Form 3575 - Annuity Service Request Form (Page 2 of 3) in pdf

page 2 of 3

5. CHANGE OF BENEFICIARY:

I/We revoke existing designations and subject to any existing assignment, make the following Beneﬁciary and Contingent Beneﬁciary Designations:

Name of Primary Beneﬁciary:

Name of Contingent Beneﬁciary:

____________________________________________________

_____________________________________________________

SSN

TIN

EIN _____________________________

SSN

TIN

EIN _____________________________

Date of Birth:_________________________________________

Date of Birth:__________________________________________

Relationship to Annuitant:______________________________

Relationship to Annuitant:_______________________________

____________________________________________________

_____________________________________________________

Mailing Address

____________________________________________________

_____________________________________________________

City

State

Zip

City

State

Zip

Designation percentages must total 100%. Complete Additional Beneﬁciary Page (Form 10073 if additional space is needed. Unless otherwise directed, the beneﬁciaries

in a class will share equally.

6. DISTRIBUTION REQUEST: A 10% Pre-Mature Distribution Penalty may be assessed if the owner of this contract is under age 59 1/2.

Please refer to a tax consultant for further information.

PARTIAL WITHDRAWAL

I hereby request a one-time withdrawal for |$ __________________________________ ($250 minimum)

10% FREE WITHDRAWAL

I hereby request a withdrawal of 10% of the annuity value as of the beginning of the contract year.

INTEREST ONLY SYSTEMATIC WITHDRAWALS

I hereby request interest withdrawals from the contract on a systematic basis.

FIXED AMOUNT SYSTEMATIC WITHDRAWALS

I hereby request systematic withdrawals in the amount of |$ ______________________ from the contract on a systematic basis.

CONTRACT SURRENDER

I hereby request a surrender of the entire contract for its full cash surrender value.

If you elected to receive distributions on a systematic basis, please specify the frequency in which the funds should be disbursed.

Monthly

Quarterly

Semiannual

Annual

Date of First Payment _____________________________

A voided check must accompany this form if you have completed a request for a distribution. Distributions will be processed as secure ACH remittances

directly into the account of your choice at your ﬁnancial institution.

7. WITHHOLDING INSTRUCTIONS: Minimum Withholding is 10%

Do not withhold taxes. I understand I am responsible for the payment of estimated taxes and that I may incur penalties if my payments are not enough.

I want to have ________% Federal Income Tax withheld from the taxable amount of the distribution.

I want to have ________% State Income Tax withheld from the taxable amount of the distribution.

Taxpayer Identiﬁcation Number:____________________________________________________

SSN

TIN

EIN

IRS regulations state that if your taxpayer identiﬁcation number (social security or employer identiﬁcation number) is not furnished, we will be required to withhold at the

current applicable withholding rate. Under penalty 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).

2.) I am not subject to backup withholding because:

(a) I am exempt from backup withholding.

(b) I have not been notiﬁed by the IRS that I am subject to backup withholding as a result of failure to report all interest/dividends.

3.) I am a U.S. person (including a U.S. resident alien).

NOTE: You may be subject to penalties under the estimated tax payment rules if enough tax has not been paid through either your estimated tax payment

or withholding.

Form 3575

AMERICAN NATIONAL INSURANCE COMPANY

12-09