Automatic Withdrawal Service Election Form - Lincoln National Life Insurance Company Page 2
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3PAYMENT FREQUENCY
Requested start date
_______________________________
(month/year)
If requested start date is not marked, withdrawals will begin on the next available start date following receipt of this form.
h Monthly
h Quarterly
h Semi-annually
h Annually
Payment frequency:
If frequency has not been marked it will be set for Annually.
h 5
th
h 10
th
h 20
th
Date of withdrawal (Allow 3-5 days from withdrawal date for receipt of funds)
If date is not marked it will be set for the 20
th
.
Note: Please use Form 28840 for establishing substantially equal periodic payments and Form 27742 for establishing required minimum distribution payments.
FEDERAL/STATE INCOME TAX WITHHOLDING
If tax information is not provided, federal income tax in the amount of 10% and applicable state tax will be withheld.
Tax will be withheld as indicated below. You may change your election at any time. If you elect not to have tax withheld, you may still
be liable for payment of federal and state income tax, if applicable, on the taxable portion of each distribution. You may also be subject
to tax penalties under the estimated tax payment rules if your payment of estimated tax and withholding, if any, are not adequate. You
may wish to discuss your withholding election with a qualified tax advisor.
Federal Tax Withholding Options:
(select one)
h Do not withhold federal income tax
h Withhold 10% federal income tax
h Indicate the total percentage of federal income tax to be withheld, _______ %
(The amount must be greater than 10%.)
State Tax Withholding Information:
If you are a resident of California or Oregon and federal tax is withheld, state tax will be withheld unless you opt out below. If federal
tax is not withheld, state tax is not required to be withheld unless requested.
If you are resident of California or Vermont and elect federal and state tax withholding, the state tax will be a percentage of the federal
amount withheld as your state requires.
If you are a resident of Delaware or Kansas and federal tax is withheld, state tax must also be withheld. If federal tax is voluntarily
withheld or not withheld, state tax withholding is not required unless requested.
If you are a resident of Iowa, Maine, Massachusetts, Nebraska, or Virginia and federal tax is withheld, state tax must be withheld. If
federal tax is not withheld, state tax is not required withheld unless requested.
If you are a resident of Arkansas, North Carolina, Oklahoma, or Vermont and federal tax is required to be withheld, state tax must
also be withheld. If federal tax is voluntarily withheld, state tax will be withheld unless you opt out.
Special preference on state tax:
State of Residence ____________________________________________________
h Voluntary Tax Amount $ ________________ OR ______%
h OPT OUT
Note: The dollar amount or percentage withheld must meet the minimum withholding guidelines for your state. (If no dollar amount or percentage is
provided, we will withhold the minimum required by your state. If no withholding is required, no state tax will be withheld.)
DISBURSEMENT METHOD - You must complete this section in order to receive your distribution and avoid processing delays.
All distributions through this service will be deposited directly into your account at your financial institution. Distributions on
Custodial contracts must be sent to the Custodian.
h $ _______________ OR _____ % Distribution Option
(If not otherwise indicated, payment will default to 100% to the first listed Financial Institution)
Financial Institution’s Name ____________________________________ Telephone Number _____________________________
h Payee Name
________________________________________________________
(check box if same as owner, complete otherwise)
h Payee Address
_______________________________________________________
(check box if same as owner, complete otherwise)
_______________________________________________________________________________________________________
h Checking
h Savings
Type of Account:
(must attach a “voided” check)
Account Number ___________________________________________________________________________________________
ABA/Transit Routing Number ________________________________________________________________________________
Note: The ABA/Transit Routing Number should be obtained from the Financial Institution.
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