Fillable DEFERRED ANNUITY TO LTCI 1035 TRANSFER AUTHORIZATION (Genworth)

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DEFERRED ANNUITY TO LTCI 1035 TRANSFER AUTHORIZATION (Genworth)

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42923LTC 05/16/18
Use this form to authorize an exchange from a non-qualified deferred annuity contract to a Long Term Care Insurance Policy.
Requirements:
1. Only individually-owned annuity to individually-owned LTCI policy or jointly-owned annuity to shared ownership LTCI policy exchanges are
permitted. The proposed/current LTCI insured(s) must be the owner(s) of the annuity.
2. Only annual mode is available for 1035 partial exchanges.
3. Genworth Life Insurance Company, Genworth Life and Annuity Insurance Company, and Genworth Life Insurance Company of New York, will be
referred to collectively as Genworth throughout.
4. We will not accept an LTCI premium payment made by 1035 exchange past the premium due date — any payment made within the grace period
must be made from another source.
In addition:
A 1035 exchange from a Genworth annuity to pay a first year LTCI premium will not be permitted unless the annuity contract has been inforce
for at least 60 days prior to the initial LTCI premium due date. Note: For suitability reasons, if the purpose for buying an annuity is to use it to pay
LTCI premiums, the contract should not be applied for prior to the LTCI applicant being approved for coverage.
A 1035 exchange from a Genworth annuity to pay LTCI premiums due in subsequent years will not be permitted unless the annuity contract is
issued and all 1035 exchange request forms are received in good order by us at least 10 business days prior to the LTCI premium due date.
Genworth’s Fixed Index Annuities (FIA) do not allow withdrawals (including partial exchanges) within the first 12 months after issue. Thus, the
owner of a new FIA contract who desires to make partial 1035 exchanges from it to pay LTCI premiums will need to pay any LTCI premiums due
within those first 12 months from another source.
• Note: If using a Genworth single premium immediate annuity (SPIA) to fund a LTCI Policy, use form 49787 (new SPIA) or 49787PI (existing SPIA).
DEFERRED ANNUITY TO LTCI 1035 TRANSFER AUTHORIZATION
Please print clearly using black ink.
Genworth Life Insurance Company
Genworth Life and Annuity Insurance Company
Genworth Life Insurance Company of New York
†
Attn: Long Term Care Insurance Customer Service
P.O. Box 40005
Lynchburg, VA 24506
†
Only Genworth Life Insurance Company of New York is admitted in and
conducts business in New York
A. EXCHANGES TO FUND A NEW LONG TERM CARE INSURANCE POLICY
○ I am applying for a new Genworth Long Term Care Insurance Policy and wish to fund it with 1035 exchange(s).
Applicant name Applicant name
Please print Please print
Instructions:
Assumes the exchange satisfies the requirements under Instruction 4 above. If not, then complete Section B of this form instead of Section A.
• The first payment (up to the full annual premium but not less than 3 months premium*) must be included with the application. The balance of
the first year’s premium and subsequent annual premiums will be withdrawn from the designated annuity.
• Attach this form to the application and submit both to the address provided on the application.
* In states of NH (ages 65 and older) and CA, one month’s premium must be submitted.
Premium information
1. Premium due date (mm/dd/yyyy)
2. Total annual premium: $ Refer to application or illustration
3. Amount submitted with application: $
4. Balance of first year’s premium due: $ Subtract line 2 from line 1
5. Subsequent annual premium to transfer: $ Enter amount from line 1
Payment method requested
○ Withdraw from the Genworth Annuity each year for a fixed dollar amount of $
and bill me for the difference, if any.
○ Withdraw from the annuity for a fixed dollar amount of $ and bill me for the difference, if any.
○ This is a one time exchange. Apply the full annuity account value (estimated to be $ ) to my policy. Cannot exceed 2 year’s premium.
Note: Automatic annual withdrawals will be scheduled to occur on or prior to the regular premium billing date to ensure timely payment of
premiums and to permit billing of the policyholder for any balance due on their normal billing schedule. Surrender charges and other charges may
apply.
Page 1 of 3
42923LTC 05/16/18
D. TRANSFER AGREEMENT
1035 Exchange and LTCI Premium Payments
I/We understand that the above requested transfer of funds from my/our existing annuity contract will be handled as a 1035 exchange. I/We hereby
authorize Genworth to request the required exchange, withdrawing the requested funds from the above designated annuity contract(s) to fund the
premiums of the Long Term Care Insurance Policy referenced above.
Other than the owner(s) mentioned herein, no person, firm or corporation, other than me and the issuing insurer, has an interest in said contract. No
proceedings in insolvency or bankruptcy have been instituted by or against me.
I/We also understand and agree that the requested withdrawals will occur automatically until I/we notify Genworth that I/we wish to terminate the
withdrawals. I/We understand that, unless otherwise designated in the Payment Options section above, the automatic withdrawals will occur even
if the annual withdrawal limit is exceeded and surrender charges may be incurred. If such surrender charges are incurred, they will be subtracted
from the contract value. I/We expressly represent that the sole purpose of this transaction is to effect an exchange of an annuity contract under
section 1035(a) of the Internal Revenue Code. I/We understand that I/we should contact an independent tax and legal advisor for advice regarding
the tax treatment of this exchange.
In the event that the requested 1035 exchange reduces the annuity contract value below stated minimums, then a full transfer of the remaining
contract value funds will occur. Any excess funds will be refunded or applied to future Long Term Care Insurance premiums due. In such an event,
I/we hereby assign and transfer without exception, limitation, or reservation to the Insurer, all assignable benefits, interest, property and rights in
the contract referenced herein. I/We understand that by executing this assignment, I/we irrevocably waive all rights, claims and demands under the
assigned contract. I/We understand that the Insurer will not treat this assignment as the equivalent of a cash payment. I/We further understand that
no part of the value of the assigned contract will be treated as a premium/purchase payment until it is received by the Insurer.
For Fixed Index Annuity contracts with the Income Protection Rider, withdrawals in excess of the guaranteed withdrawal amount, called “excess
withdrawals”, will result in a permanent reduction in future guaranteed withdrawal amounts. If you would like to make an excess withdrawal and
are uncertain how an excess withdrawal will reduce your future guaranteed withdrawal amounts, then you may contact us prior to requesting the
withdrawal to obtain a personalized, transaction-specific calculation showing the effect of the excess withdrawal.
Caution: Effecting an exchange of your annuity contract may adversely affect your rights and benefits including, potentially reducing death
benefit and living benefit values. Please discuss with your Financial Professional and refer to your contract for a description of these rights
and benefits. Prior to engaging in a 1035 exchange, you should carefully consider a number of factors including the impact to the features
and provisions of your current product, and any applicable surrender charges associated with this exchange.
Owner name Street address City State Zip code
Social Security number Date of birth mm/dd/yyyy
Joint owner name If applicable Joint owner Social Security number If applicable
Institution name Street address City State Zip code
Telephone number Annuity contract number
Estimated contract value
$
C. ANNUITY CONTRACT INFORMATION
Page 2 of 3
B. EXCHANGES TO FUND EXISTING LONG TERM CARE INSURANCE POLICY
○ I am funding an existing Genworth Long Term Care Insurance policy number:
Policyholder name Joint Policyholder name If applicable
Please print Please print
Premium information
Premium due date (mm/dd/yyyy)
Premium to transfer: $ Transfer amount should not exceed LTCI annual premium
Payment method requested
○ Withdraw from the Genworth Annuity each year for a fixed dollar amount of $
and bill me for the difference, if any.
○ Withdraw from the annuity for a fixed dollar amount of $
and bill me for the difference, if any.
○ This is a one time exchange. Apply the full annuity account value (estimated to be $ ) to my policy. Cannot exceed 2 year’s premium.
Note: Automatic annual withdrawals will be scheduled to occur on or prior to the regular premium billing date to ensure timely
payment of premiums and to permit billing of the policyholder for any balance due on their normal billing schedule. Surrender charges and other
charges may apply.
42923LTC 05/16/18
The Genworth Financial companies developed these materials to help you understand the ideas discussed. Any examples are hypothetical.
They may not reflect your particular circumstances. You should carefully read the contract/policy. What we say about legal or tax matters is our
understanding of current law. We are not offering legal or tax advice. Tax laws and IRS administrative positions may change. We did not develop
these materials for use in avoiding any IRS penalty and you may not use it for that purpose. Insurance companies’ tax reporting practices may vary.
You should ask your independent tax and legal advisors for advice based on your particular circumstances. We reserve the right to change the
information reporting described herein to comply with forms and instructions issued by the Internal Revenue Service.
Overnight Delivery
Genworth
Attn: Long Term Care Insurance Customer Service
3100 Albert Lankford Drive
Lynchburg, VA 24501-4948
Mailing instructions (If a new Long Term Care Insurance policy is being funded, please attach this form to the application and return both
to the address provided on the application. If funding an existing Long Term Care Insurance policy, return this form to the address below:
Regular First Class Mail:
Genworth
Attn: Long Term Care Insurance Customer Service
P.O. Box 40005
Lynchburg, VA 24506
E. IMPORTANT INFORMATION
Declaration and signature(s)
If you are signing as a fiduciary
or representative, you must
indicate capacity or title
and provide documentation
of authority (see signing
instructions below).
Other signatures that may
be required include: spouse
(if community property state),
irrevocable beneficiary
(must sign with title), and
collateral assignee (if contract is
collaterally assigned).
Your signature authorizes us to
change your billing mode to
Annual billing if needed.
• Your signature indicates that you have read and understand all sections of this form
• You certify under penalty of perjury that the statements and answers given on this form are true,
complete and correct to the best of your knowledge and belief. The penalty of perjury does not
apply to income tax withholding.
• You declare that no bankruptcy proceedings are now pending against you and you are not subject
to back-up withholding
○ I elect not to have California income tax withheld from my withdrawals.
Owner signature Date of signature
X
▪
Joint owner signature Date of signature
X
▪
Other required signature If applicable Date of signature
X
▪
◯
Trustee
◯
Attorney-in-fact POA
◯
Guardian
◯
Title/office:
◯
Trustee
◯
Attorney-in-fact POA
◯
Guardian
◯
Title/office:
◯
Trustee
◯
Attorney-in-fact POA
◯
Guardian
◯
Title/office:
Note: California participates in the IRS combined reporting program and receives a copy of the federal Form 1099-R. Nevertheless, you should
be aware that California has declined to adopt, for state income tax purposes, the provisions of the federal tax law that make 1035 exchanges to
fund LTCI nontaxable. Accordingly, notwithstanding any Forms 1099-R you may receive, 1035 exchanges to fund long term care insurance may
result in California income tax liability.
Page 3 of 3
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DEFERRED ANNUITY TO LTCI 1035 TRANSFER AUTHORIZATION (Genworth)

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Completed 24 May 2022

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