Notice Regarding Hardship Request - Standard Life Of Indiana (Page 3 of 4) in pdf

Notice Regarding Hardship Request - Standard Life Of Indiana Page 3

ANNUITIZATION FORM

BENEFIT PAYMENT REQUEST

CONTRACT NUMBER_________________________

Please complete each section where “>” is shown.

I authorize the value of this contract to be paid in the form of an Annuity Benefit.



BENEFIT OPTION ELECTED:

[ ] LIFE EXPECTANCY: Level payments

[ ] LIFE EXPECTANCY: Interest plus $10.00 with Balloon Payment

[ ] _____% increase per year (maximum 15%) for _____ years period certain.

[ ] Life Annuity payments with Period of _______Months Certain

Pays monthly income payments for as long as the annuitant lives, with payments

guaranteed for a certain period.

[ ] Certain Period Only for ____________________Months

Pays monthly income payments for a set period of time only.

[ ] Life Only Annuity $_____________

Pays monthly income payments for the life of the annuitant only.



Payment Frequency (After election, frequency may not be changed.)

[ ] Monthly

[ ] Quarterly

[ ] Semi-annually

[ ] Annually

Please Note: Once a payment election is made, there can be no change in payment

period.



FEDERAL TAX WITHHOLDING FOR PERIODIC DISTRIBUTIONS

TO BE COMPLETED ONLY FOR TAXABLE GAIN

A. [ ] I elect NOT to have Federal income tax withheld from monthly annuity payments.

B. [ ] I elect to have Federal income tax withheld from monthly annuity payments.

If taxes are to be withheld, please choose one option below:

____________ % to be withheld

$___________ amount to be withheld



PAYEE – THE ANNUITY BENEFIT IS TO BE MADE PAYABLE TO:

[ ] Owner

[ ] Other ______________________________________________________

[ ] Payee is irrevocable

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

Notice Regarding Hardship Request - Standard Life Of Indiana Page 3