Form 4083 - Required Minimum Distribution Withdrawal Request - American Equity
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P .O. Box 10343
Required Minimum Distribution
Des Moines, IA 50306-0343
888-221-1234
Withdrawal Request
Overnight Address: 6000 Westown Parkway, West Des Moines, IA 50266
Fax 515-226-3129
Contract Number _____________________________ Contract Owner _______________________________________________
REQUIRED MINIMUM DISTRIBUTION INFORMATION
I wish to begin receiving the required minimum distribution as set by the Internal Revenue Code. American Equity
Investment Life Insurance Company is instructed to begin paying minimum distributions on ___________________________
Month/year
And paid at the following intervals:
Monthly
Quarterly
Semi-Annually
Annually
Select One:
Individual Life Expectancy (Based on 2002 Uniform Distribution Table)
Joint Life Expectancy (Available only when a spouse is the designated beneficiary and is more than 10 years younger
than you.)
___________________________________________________
_____________________________
Spouse (required only if joint option is selected)
Spouse’s Date of Birth
Inherited IRA (Single Life Expectancy Table)
Decedent’s Date of Death: _________________________________
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. You have the right to revoke this
election at any time. This election remains effective until revoked.
Select One:
I DO NOT want federal/state income tax withheld from my payment.
I DO want federal/state income tax withheld from my payment.
(The minimum amount of tax withholding is $10.00)
FEDERAL__________%
STATE__________%
In which state do you file your taxes?_______
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.
X __________________
Owner’s Initials
ORIGINAL FORM NOT REQUIRED - FAXED COPIES ARE ACCEPTABLE
4083
06.01.15
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