Form 3575 - Annuity Service Request Form Page 3
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8. SIGNATURES:
The policyowner must sign this form. For ownership changes, the present policyowner and new policyowner must sign this form. When a change of ownership or ben-
eficiary is occurring in a community property state, the spouse must also sign this form. Community property states are Arizona, California, Idaho, Louisiana, Nevada,
New Mexico, Texas, Washington and Wisconsin. The effective date of this request will be the date received in the Administrative Office of American National Insurance
Company.
Current Owner Signature - Required
Date of Signature
Phone Number
Joint Owner Signature - if applicable
Date of Signature
Spousal Signature - if applicable
Date of Signature
New Owner Signature - if applicable
Date of Signature
New Joint Owner Signature - if applicable
Date of Signature
Witness Signature
Date of Signature
FOR HOME OFFICE USE ONLY
AMERICAN NATIONAL INSURANCE COMPANY HAS RECORDED THE CHANGE REQUESTED
DATED ON ________________________________________ BY __________________________________
EFFECTIVE DATE
REGISTRAR
Form 3575
AMERICAN NATIONAL INSURANCE COMPANY
AMERICAN NATIONAL INSURANCE COMPANY
AMERICAN NATIONAL INSURANCE COMPANY
RV
RV
12-09
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