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TRANSFER OF OWNERSHIP

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Page 1 of 3 - Incomplete without all pages. Order #131538 07/01/2020
New Owner Physical Address
(Required)
Policy/File Code Number
• Do not return your policy with this request. Complete the form and forward it to Customer Service.
• The current owner and the new owner must authorize this request by signing in section H.
• If a company is to be named the new owner, provide ONE of the following: 1) a copy of the Corporate Resolution stating who is authorized to sign on
behalf of the Company, 2) a letter signed by a corporate secretary on company letterhead stating who is authorized to sign on behalf of the Company, or
3) a Secretary of State Certificate from the state, stating the Company's name and who is authorized to sign on behalf of the Company.
• If a partnership or a limited liability partner (LLP) is to be named the new owner, provide ONE of the following: 1) a copy of the legal entity paperwork
stating the name of the partnership, 2) a copy of the partnership contract/agreement showing the date, the names of partners and who is authorized to
sign, or 3) a letter on partnership letterhead stating who is authorized to sign on behalf of the partnership.
• The transfer of ownership is subject to any policy loan and any assignment on file at Customer Service.
• For multiple owners, use the Multiple Ownership form number 128697.
• To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and
record information that identifies each person who purchases a life insurance policy. What this means for you: When you apply for an insurance policy or
apply for a change of ownership, we will ask for your name, address, birth date, Social Security number and other information that will allow us to identify
you. We may also ask to see your driver's license or other identifying documents.
A. CURRENT OWNER INFORMATION
(Please print.)
IMPORTANT INFORMATION AND INSTRUCTIONS
If you are considering making changes in the status of your policy, you should consult with a licensed insurance or financial advisor.
B. NEW OWNER INFORMATION
(Physical address is required, however you may provide a different mailing address
.
)
Owner Phone ( ) SSN/TIN
(Required)
Mailing or PO Box Address
TRANSFER OF OWNERSHIP
Birth Date Phone ( ) SSN/TIN
(Required)
Gender: Male Female
Relationship to the Insured
City State ZIP
City State ZIP
Insured Name
(First)
(Middle Initial)
(Last)
Owner Name
(First)
(Middle Initial)
(Last)
New Owner Name
(First)
(Middle Initial)
(Last)
Reminder to Producer regarding New York Issued Contracts: Before making any recommendation, you must have adequate knowledge of the transaction
you’re recommending and provide your client with the relevant features of the contract and potential consequences of the transaction, both favorable and
unfavorable. If you have any questions about the contract or transaction prior to making a recommendation, contact the Company.
Security Life of Denver Insurance Company (SLD), Denver, CO
Midwestern United Life Insurance Company (MULIC), Indianapolis, IN
SLD and MULIC (“SLD/MULIC”) affiliated
ReliaStar Life Insurance Company (RLIC), Minneapolis, MN
ReliaStar Life Insurance Company of New York (RLNY), Woodbury, NY
RLIC and RLNY (“RLSTR”) affiliated
Venerable Insurance and Annuity Company (Venerable), Des Moines, IA
(the “Company”)
Customer Service, 2000 21st Ave., NW, Minot, ND 58703
Fax: 877-788-6308; Website: voya.com; Completed forms can be emailed to: liferequest@voya.com
SLD/MULIC, RLSTR and Venerable may provide administrative services to each other, but are otherwise unaffiliated. All contractual obligations
under each insurance policy or contract are the sole responsibility of the issuing insurance company.
RESET FORM
Page 2 of 3 - Incomplete without all pages. Order #131538 07/01/2020
If this policy is under a plan that is subject to the Employee Retirement Income Security Act (ERISA), complete the information in this section. If you are
married, your spouse must sign the spousal consent in section H before a notary public. If you do not complete the information in this section, your signature
in section H is certification that the policy is not subject to ERISA or that you are not married.
Will the new owner be a “Funded ERISA Plan” as specified below?
(If “yes,” indicate the type of plan below. If “no,” the change of ownership may disqualify the policy
and cause a taxable event. Contact your tax consultant for more information on the consequences of disqualifying your policy.)
Yes
No
Tax-qualified plan (specify, e.g., 401(k), profit sharing, defined benefit, defined contribution, HR-10):
Section 419/419A plan (specify trust name):
VEBA Trust (specify trust name):
Secular Trust
D. ERISA PLANS
(Please print.)
Phone ( ) Employer Name
B. NEW OWNER INFORMATION
(Continued)
Billing Method
(If no box or multiple boxes are selected, the EFT will automatically be removed and premium notices will be sent to the new owner.)
Billing is to remain the same.
Direct premium notices to new owner.
Electronic Funds Transfer (EFT) change to new owner. (The EFT form must be sent to the new owner for completion.)
The new owner may exercise all the rights and receive all the benefits of this policy during the insured’s lifetime. The change of ownership will not
change any beneficiary designation or any method of optional settlement previously elected. However, if the new owner is an irrevocable life
insurance trust (ILIT) as indicated above, the beneficiary designation will automatically change to the trust unless the following option is checked:
EXCEPTION: The beneficiary designation should remain as it is presently designated.
Trust Mailing or PO Box Address
Trustee Name(s) Phone ( )
Trust Name SSN/TIN
(Required)
Is this trust: Revocable Irrevocable or Irrevocable Life Insurance Trust (ILIT)?
Trust Date
If New Owner Is a Trust:
(The Trust Certification form is required.)
Relationship to the Insured
E. COMMUNITY PROPERTY STATE REQUIREMENTS
(If the owner currently lives in a community property state (AZ, CA,
ID, LA, NM, NV, TX, WA or WI), a spouse signature is required unless one of the two areas are completed below. Failure to provide
a spouse signature or the completion of this section will result in a delay in completing the requested change.)
C. BILLING METHOD
F. REQUIRED TAX REPORTING INFORMATION
(This section must be completed for this form to be considered in good
order for processing.)
Internal Revenue Code § 6050Y incorporates certain tax reporting requirements when ownership of a life insurance policy is transferred in a reportable
policy sale. The Internal Revenue Service defines a reportable policy sale as “the acquisition of an interest in a life insurance contract, directly or indirectly,
if the acquirer has no substantial family, business, or financial relationship with the insured apart from the acquirer’s interest in such life insurance contract.”
This transfer IS NOT a reportable policy sale.
The Company will assume the previous owner’s cost basis will carry over to the new owner unless an alternate cost basis is provided here $ ___________
Reason for cost basis adjustment ____________________________________________________________________________________________________
This transfer IS a reportable policy sale under IRC § 6050Y.
The acquirer must submit the required IRS Form 1099-LS to the Company at the address provided on page 1 of this form. The new owner’s cost basis
will be re-set to $0.00.
Tax laws are complex and change frequently. The Company and their agents and representatives do not give tax or legal advice. For further information on
how this transaction may affect your personal tax situation, always consult your professional tax advisor.
• If never married, initial here.
• If deceased, indicate Date of Death of Spouse
• If divorced, this section must be completed. Check the box below and provide the Date of Divorce.
I confirm that I am no longer married. Date of Divorce
I understand that the Company is not a party to my divorce decree or marriage settlement agreement and that I am responsible for any requirements
included in these documents. Additionally, I understand that my failure to comply with property settlement requirements involving my divorce may give rise
to a claim against my estate in the future.
Page 3 of 3 - Incomplete without all pages. Order #131538 07/01/2020
This request has been filed with the Company and recorded at Customer Service.
Filed by Date
G. U.S. TAXPAYER CERTIFICATIONS
(Applicable to new owner only.)
H. SIGNATURES
The undersigned verify that the change of ownership requested is in accordance with the terms of the plan and applicable laws and regulations. This change
will be effective as of the date the change of ownership is signed, but it will not apply to any payment made or action taken before this form is
acknowledged at Customer Service.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid
backup withholding.
CUSTOMER SERVICE USE ONLY
2
Completion of Section E or a Spouse signature is required if the owner lives in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA or WI).
3
Required if plan is 403b or ERISA.
Plan Administrator/Employer Title
My commission expires
Notary Public Signature
3
Subscribed and sworn before me this day of , 20
Spouse of Current Owner Signature
2, 3
Date
Irrevocable Beneficiary Signature
(if applicable)
Date
New Owner Signature Date
Current Owner Signature Date
Plan Administrator/Employer Signature
3
Date
Assignee Signature
(if applicable)
Date
Irrevocable Beneficiary Title
(If the owner is a trust, partnership, or corporation, a signature is required from an ocer, partner, corporate
representative or authorized corporate representatives. If a trust, partnership or corporation, attach corporate
resolution or Trust Certification. If entity has had a name change, include supporting documentation of successor in
interest with listing of authorized signatories.)
Assignee Name
(Print full name of individual or entity. If an entity, attach corporate resolution or similar document listing authorized signatories.
If entity has had a name change, include supporting documentation of successor in interest with listing of authorized signatories.)
Current Owner Title
(If the owner is a trust, partnership, or corporation, a signature is required from an ocer, partner, corporate representative
or authorized corporate representatives. If a trust, partnership or corporation, attach corporate resolution or Trust
Certification. If entity has had a name change, include supporting documentation of successor in interest with listing of
authorized signatories.)
New Owner Title
(If the owner is a trust, partnership, or corporation, a signature is required from an ocer, partner, corporate representative or
authorized corporate representatives. If a trust, partnership or corporation, attach corporate resolution or Trust Certification. If
entity has had a name change, include supporting documentation of successor in interest with listing of authorized signatories.)
Under penalties of perjury, I certify that:
1. The Taxpayer Identification Number that appears on this form is correct.
2. I am not subject to backup withholding due to failure to report interest and dividend income;
If I am subject to backup withholding, I have checked here.
3. I am a U.S. person.
NON-RESIDENT ALIEN STATUS
(If you are not a U.S. citizen or U.S. resident alien, additional IRS forms may be required.)
If you are a Non-Resident Alien, check the box and provide your country of residence below.
Under penalties of perjury, I certify that I am a Non-Resident Alien and my country of residence is: .
Any taxable amounts paid to you under this policy will be subject to 30% withholding, unless you submit an IRS Form W-8, and are entitled to claim a reduced
rate of withholding under the applicable US tax treaty.
Note to Owner regarding New York Issued Contracts: If your producer is providing a recommendation regarding this transaction, the producer is
required to provide you with the relevant features of the contract and potential consequences of the transaction, both favorable and unfavorable.
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TRANSFER OF OWNERSHIP

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Completed 13 September 2021

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