Automatic Withdrawal Service Election Form - Lincoln National Life Insurance Company Page 3
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3h $ _______________ OR _____ % Distribution Option
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.
h Remaining Disbursement Option (
) -
if any
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.
SPECIAL INSTRUCTIONS
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
AUTHORIZATION AND SIGNATURES
By signing below, you certify that you:
Understand the withdrawal and surrender process as stated in the contract or prospectus
.
(if applicable)
Authorize the direct deposit of the payment into the account identified on this form. This authorization requires the financial institution
to be a member of the National Automated Clearing House Association
. The company is also authorized to initiate corrections,
(NACHA)
if necessary, to any amounts credited or debited to your account in error. You also agree to hold the company authorized harmless for
the date funds are actually credited to your account by your financial institution.
Understand and assume full responsibility for meeting the Internal Revenue Code requirements to qualify for this distribution. You
further agree to hold the company authorized harmless for any adverse tax ramifications that may arise based on the information
provided on this form.
Understand that in the event the contract value falls below the requested automatic withdrawal amount, your automatic withdrawal
request may be treated as a SURRENDER REQUEST and the company may send all remaining proceeds to you. It will not be treated
as a surrender request if you have a living benefit rider that provides payments after the account value is depleted.
__________________________________________________________________________
______________________________
Contract Owner’s Signature
Date
__________________________________________________________________________
______________________________
Joint Contract Owner’s Signature (if applicable)
Date
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