Required Minimum Distribution (Rmd) Form Ira Owner/plan Participant Form Page 3
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3REQUIRED MINIMUM DISTRIBUTION (RMD) FORM
IRA OWNER/PLAN PARTICIPANT
INSURER: FIDELITY & GUARANTY LIFE INSURANCE COMPANY
this transaction with my own tax or legal advisor. Neither the Company, nor any of its affiliates, employees or agents, may provide tax or legal
advice, nor have I relied on any of these parties for such advice.
Generally, when calculating the RMD the Company will take into account any withdrawals processed in the current calendar year so that the
6.
amount of the RMD distribution will be net of previous withdrawals, resulting in a total annual distribution of only the RMD amount. The
distributions will be taken proportionately from all your investment options.
When distributions made during the contract year, exceed the greater of the free withdrawal amount or the amount necessary to satisfy the
7.
RMD, for this contract only, then the distribution may be subject to surrender charges and/or market value adjustment (MVA).
I understand that if my annuity product offers a GMWB, guaranteed withdrawal payment, that the GMWB calculation may not satisfy my RMD
8.
for the calendar year.
I have read, understand and made my elections in the Notice and Election of Tax Withholding section or provided Form W-4P and any
9.
applicable State Income Tax Withholding form. You must sign in the Authorization section of this form in order for the withholding elections you
make to be effective. Otherwise the Company will withhold as required by Law)
I certify that my Social Security/Taxpayer identification number on this form is correct, that I am a U.S. person (U.S. citizen or resident alien).
10.
The Internal Revenue Service does not require your consent to any provision of this document other than the certification required to
avoid backup withholding.
I certify that I am not subject to backup withholding due to failure to report interest and dividend income
11.
By not furnishing or not furnishing the correct taxpayer identification number I may be subject to additional IRS penalties imposed by the Internal
12.
Revenue Service for failure to furnish the correct information.
Owners Signature
Date
X
Witness to all signatures
Irrevocable Beneficiary, if any
X
Please return the completed form by mail or fax to:
Mailing Address:
Overnight Deliveries:
Fax:
Fidelity & Guaranty Life Insurance Company
Fidelity & Guaranty Life Insurance Company
1-402-328-2266
PO Box 81497
777 Research Drive
Lincoln, NE 68501
Lincoln, NE 68521
ADMIN 5275 (10-2012)
Rev. 6-2013
Fidelity & Guaranty Life Insurance Company Baltimore, MD
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