Varifund Automatic Dollar-Cost Averaging (Dca) Authorization Form Page 2
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2D. Select a Periodic Interval and Start Date
I would like funds transferred: (Check One)
Monthly
Quarterly
Semi-Annually
Annually
I would like the first transfer on _______________________________.
Month/Day/Year
E. Stop Date or Number of Transfers _____________. (If left blank, Dollar Cost Averaging will continue until we receive notification
to stop this program.)
F. To Terminate an Existing Program
I would like to terminate the Program. (Please sign and date form below.)
G. Please Sign and Date Below
I accept the terms and conditions contained in this form. I understand that the Program will be terminated at Annuitization.
X __________________________________________________________________________________________________________
Owner / Trustee
Date
X __________________________________________________________________________________________________________
Joint Owner / Trustee
Date
All other parties holding a legally enforceable interest under the annuity must sign here (i.e. irrevocable beneficiaries, collateral
assignees, security interest holders, court ordered interest holders)
X __________________________________________________________________________________________________________
Holder of Interest (i.e. irrevocable beneficiaries, collateral assignees, court ordered interest holders)
Interest Held
Signed at ______________________________, this ___________, day of _____________________, _______________
(city, state)
(day)
(month)
(year)
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY OF NEW YORK
The principal underwriter is GWFS Equities, Inc., a wholly owned subsidiary of Great-West Life & Annuity Insurance Company and an
affiliate of Great-West Life & Annuity Insurance Company of New York.
Varifund Dollar Cost Averaging Form
Last Updated 01/2016
Page 2 of 2
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