Form 4786 - Partial Withdrawal Request - American Equity Page 2
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2P .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
CONSENT OF SPOUSE
If the contract owner(s) resides in AZ, CA, ID, LA, NV, NM, TX, WA, or WI, spousal consent, or the consent of any individual who is
established by law as being a party to a legally recognized domestic relationship according to the laws of the state of the owner’s
domicile, is required to complete this transaction, acknowledged by signing below. Failure to include the signature may result in a
delay or inability to process the requested transaction. Unless otherwise provided on this form the Company shall be entitled to rely
on its good faith belief that no community property interest exists and assumes no responsibility for inquiry. All persons signing this
form agree to indemnify and hold the Company harmless from the consequences of accepting this transaction.
X
Spouse Signature
Date
COMPLETE THIS SECTION IF YOU WOULD LIKE THIS PAYMENT AUTOMATICALLY DEPOSITED TO YOUR BANK ACCOUNT
Select One:
I have previously submitted my bank account information to American Equity for the purpose of receiving
electronic payments. I would like to use the bank account information on file with American Equity for this
request. Please Note: If no bank information is on file I understand a paper check will be mailed.
Enclosed is American Equity form 4062 and a voided check or letter from my bank to setup direct deposit. I
am aware of the pre-note period which may take up to four business days.
PLEASE SIGN & DATE BELOW
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
X
Contract Owner’s/Assignee’s Signature*
Phone Number
Date
X
Contract Joint-Owner’s Signature (if applicable)
Phone Number
Date
*For corporations, signature must be that of an authorized officer and must include title.
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ORIGINAL FORM NOT REQUIRED - FAXED COPIES ARE ACCEPTABLE
06.01.15
4786
Page 2 of 2
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