Form Hc-0281vl - Policyowner'S Request For Service Page 2
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2SECTION C – Review important information and select tax withholding below:
OPTION 1: Tax Withholding
•
Selection required if you are requesting a policy loan, partial surrender/withdrawal, or flexible premium annuity withdrawal only.
•
See the “Important Notice” below for withholding information.
Select the appropriate box:
Do not withhold Federal Income Tax
Withhold Federal Income Tax
Important Notice
Federal tax law requires that certain non-periodic distributions from a life insurance policy be subject to federal income tax withholding
of ten percent (10%), unless you elect not to have withholding apply. Withholding only applies to that portion of your distribution
included in your income. If you elect not to have withholding apply, or if you do not have enough federal income tax withheld from
your distribution, you may still be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if
your withholding and estimated tax payments are insufficient. Hartford Life reports and withholds on distributions from your policy
based on its business records. These records may include policy information received from any prior insurance carrier. Regardless of
the information reporting and withholding that Hartford Life conducts, it remains your responsibility to file any required tax returns and
pay any taxes associated with this distribution.
Important Notice
When requesting a withdrawal, if the death benefit option then in effect is Level or Return of Premium, the Face Amount will be
reduced by the reduction of Account Value as a result of the withdrawal. You may wish to review and possibly change your death
benefit option prior to requesting a withdrawal. Please refer to your prospectus for more information on the different consequences of
loans and withdrawals on your life insurance policy. You should consult your registered representative to ensure your actions are
consistent with your financial objectives. You should consult a tax adviser regarding the possible adverse tax consequences resulting
from a change in your death benefit option.
SECTION D – Complete policyowner and assignee (if applicable) sections below:
Certification and Signature Section
Under penalties of perjury, I, the undersigned policyowner, certify that my Taxpayer Identification Number (TIN) is:
_______________________________
(For U.S. citizens and resident aliens, the TIN is your Social Security Number.)
I also certify that:
The Internal Revenue Service has not notified me that I am subject to backup withholding.
I have been notified by the Internal Revenue Service that I am subject to backup withholding due to underreporting
of interest dividends.
Further, I declare that no bankruptcy proceedings are now pending against the policyowner, and I have made the withholding
election as designated above.
___________________________________________________
________________________________________________
Signature of Policyowner(s)
Date
Signature of spouse (if required)
Date
___________________________________________________
________________________________________________
Signature of second officer of company (if needed)
Date
Signature of irrevocable beneficiary (if required)
Date
To Be Completed by Assignee:
The undersigned assignee hereby agrees with the above request. Any check for policy values shall be payable to:
The sole order of the policyowner
The sole order of the assignee
Jointly to the policyowner and assignee
____________________________________________________________________________________________
Signature of Assignee (If the assignee is a corporation, print the full name and full title of the officer of the corporation.)
/
/
Date
________________________________________________
(_
)
Address of Assignee
Telephone
HC-0281VL (01/09)
Hartford Life Insurance Company, Hartford Life and Annuity Insurance Company, Hartford Life and Accident Insurance Company
THE HARTFORD is
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