Notice Regarding Hardship Request - Standard Life Of Indiana (Page 2 of 4) in pdf

AUTHORIZATION FOR

HARDSHIP WITHDRAWAL

Re: Contract Number:____________________________________________________

Owner:_________________________________________________________________

, Owner of this contract, authorize a withdrawal of $_________.

Check one:

____ I understand that this amount may be reduced by any surrender charges

or taxes withheld.

____ I understand that this contract contains a Market Value Adjustment, and as a

result, the total withdrawal may be larger if surrender charges apply or taxes are

withheld.

Do you have other liquid assets or other annuities available for monthly living expenses and

emergencies

other than the money you plan to withdraw from this annuity?

____ Yes. Please list amount of liquid assets $__________

(Examples: annuities, checking, savings, money market accounts, short term CDs,

bonds, etc.)

____ No.

This withdrawal may be subject to a contract withdrawal charge and/or a Market Value

Adjustment, if applicable. Please review your contract.

Federal Income Tax Withholding - I understand if there is a reportable distribution as a result of

the withdrawal, it will be reported to the Internal Revenue Service (IRS) for the calendar year the

withdrawal is made. Unless waived by me, if there is a reportable distribution, it will have

income tax withheld at a flat 10% rate.

Federal Excise Tax - If you are under age 59½, a Federal excise tax may apply.

State Income Tax Withholding - If you reside in OR or GA, state taxes will be withheld

regardless of election to withhold Federal income tax, due to state regulations. If you reside in

DE, IA, LA, MA, ME, NE, NC, OK, or VT, state tax withholding is mandatory if Federal income

tax is withheld.

Reportable Distribution - I further understand that even if I elect not to have Federal income tax

withheld, any reportable distribution will still be reported to the Internal Revenue Service.

____ I elect NOT to have Federal income tax withheld.

____ I elect to have Federal income tax withheld.

NOTE: TAX AUTOMATICALLY WITHHELD IF NO WITHHOLDING OPTION IS ELECTED

I am not under guardianship, nor have I made any assignment, pledge, or executed any

document affecting ownership or right to any monies due or to become due under the contract,

and I further certify that no proceedings in bankruptcy are pending to which I am a part.

This form is dated at__________ this_____ day of______________, 2009.

________________________________

____________________________________

Signature of Owner

Signature of Joint Owner (if applicable)

________________________________ _____________________________________

Signature of Witness

Owner’s Telephone & Social Security Number

10689 N Pennsylvania Indianapolis, IN 46280 (800) 222-3216

Notice Regarding Hardship Request - Standard Life Of Indiana Page 2

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