Fillable Withdrawal Request For xed and xed index annuities

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Withdrawal Request For xed and xed index annuities

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GS0004PW [Rev 04/2021]Page 1 of 6
• You should talk with your financial and tax advisors and read your contract carefully to understand how this withdrawal
will affect your contract values and living benefits.
• Taking withdrawals (including withdrawals to pay advisory fees) can reduce or eliminate your living benefits.
• This form cannot be used to set up Substantially Equal Periodic Payments (SEPP). Please use a SEPP Enrollment form.
• If you are already taking withdrawals under the Substantially Equal Periodic Payments (SEPP) program, any additional
withdrawals will cancel your SEPP program and any previous withdrawals taken under the program may be subject to
a 10% early withdrawal penalty.
• 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.
For questions or help with this form, call us at 877-253-2323.
Throughout this form, “the Company” refers to the issuing company.
1
Use this form to request a single withdrawal.
To start the Retirement Chapters 10
®
, Retirement Stages 7
®
, Assured Income 7
®
, or Target Income 10
®
Lifetime Income
Benefit, please complete the Lifetime Income Benefit form.
Check here if your address has changed. We will update your address, and we require Notarization of this document to
process this withdrawal. See section 6.
Contract Number
Owner SSN/TIN
Co-Owner (if applicable) SSN/TIN
Address
City State Zip Code
Phone Number
In case we need to contact you about this request
Withdrawal Request
For fixed and fixed index annuities
Contract Information (please print clearly)1
1
Delaware Life Insurance Company (Waltham, MA) is authorized to transact business in all states (except New York), the District of Columbia, Puerto Rico, and the
U.S. Virgin Islands and is a member of Group One Thousand One, LLC (Group1001).
© 2021 Delaware Life Insurance Company. All rights reserved.
GS0004PW [Rev 04/2021]Page 2 of 6
Interest only withdrawal (available for Fixed Annuities only) Please select only one option:
Interest accrued since the previous contract anniversary.
All interest accrued above the initial contribution.
Full withdrawal — this will close the contract and end all of your benefits under the contract.
Specific amount $______________________________
(Optional) Please send me the exact withdrawal amount shown above. I understand that any withdrawal charges,
fees, adjustments, tax withholding amounts, and/or delivery costs that result from this withdrawal will
be charged to my contract.
Annual free amount balance
Please refer to your contract or call us if you have any questions regarding your free amount, surrender charges,
or applicable Market Value Adjustment.
When should withdrawal occur? (Please select only one option)
Immediate withdrawal Withdrawal upon contract maturity (not to exceed 60 days)
• If you do not complete this section, we will process the withdrawal upon receipt of the withdrawal request in good order.
• If this withdrawal request is associated with an end of term renewal, surrender charges may apply if it occurs more than
30 days prior to maturity.
Withdrawal Amount (select only one option)
Withdrawal Allocation (for Fixed Index annuities)
2
3
Please select only one option:
Proportionally from all existing allocations
From the following accounts at the dollar amounts or percentage(s) shown below:
Account $ or % (whole number)
Total
(Percentages must total 100%)
• If you do not make a selection, we will take withdrawals proportionally from all existing investment allocations.
• In the list above, if you include percentages with decimals, we will round them to the nearest whole percentage.
GS0004PW [Rev 04/2021]Page 3 of 6
The tax withholding options that you select will remain in effect until revoked in writing. Federal and/or state taxes may apply.
Federal income tax withholding
Would you like Federal income tax withheld from your withdrawal?
Yes, withhold at the default 10% withholding rate.
• Additional amount as a whole percentage, if any, you want withheld ____________%.
No, do not withhold Federal income tax.
• If you choose “no” withholding or if you do not have enough tax withheld from your withdrawal, you may have to pay
estimated taxes.
• If your withholding and estimated tax payments are not sufficient, you also may incur penalties under the estimated
tax rules.
• If you are taking a full withdrawal, you may need to pay a state premium tax as well, based on your resident state.
Note: If you do not make an election for Federal withholding, we will use the tax withholding instruction from the most
recent withdrawal. If no previous tax withholding instruction is available, we will automatically withhold at the default 10%
withholding rate.
State income tax withholding
Would you like state income tax withheld from your withdrawal?
Yes, withhold state income tax from my withdrawal in the amount of $________________________ or ____________%.
No, do not withhold state income tax.
• In some states, state income tax withholding is mandatory when federal income taxes have been withheld. If you elect
a specific state withholding amount or percentage we will process according to your instructions. Please consult with
your tax advisor to ensure that the amount you have requested is sufficient to satisfy your state’s requirements.
– If you do not otherwise make an election, and you live in a mandatory state that employs a percentage calculation,
we will default to your state’s default withholding percentage rate.
– If you live in a mandatory state that uses a wage table calculation, we will default to “single with one dependent.”
– You may contact us at any time to change your tax withholding election.
Tax Withholding4
We will mail your check by first class mail to the address we have on file, unless you choose one of the options below. If you
prefer to receive your payment by check mailed to the owner at the address on file, skip to section 6.
Please select only one option.
Direct Deposit/EFT to a bank account (Please select only one direct deposit option.)
I wish to establish and use direct deposit banking information for this and future EFT withdrawals (Direct Deposit
form required).
• If you choose this option, you must complete and submit the Direct Deposit form with this withdrawal request.
Please call Customer Service for details.
• Bank information will remain on file for future use.
• A Notarized signature on this withdrawal form is required for this option. See section 6.
• If the Direct Deposit form is not in good order, or we are unable to validate the direct deposit/EFT banking
information, your withdrawal will be processed as a check mailed to the address on file.
Please use the direct deposit/EFT banking information on file, bank account ending in ____ ____ ____ ____ , to process
this request.
• Do not list your Bank Routing number.
• If you do not have banking information on file, do not provide the last four digits of your bank account above, or
we are unable to validate the direct deposit/EFT banking information on file, this withdrawal will be processed as
a check mailed to the address on file.
Delivery Instructions (optional)5
GS0004PW [Rev 04/2021]Page 4 of 6
Wire transfer
• If wiring to a bank account that is not in the name of the owner(s), we require a Signature Guarantee. See section 6.
• If the receiving bank returns or rejects the wire transfer, this withdrawal will be processed as a check mailed to the
address we have on file.
• We will only send a wire payment to a bank in the United States or Puerto Rico.
• We will deduct a $25 fee for this service. (Your bank may charge an additional fee.)
Overnight delivery
• Please provide a street address in section 1. We cannot deliver overnight to a P.O. Box.
– If a street address is not provided, we will send your check by first class mail to the address we have on file.
• We will deduct a $15 fee for this service.
Delivery Instructions (continued)5
Bank Name Nine-Digit Routing Number
Account Name Account Number
Further Credit Account Name Further Credit Account Number
Make Check Payable to
Mailing Address
City State Zip Code
Send a check for the withdrawal amount to a different address, payee, or both.
• If you want your check made payable to another person, we require a Signature Guarantee. Complete the “Make
Check Payable to” field below and see section 6.
– A check can never be made payable to the agent of record.
• If you want your check mailed to an address other than the address we have on file for the owner, we require
Notarization of this document. Complete the “Mailing Address” fields below and see section 6.
– A Notarized Agent Check Acceptance form is also required to mail a check to an agent’s office. Please call
Customer Service for details.
• If you want your check made payable to another person and mailed to another address, we require a Signature
Guarantee. Complete all fields below and see section 6.
GS0004PW [Rev 04/2021]Page 5 of 6
All owners must sign this form.
If you are signing this form as a fiduciary (power of attorney, trustee, guardian, custodian, etc.) for the contract owner, you
must sign in your fiduciary capacity and not in your individual capacity. We will need your authorizing documents to process
this request. If we do not have them on file, please attach them to this form.
We require original Notarization (no faxes/emails) if any one of the following situations applies:
• A withdrawal request to mail the check to an address other than the address we have on file for the owner.
– Any withdrawal request to mail a check (made payable to the owner) to the agent’s address of record requires a
Notarized Agent Check Acceptance form. Please call Customer Service for details.
• Any withdrawal requesting a one-time direct deposit/EFT (unless established banking information is on file).
• Any withdrawal request when the owner’s address has changed within the last 30 days of us receiving the request.
We will accept a Signature Guarantee in place of Notarization.
We require an original Signature Guarantee stamp (no faxes/emails) with each signature, if any one of the following
situations applies:
• Any withdrawal requesting $250,000 or more.
• Any withdrawal requesting the check be made payable to someone other than the contract owner(s).
– A check can never be made payable to the agent of record.
• Any withdrawal requesting a wire transfer or direct deposit to a bank account in the name of someone other than the
contract owner(s).
– We will only send a wire or direct deposit payment to a bank in the United States or Puerto Rico.
• Any withdrawal request on a contract with multiple owners where the check is to be made payable to only one owner.
– Both owner signatures must have a Signature Guarantee.
We will not accept Notarization in place of a Signature Guarantee.
You may obtain a Signature Guarantee stamp at an FDIC-insured bank; a member firm of the New York, American, Boston,
Midwest, Philadelphia, or Pacific Stock Exchange; or any company that is a member of the Securities Transfer Agents
Medallion Program (STAMP).
• The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
Signature(s)6
Owner Signature Date (mm/dd/yyyy)
X
Please Print Owner Name
Signature Guarantee Stamp (if applicable)
Co-Owner Signature (if applicable) Date (mm/dd/yyyy)
X
Please Print Co-Owner Name (if applicable)
Signature Guarantee Stamp (if applicable)
Notary Signature and Stamp: The person(s) whose signature(s) appears above have appeared before me, have been sworn,
and have attested that the information contained in this document is true.
Notary Signature Date (mm/dd/yyyy)
X
Notary Seal (if applicable)
My Commission Expires:
_____________________
GS0004PW [Rev 04/2021]Page 6 of 6
By mail
Delaware Life
P.O. Box 758581
Topeka, KS 66675-8581
By express mail
Delaware Life
Mail Zone 581
5801 SW 6th Avenue
Topeka, KS 66636
By fax
785-286-6118
Online By phone
delawarelife.com Customer Service 877-253-2323 M-F 7:30 a.m.-5:00 p.m., CT
Contact Us
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Withdrawal Request For xed and xed index annuities

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Completed 27 September 2021

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