Form An07119 - Rmd Withdrawal Form - Fixed And Indexed Annuity Withdrawal - Lincoln Financial Group
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1
2
3The Lincoln National Life Insurance Company (“Company”)
Lincoln Life & Annuity Company of New York (“Company”)
Servicing Office: PO Box 2348, Fort Wayne, IN 46801-2348
Fax Number 260 455-0263
Overnight Address: Lincoln Financial Group, In-Force - IA
1300 S Clinton St., Fort Wayne, IN 46802-3506
RMD WITHDRAWAL FORM – FIXED AND INDEXED ANNUITY WITHDRAWAL
*
For contracts with the “Lincoln Lifetime Income Edge living benefit rider, please use form AN10100 for distributions.
1. CONTRACT
INFORMATION
**
Contract Number ____________________________________________________________________________________________
Contract Owner’s Name _______________________________________________________________________________________
Issuing Company: The LincolnNational Life Insurance Company or Lincoln Life & Annuity Company of New York
(as set forth in your contract)
Social Security Number
_________________________
XXX-XX-
Date of Birth _______________________________________
(Last 4 digits)
Telephone Number: Daytime _______________________________
Evening ___________________________________________
IMPORTANT INFORMATION
This form authorizes the Company to calculate the Required Minimum Distribution for the contract number referenced.
d
The information contained on this form is based on the Company’s current analysis of the Internal Revenue Service rules and
d
regulations and should not be taken as legal or tax advice.
There is a 30 day waiting period from the date of receipt of this request at the Company to complete processing.
d
Payment requests for an indexed policy will be withdrawn from the Fixed Account. When the Fixed Account is depleted, the
d
payments will be changed to pro rata based on current allocations.
Variable policies will be withdrawn pro rata based on current allocations.
d
For Granite I, Granite II, Allegiance, Alpha, Alpha Flex, Pilot Classic
®
and Pilot Elite
®
policies, payments can be made on a date other
d
than the anniversary date. All other policies will receive payment on an annual basis and distributed on the policy anniversary.
All declared interest rates are expressed as annual effective rates. Any payment taken during the policy year will reduce the actual
d
amount earned because of interruption of interest compounding.
This form should only be used to request your Required Minimum Distribution amount.
d
2. UNIFORM TABLE INFORMATION
Select one:
h Uniform Lifetime Table - The payment will be based on the Uniform Lifetime Table issued by the Internal Revenue Service.
h Joint Life and Last Survivor Expectancy Table - the payment will be based on the combined life expectancies of you
and your spouse beneficiary as of your required beginning date. This option may only be chosen if the age of the spouse is
more than 10 years younger than the contract owner. The person whose joint life is used for calculation of the Required Minimum
Distribution must be your spouse and designated beneficiary on your contract. Complete the spouse beneficiary information below.
Spouse’s Name ____________________________________________________________________________________________
Spouse’s Date of Birth ___________________________________
If funds were transferred from another carrier to establish your contract, please provide the most recent December 31
value of your
st
former contract/account.
Contract/Account balance as of 12/31/ ____________
Contract/Account value $ ________________
3. PAYMENT INFORMATION -
(Refer to Important Information)
h Indexed policies - Set up my Required Minimum Distribution request as an annual automatic withdrawal on my policy anniversary.
Select this option for contracts with Lincoln Living Income
Advantage.
SM
h Fixed/Variable policies - Set up my Required Minimum Distribution request as an annual automatic withdrawal on the specified date below.
Requested Start Date
_____________
(month/day/year)
(cannot be 29
th
, 30
th
, or 31
st
)
h Send my Required Minimum Distribution amount as a one time distribution for the current tax year.
If selected, this form must be submitted on an annual basis in order to receive your Required Minimum Distribution.
*
Withdrawal may be referred to as “payment” or “distribution.”
**
Contract may be referred to as “policy” or “certificate.”
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
SYSWD/WITHDRAWAL
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