<html> <head> <title>Rule 20:06:08:0B Uniform Form for Life Insurance or Annuity Cash Surrender.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:08:0B"> <META NAME="Description" Content="Administrative Rules 20:06:08:0B Uniform Form for Life Insurance or Annuity Cash Surrender."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <title>DEPARTMENT OF REVENUE AND REGULATION</title> <style> <!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:10.0pt; font-family:"Times","serif";} h1 {margin:0in; margin-bottom:.0001pt; text-align:justify; page-break-after:avoid; font-size:12.0pt; font-family:"Times New Roman","serif"; font-weight:normal;} h2 {margin:0in; margin-bottom:.0001pt; text-align:center; page-break-after:avoid; font-size:12.0pt; 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style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>UNIFORM FORM FOR LIFE INSURANCE OR ANNUITY CASH SURRENDER</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Chapter 20:06:08</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>APPENDIX B</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>SEE:&nbsp; &#167; 20:06:08:42(2)</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b><span style='font-weight:bold'>Source:</span></b> 29 SDR 48, effective October 10, 2002; 39 SDR 55, effective October 4, 2012.</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal align=center style='text-align:center'><b><font size=4 face="Times New Roman"><span style='font-size:14.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>Uniform Transaction Form for Cash Surrender:</span></font></b></p> <p class=MsoNormal align=center style='text-align:center'><b><font size=4 face="Times New Roman"><span style='font-size:14.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>&nbsp;</span></font></b></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='border-collapse:collapse;border:none'> <tr height=31 style='page-break-inside:avoid;height:23.25pt'> <td width=235 height=31 valign=top style='width:2.45in;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Name of Insured/Annuitant:</span></font></p> </td> <td width=186 height=31 valign=top style='width:139.5pt;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Social Security or Taxpayer ID No:</span></font></p> </td> <td width=216 height=31 valign=top style='width:2.25in;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Policy/Contract No:</span></font></p> </td> </tr> <tr height=31 style='page-break-inside:avoid;height:23.25pt'> <td width=235 height=31 valign=top style='width:2.45in;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Joint Insured/Annuitant:</span></font></p> </td> <td width=186 height=31 valign=top style='width:139.5pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Social Security or Taxpayer ID No:</span></font></p> </td> <td width=216 height=31 valign=top style='width:2.25in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Daytime Phone No:</span></font></p> </td> </tr> <tr height=31 style='page-break-inside:avoid;height:23.25pt'> <td width=235 height=31 valign=top style='width:2.45in;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Policy Owner (if different than insured):</span></font></p> </td> <td width=186 height=31 valign=top style='width:139.5pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Social Security or Taxpayer ID No:</span></font></p> </td> <td width=216 height=31 valign=top style='width:2.25in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Street Address:</span></font></p> </td> </tr> <tr height=31 style='page-break-inside:avoid;height:23.25pt'> <td width=235 height=31 valign=top style='width:2.45in;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Joint Policy Owner (if different than insured):</span></font></p> </td> <td width=186 height=31 valign=top style='width:139.5pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>Social Security or Taxpayer ID No:</span></font></p> </td> <td width=216 height=31 valign=top style='width:2.25in;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:23.25pt'> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>City, State, and Zip Code:</span></font></p> </td> </tr> </table> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>I own the following:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;Life Insurance Policy </span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;Endowment </span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;Annuity Contract</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>This policy was issued by _____________________ on __________.</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font><font size=1 face="Times New Roman"><span style='font-size:8.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;(Company)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='background:#DFDFDF;border-collapse:collapse;border:none'> <tr> <td width=637 valign=top style='width:477.9pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"; font-weight:bold'>Cash Surrender </span></font></b></p> </td> </tr> </table> <p class=MsoNormal style='margin-left:.25in;text-indent:-.25in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>1.<font size=1 face="Times New Roman"><span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>With respect to the above numbered policy/contract I (we) wish to:</span></font></p> <p class=MsoNormal style='margin-left:.25in'><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'><a name=Check7></a></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;obtain the <b><span style='font-weight:bold'>entire</span></b> cash surrender or account value which will be accepted, irrevocably, in full&nbsp; payment of all claims under the policy or contract, <b><span style='font-weight:bold'>or</span></b></span></font></p> <p class=MsoNormal style='text-indent:.25in'><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'><a name=Check8></a></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;obtain the <b><span style='font-weight:bold'>entire</span></b> cash surrender value of rider or paid up addition only, <b><span style='font-weight:bold'>or</span></b></span></font></p> <p class=MsoNormal style='text-indent:.25in'><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'><a name=Check11></a></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;obtain a <b><span style='font-weight:bold'>partial</span></b> withdrawal from the policy/contract only of $______________, <b><span style='font-weight:bold'>or</span></b></span></font></p> <p class=MsoNormal style='text-indent:.25in'><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'><a name=Check12></a></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;obtain a <b><span style='font-weight:bold'>partial</span></b> withdrawal from the rider or paid up addition only of $_____________.</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-indent:-.25in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>2.<font size=1 face="Times New Roman"><span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>The policy/contract is: </span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'><a name=Check9></a></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;submitted herewith, or </span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'><a name=Check10></a></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;I (we) certify that the original policy/contract, any&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; duplicates, certificates, or riders have been lost or destroyed.</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:.25in;text-indent:-.25in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>3.<font size=1 face="Times New Roman"><span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>I (we) certify that no bankruptcy proceeding, attachment, other lien, or claim is now pending against the owner(s) of the policy/contract.&nbsp; _______</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp; Initial</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='background:#DFDFDF;border-collapse:collapse;border:none'> <tr height=22 style='height:16.6pt'> <td width=637 height=22 valign=top style='width:477.9pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:16.6pt'> <h1 align=center style='text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Federal Income Tax Withholding and Instructions</span></font></b></h1> </td> </tr> </table> <p class=MsoBodyText><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>We (the company) are required to inform you of and give you an opportunity to make a tax withholding election.&nbsp; The provisions apply to qualified and non-qualified deferred compensation plans, annuities, pension plans, IRA distributions and gains realized from life insurance and endowment policy distributions.&nbsp; If you elect not to have withholding apply to your payment, or if you do not have enough federal income tax withheld, you may be responsible for payment of estimated tax.&nbsp; You may also incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient.&nbsp; You may wish to consult a tax advisor.</span></font></p> <p class=MsoNormal><font size=2 face="Times New Roman"><span style='font-size: 10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;I elect <b><span style='font-weight:bold'>not</span></b> to have federal income tax withheld from the taxable portion of my distribution check.</span></font></p> <p class=MsoNormal><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>&nbsp;I elect to have federal income tax withheld from the taxable portion of my distribution check, reducing the indicated amount by the amount withheld.&nbsp; </span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='background:#DFDFDF;border-collapse:collapse;border:none'> <tr> <td width=637 valign=top style='width:477.9pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <h2><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt; text-decoration:none'>Certification and Signature</span></font></b></h2> </td> </tr> </table> <p class=MsoBodyText><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>I certify that:</span></font></p> <p class=MsoBodyText><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText style='margin-left:.25in;text-indent:-.25in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>1.<font size=1 face="Times New Roman"><span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>The number shown on this form is my correct taxpayer identification number, and </span></font></p> <p class=MsoBodyText style='margin-left:.25in;text-indent:-.25in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>2.<font size=1 face="Times New Roman"><span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>I am not subject to any backup withholding, and</span></font></p> <p class=MsoBodyText style='margin-left:.25in;text-indent:-.25in'><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>3.<font size=1 face="Times New Roman"><span style='font:7.0pt "Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></font></span></font><font face="Times New Roman"><span style='font-family:"Times New Roman","serif"'>I am a US person (including US resident alien).</span></font></p> <p class=MsoBodyText><font size=2 face="Times New Roman"><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText><font size=1 face="Times New Roman"><span style='font-size:9.0pt;font-family:"Times New Roman","serif"'>_____________________________________&nbsp; ____________&nbsp; _____________________________________ ____________</span></font></p> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size: 9.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Policy Owner Signature)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Joint Policy Owner Signature)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;(Date)</span></font></p> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size: 9.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoBodyText><font size=1 face="Times New Roman"><span style='font-size:9.0pt;font-family:"Times New Roman","serif"'>_____________________________________&nbsp; ____________&nbsp; _____________________________________&nbsp; ____________</span></font></p> <p class=MsoNormal><font size=1 face="Times New Roman"><span style='font-size: 9.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Irrevocable Beneficiary or Assignee)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Irrevocable Beneficiary or Assignee)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Date)</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></font></p> <p class=MsoNormal><font size=2 face=Times><span style='font-size:10.0pt'>&nbsp;</span></font></p> </div> </body> </html>