Form Cs06341 - Request For Partial Surrender/withdrawal - Lincoln Financial Group

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REQUEST FOR PARTIAL SURRENDER/WITHDRAWAL
General Information
Policy/Certificate No: __________________________ Issued by (the Company): ______________________________________
Insured’s Name: _____________________________________________________________________________________________
Owner’s Name: ______________________________________________________________________________________________
Owner’s Address: ____________________________________________________________________________________________
City, State, Zip: _____________________________________________________________________________________________
Daytime Telephone No.: ________________________
Email Address: ______________________________________________
Income Tax Withholding Election - Substitute W4P
Federal law requires 10% tax be withheld from the taxable portion of certain life insurance payments, unless you request not to have
tax withheld. The tax applies only to the taxable portion of the payment, not the entire payment, should this withdrawal be considered
taxable.
Elect withholding or no withholding by checking the appropriate box below. Be sure to complete this form by signing it and filling in
your Social Security number/Tax Identification number. If you do not make a choice, or if you do not furnish us with your Social
Security number/Tax Identification number, we will withhold 10% for federal income tax in addition to any appropriate State Income
tax from any taxable portion of your payment.
Even if you decide not to have federal/state tax withheld, you are still liable for payment of the income tax on the taxable portion of
this payment. You may be subject to tax penalties under the Estimated Tax Payment Rules if your payment of estimated tax and
withholding, if any, are not sufficient.
Tax withholding not available for withdrawals applied as loan repayments.
This section must be completed. If no selection is made and your withdrawal is considered taxable, taxes will be withheld.
Check ONE BOX:
I do NOT want to have Federal Income Tax and State Income Tax withheld.
I DO want to have Federal Income Tax and State Income Tax (if state mandated) withheld.
This is an IRS requirement, signature required on page 2.
Taxpayer Identification Number and Certification Substitute W9
This section must be completed.
Under penalties of perjury, I certify that:
The number shown below is my correct taxpayer identification number.
Social Security Number: _______________________________________
Tax Identification Number: ____________________________________
I am not subject to backup withholding either because I have not been notified by the Internal Revenue Service that I am subject as
a result of a failure to report all taxable income, including all interest or dividends, or the IRS has notified me that I am no longer
subject to backup withholding. (You must cross out this item if you have failed to report all interest and dividends on your tax
report.)
I am a U.S. citizen (including a U.S. resident).
This is an IRS requirement. Signature required on page 2.
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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CS06341
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