WithSurr0917
Transamerica Financial Life Insurance Company
Home Ofce: Harrison, New York
Transamerica Life Insurance Company
Transamerica Premier Life Insurance Company
Withdrawal/Surrender
Request
Check if Insured and Owner are the same.
Policy/Certicate # Policy Owner Name
Insured Name Policy Owner Address
Insured Street Address Policy Owner City, State and Zip
Insured City, State and Zip Policy Owner Email Address
Special Instructions:
Is this a new policy owner address?
Yes
No
For variable policies: When an address change is completed within a 10 day period of a surrender request, the company will hold
mailing the payment for 10 business days.
NF
Amount of Withdrawal: $
Net Amount or
Gross Amount
Withdrawal from side fund or deposit fund $ from
Withdrawal/Partial Surrender to pay premiums for policy # due date / /
Surrender Options:
Request termination of policy/certicate
Once your policy is surrendered, please destroy your policy as it is of no further value. All claims and rights under the
contract are forfeited at time of surrender.
Request surrender of a rider only
Special Instructions:
Please send disbursement: (Please select only one option)
Regular Mail
Overnight ($20 fee for weekdays, $30 fee for weekends)
Wire ($50 fee, Bank Information is required)
Bank Name Bank Address
Bank Phone Number Bank Routing Number Bank Account Number
Name on Bank Account
SECTION 2. Withdrawal/Surrender (Select only one)
SECTION 1. Policy Information (Fill out all information in this section)
Withdrawal Options:
Reset Form
WithSurr0917
I elect to have no Federal Income Tax withheld from the taxable portion of the proceeds. (If Federal withholding is elected and
your state also requires it, state withholding will be deducted.)
Unless specically indicated, I have elected to have withholding apply. Any gain included in the distribution if the life
insurance policy is considered a MEC may be subject to a 10% federal tax penalty if I am not 59 1/2.
Unless we have been notied of a community or marital property interest in this policy, we will rely on our good faith belief that no such
interest exists and will assume no responsibility for inquiry. I further agree to indemnify and protect the existing Insurer from any claim
which may be asserted against it under the existing Policy or for any losses, injuries or expenses it may incur as a result of honoring this
Agreement. The indemnication shall be binding on my heirs, executors, administrator, successors and assigns.
I certify that I am the Policy Owner and that all information provided by me is correct. I also certify that all decisions regarding this
distribution have been made by me, and that no tax advice has been furnished by the Company. I acknowledge that I am personally
responsible for any taxes and penalties that may result from this distribution and I release the Company from any responsibility or
liability thereof. By signing this form I acknowledge that I have read the information on this form, and that I understand any distributions
requested will be subject to applicable policy penalties. I understand that failure to provide the Company with my correct name and
Taxpayer Identication Number will result in the Company having to ignore my election out of income tax withholding.
FEDERAL INCOME TAX WITHHOLDING INFORMATION: INTEREST ON DIVIDENDS ON DEPOSIT
Purpose of Statement: A person or payer who is required to le an information return with the IRS must get your correct Taxpayer
Identication Number (TIN) to report income paid to you. Giving your correct TIN and making the appropriate certications will
pre-vent certain payments from being subject to backup withholding. If you do not certify to your TIN, the payer may be required
to withhold the currently applicable percentage of payments to you.
What is Backup Withholding: Persons or payers making certain payments to you must withhold and pay to the IRS the currently
applicable percentage of such payments under certain conditions. This si called “backup withholding.” Payments you recieve will
be sucject to backup withholding if:
(1) IRS noties the payer that you furnished an incorrect TIN, or
(2) You are notied by IRS that you are subject to backup withholding because you failed to report all your interest and
dividends on your tax return (for interest and dividend accounts only,) or
(3) You fail to certify to the payer that you are not subject to backup withholding under (3) above
(for interest and dividend accounts opened after 1983 only), or
(4) You fail to certify TIN.
WHEN REQUESTING WITHDRAWAL OR SURRENDER, PLEASE READ THE FOLLOWING:
You have the option to elect to have no Federal Income Tax withheld from the taxable portion of the distribution. However, if you elect
not to have withholding apply or if you do not have enough Federal Income Tax withheld, you may be responsible for payment of
estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufcient.
Withholding will apply only to the taxable portion of your distribution. Therefore, tax liability may be calculated on a gure other
than the full amount of any distribution. The Company does not provide tax or legal advice. We recommend that you seek advice
from a qualied advisor.
If you, the policy owner, are a resident of a state that requires income tax withholding, you are electing not to have amounts withheld
for state income taxes when you elect not to have federal income taxes withheld. If state income tax withholding applies, we will
withhold the amount required by your state. No election out of withholding may be made for any payment made outside the U.S.
unless the payee certies that he is not a US citizen or US resident alien. 30% must be withheld from the taxable portion of any
payment made to non-US citizen or a non-resident alien unless a lower rate is available under a treaty of the United States of America
with such person’s country. If you qualify for reduced withholding, please  le a Form W-8.
WHEN REQUESTING A DISTRIBUTION, PLEASE READ THE FOLLOWING:
A full or partial surrender of a life insurance policy or a loan or other distribution from a life policy that is classied as a Modied
Endowment Contract (MEC) for federal income tax purposes is subject to a federal tax penalty under Section 72(v) equal to 10%
of any gain in the distribution or loan unless the policy owner is at least 59 1/2 or is disabled. Any distribution or loan from a MEC
is considered rst to be from gain in the contract and taxable and then a non-taxable recovery of investment or basis in the contract.
Please consult with and rely on your tax advisor for any tax advice.
The taxable portion of your distribution is subject to federal (and applicable state) income tax withholding. Alternatively, you may
elect to not have federal income tax withheld. If you elect not to withhold taxes from a taxable distribution you may be responsible
for payment of estimated tax. You may incur penal- ties under the estimated tax rules if your withholding and estimated tax payments
are not sufcient.
If you, the policy owner, are a resident of a state that requires income tax withholding, you are electing not to have amounts withheld
for state income taxes when you elect not to have federal income taxes withheld. If state income tax withholding applies, we will
withhold the amount required by your state. The undersigned certies that; (1) the Policy is not subject to any Lien, assignment,
or legal claim by any person or organization who is not a party to this agreement; and (2) that he/she/it is not involved in pending
bankruptcy proceedings.
SECTION 3. Federal Income Tax Withholding - (Refer to Notice to all Policy Owners)
WithSurr0917
WE WILL NEED: Medallion Signature Guarantee (Variable Life Insurance) or Notary Public Stamp (Fixed Life Insurance) for any withdrawals
or surrenders $250,000 or above.
State of On this day of (month/year), before me personally
County of appeared , and executed the foregoing
(Seal)
(name of signer)
instrument and acknowledged it to be his/her/its free act and deed.
Notary Public
My Commission Expires
SECTION 4. Signatures
A printed name will not be accepted, please sign with a signature. Please complete all applicable elds - refer to requirements on page 4.
Before signing this form please read the Notice to all Policy Owners enclosure that could affect the nancial transaction(s).
Owner Signature Title (for Trust or Corporation) Date Signed
Social Security Number/Tax ID Number Date of Birth
Joint Owner Signature (if applicable) Date Signed
Joint Owner Social Security Number/Tax ID Number Date of Birth
Assignee Signature (if applicable) Title Date Signed
Irrevocable Beneciary Signature (if applicable) Date Signed
*Under penalties of perjury, I certify:
1) that the number shown on this form is my correct taxpayer identication number, and
2) that I am not subject to backup withholding because
a. I have not been notied that I am subject to backup withholding as a result of a failure to report all
interest or dividends, or
b. the Internal Revenue Service has notied me that I am no longer subject to backup withholding, and
3) I am a U.S. citizen or U.S. resident for tax purposes
click to sign
signature
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WithSurr0917
If a Medallion Signature Guarantee stamp is required, when faxing please photocopy the Withdrawal/Surrender Form in
black and white prior to faxing it since the original green ink may not be visible when faxed.
SIGNATURE REQUIREMENTS
Individual Owners – Must sign this form on the line provided as owner and provide date of birth.
Partnerships – Two authorized partners must sign below the name of the partnership, the title ‘partner must follow each signature.
Corporation is owner One ofcer other than the insured or owner must sign below the name of the corporation. The
ofcers title must follow the signature. A corporate signature is required to support any signature. An entity form or corporate resolution
is required.
Trust is the owner – The Trustee must sign using the following layout as an example, “John Doe, trustee under XYZ trust dated June,
1, 1999”.
Power of Attorney – The Power of Attorney must sign using the following layout as an example, “John Doe, POA”.
Guardian or Conservator or agent acting under power of attorney – the signature of the guardian/conservator or agent acting under
a power of attorney must sign on behalf of the owner. Paperwork received from the court should be provided as proof if not already on
le with the insurance company.
BeneciaryAny irrevocable beneciary must sign this form for a withdrawal request.
Assignee If the policy has been assigned as collateral security, the assignee must sign this Withdrawal request. If the
assignee is a business, an ofcer of the assignee must sign and include the ofcers title (please sign and print).
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