Form 4786-Elife - Partial Withdrawal Request - Eagle Life Insurance Company
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P.O. Box 71279
Partial Withdrawal Request
Eagle Life Insurance Company
®
Des Moines, Iowa 50325-0279
Telephone: (866) 526-0995
Overnight Address: 6000 Westown Parkway, West Des Moines, IA 50266
Fax: (515) 457-1911
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Contract Number ___________________________________________________ Contract Owner(s) ________________________________________________
PARTIAL WITHDRAWAL INFORMATION
10% Penalty-free
Total Accrued Interest
Please select one of the following:
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.
You must indicate if federal/state income tax should be withheld from your payment. Even if you elect not to have federal/
FEDERAL/STATE WITHHOLDING INSTRUCTIONS (MUST BE COMPLETED)
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.
I DO NOT want federal/state income tax withheld from my payment.
Select One:
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
ARIZONA residents: If you want to have Arizona state taxes withheld, you must submit form A-4P.
STATE SPECIFIC INSTRUCTIONS:
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
___________________________
___________________________
Owner’s Initials
Joint Owner’s Initials
X
X
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ORIGINAL FORM NOT REQUIRED - FAXED COPIES ARE ACCEPTABLE
06.01.15
4786-ELIFE
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