Change Of Ownership
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1
2The Lincoln National Life Insurance Company
Lincoln Life & Annuity Company of New York
Servicing Office - PO Box 2348
Fort Wayne IN 46801-2348
Fax Number 260-455-6310
Overnight Address: Lincoln Financial Group, Policy Change - IA
1300 S Clinton St
Fort Wayne IN 46802-3506
CHANGE OF OWNERSHIP
CONTRACT INFORMATION
Contract Number_ ____________________________________________________________________________________________
Contract Owner’s Name_ _ ______________________________________________________________________________________
Social_Security_Number_
_ _ ____________________________ Date_of_Birth_ _ __________________________________
XXX-XX-
(Last_four_digits)
Telephone_Number:__Daytime_ _ ____________________________________ Evening_ ______________________________________
IMPORTANT INFORMATION
_ Taxation_of_annuity_contracts_is_governed_under_Section_72_of_the_Internal_Revenue_Code.
_ Changes_of_ownership_may_result_in_premature_distributions_and_substantial_tax_penalties.
_ You_are_strongly_urged_to_consult_your_attorney_or_a_qualified_tax_consultant_before_you_implement_any_change_of_ownership.
_ A_change_of_ownership_may_forfeit_the_death_benefit_and_any_living_benefit_rider.
IMPORTANT INFORMATION
The_USA_PATRIOT_Act_requires_financial_institutions_to_obtain,_verify,_and_maintain_information_that_identifies_each_person_who_opens_a_
new_account_or_is_added_to_an_existing_account_with_the_Company._To_meet_this_Federal_obligation_the_Company_will_ask_individuals_for_their_
name,_address,_date_of_birth,_including_a_driver’s_license_or_other_governmental_issued_identification_that_will_allow_us_to_verify_their_identity._
For_certain_entities,_such_as_trusts,_estates,_corporations,_partnerships,_or_other_organizations,_identifying_documentation_is_also_required._
For_both_individuals_and_legal_entities,_the_Company_may_include_the_use_of_third_party_sources_to_verify_the_information_provided.
CHANGE OF OWNERSHIP
Maximum age limits apply; please see your product prospectus for details.
Date_of_Change________________________________________________________________________________________________
Reason_For_Change_____________________________________________________________________________________________
New_Owner’s_Name_ ___________________________________________________________________________________________
New_Owner’s_Social_Security_Number_______________________________ Date_of_Birth_ _ __________________________________
New_Owner’s_Address_ _ _________________________________________________________________________________________
City__________________________________________________________________ _ State_ _ ________ Zip_ __________________
New_Owner’s_Telephone_Number_ _ _________________________________ Relationship_to_Prior_Contract_Owner________________
If the new owner is a trust, please attach a copy of the first page, signature page and the trust page that identifies current and successor trustees of the
existing trust (or any amendments thereto), and complete the additional information below. Please note: Memorandums, Affidavits, and Certifications
of Trust are not acceptable and cannot be used.
_ Revocable_
_ Irrevocable
Is_the_trust:_
Trustee’s_Name_________________________________________________________ _ Date_of_Trust__________________________
JOINT OR CONTINGENT OWNER
Maximum age limits apply; please see your product prospectus for details.
_ Add_
_ Joint_owner
_ Delete_ _ Contingent_owner
Date_of_Change_________________________________________________ Relationship_to_Prior_Contract_Owner________________
Joint_Owner’s_Name____________________________________________________________________________________________
Social_Security_Number_ _________________________________________ Date_of_Birth_ _ __________________________________
Address______________________________________________________________________________________________________
City__________________________________________________________________ _ State_ _ ________ Zip_ __________________
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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