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Form Dc-2084-0313 - Form Group Tax Deferred Annuity Financial Hardship Request Instructions Page 4

CERTIFICATION

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number

to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have

not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of

a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to back-

up withholding, and

3. I am a U.S. citizen or other U.S. person.

ALL INFORMATION MUST BE COMPLETED AND DOCUMENTS MUST BE ATTACHED IN ORDER FOR

THIS FINANCIAL HARDSHIP APPLICATION REQUEST TO BE PROCESSED.

I hereby certify that the statements and figures shown on the Financial Hardship Application and Financial

Hardship Statement are true and accurate to the best of my knowledge.The Internal Revenue Service does

not require your consent to any provision of this document other than the certifications required to

avoid backup withholding.

Signature: _____________________________________________________

Date: _________________

Service Provider (NRS): __________________________________________

Date: _________________

DC-2084-0313

Form Dc-2084-0313 - Form Group Tax Deferred Annuity Financial Hardship Request Instructions Page 4