Form 4786 - Partial Withdrawal Request - American Equity
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P .O. Box 10343
Partial Withdrawal Request
Des Moines, IA 50306-0343
888-221-1234
Overnight Address: 6000 Westown Parkway, West Des Moines, IA 50266
Fax 515-226-3129
Contract Number _____________________________ Contract Owner(s) _____________________________________________
PARTIAL WITHDRAWAL INFORMATION
Please select one of the following:
10% Penalty-free
Total Accrued Interest
Maximum Penalty-free
Fixed Amount_________________________
Net
Gross
PLEASE NOTE: A surrender charge will be assessed for withdrawals that exceed the penalty-free amount under
contract provisions. Distributions prior to age 59½ may also be subject to IRS premature distribution penalties.
FEDERAL/STATE WITHHOLDING INSTRUCTIONS (MUST BE COMPLETED)
You must indicate if federal/state income tax should be withheld from your payment. Even if you elect not to have federal/
state income tax withheld, you are liable for federal/state income tax on the taxable portion of your distributions. You also
may be subject to tax penalties under the estimated tax payment rules if your payment of estimated tax and withholding, if
any, is not adequate. If you have any questions about your tax liability, please contact your tax advisor.
Select One:
I DO NOT want federal/state income tax withheld from my payment.
FEDERAL__________%
STATE__________%
I DO want federal/state income tax withheld from my payment.
In which state do you file your taxes?_______
(The minimum amount of tax withholding is $10.00)
If you are a tax resident in any of the following states/jurisdictions please see state specific instructions below: ARIZONA,
IOWA, KANSAS, MAINE, MASSACHUSETTS, MICHIGAN, NEW YORK, NEBRASKA, or OKLAHOMA
STATE SPECIFIC INSTRUCTIONS:
ARIZONA residents: If you want to have Arizona state taxes withheld, you must submit form A-4P .
MICHIGAN residents: State taxes will be withheld at the statutory rate unless you submit form MI W-4P .
IOWA, KANSAS, MAINE, MASSACHUSETTS, NEBRASKA, or OKLAHOMA residents: If federal withholding is
elected, applicable state withholding will be withheld.
NEW YORK residents: If you want to have New York state taxes withheld, you must submit form IT-2104-P .
Withholding is only permitted on payments payable over a period of longer than one year.
TAX PAYER IDENTIFICATION NUMBER (MUST BE COMPLETED)
______________________________________
___________________________________________________
OR
Employer Identification Number
Social Security Number
TAX IDENTIFICATION CERTIFICATION (SUBSTITUTE W-9)
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number; and
2. I am not subject to backup withholding due to failure to report interest and dividend income; and
3. I am a U.S. Citizen or other U.S. Person (defined in the W-9 instructions).
Certification Instructions: You must strike out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding.
__________________
____________________
X
X
Owner’s Initials
Joint Owner’s Initials
ORIGINAL FORM NOT REQUIRED - FAXED COPIES ARE ACCEPTABLE
06.01.15
4786
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