owner’s Name (if applicable)
Checking
Bank Account Number
ABA or Bank Routing Number
Savings
PLACE VOIDED CHECK FOR CHECKING ACCOUNT OR
DEPOSIT SLIP FOR SAVINGS ACCOUNT
SECTION 6 – CERTIFICATION & AUTHORIZATION
As owner of the above-referenced policy/contract, I certify that the above information supplied by me is true and
correct to the best of my
1.
knowledge.
I understand that I can terminate this agreement at any time by notifying the company in writing, or submitting a new form.
2.
I certify that I have read and understand all of this form and that I have completed all applicable sections.
3.
The Company will calculate your RMD from this contract in a manner that satisfies IRS Guidelines provided that (1) all information that I provide
4.
is accurate and complete, and (2) I will immediately notify the Company of any changes which affect my calculation.
The Company is furnishing this form and participating in this transaction at my specific request and has made no representation that the above
5.
distribution schedule will fulfill my specific tax obligations. I have been advised by the Company that I should discuss the tax consequences of
ADMIN 5275 (10-2012)
Rev. 6-2013
Fidelity & Guaranty Life Insurance Company Baltimore, MD
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