EX-99.(E)(8) 12 d125875dex99e8.txt NAME AND ADDRESS CHANGE, FORM NO. AGLC0222 REV0715 Exhibit (e) (8) [BARCODE] LOGO [AIG] NAME AND ADDRESS CHANGE [_] AMERICAN GENERAL LIFE INSURANCE COMPANY [_] THE UNITED STATES LIFE INSURANCE COMPANY IN THE CITY OF NEW YORK A member of American International Group, Inc. (AIG) In this form, the "Company" refers to the insurance company whose name is checked above. The Company shown above is solely responsible for the obligation and payment of benefits under any policy that it may issue. No other Company is responsible for such obligations or payments. Mailing Instructions: Send form(s) to: [_] Standard Address . PO Box 305355 . Nashville, TN 37230-5355 . Fax: 615-749-2941 [_] Variable Life Service Center . PO Box 305600 . Nashville, TN 37230-5600 . Fax: 713-620-6653 ----------------------------------------------------------------------------------------------------------------------------- A. POLICY Complete all policy information in this section. You may use this form for multiple policies that have IDENTIFICATION the same policyowner and require the same signatures. POLICY NO.: __________________ COMPANY CODE (Financial Network Use Only): _____________________________ OWNER: _________________________________________ SSN/ITIN OR EIN: ______________________________________ ADDRESS: _______________________________________ PHONE NO.: ____________________________________________ _______________________________________ EMAIL ADDRESS: __________________________________________________________________________________________ INSURED/ANNUITANT (IF OTHER THAN OWNER): _______________________________________________________________ -----------------------------------------------------------------------------------------------------------------------------
B. [_] NAME CHANGE Check the box of the person whose name is to be changed. Check the reason for the name change. [_] Insured/Annuitant [_] Owner [_] Co-Owner Reason: [_] Marriage [_] Divorce [_] Payor [_] Beneficiary [_] Correction [_] Other (Attach Certified Copy) FROM: (First, Middle, Last) TO: (First, Middle, Last) __________________________________ ______________________________________ NOTE: THIS FORM CAN NOT BE USED TO CHANGE THE OWNERSHIP OR BENEFICIARY DESIGNATIONS. -------------------------------------------------------------------------------------------------------------------------------
C. [_] ADDRESS Check the box of the person whose address is to be changed. Indicate the new address. CHANGE [_] Insured/Annuitant [_] Owner [_] Co-Owner [_] Payor [_] Assignee [_] Beneficiary NAME: (First, Middle, Last) ________________________________________________________________________ ADDRESS: (Number and Street) _______________________________________________________________________ CITY __________________________ STATE _____________ ZIP CODE ______________ + __________________ PHONE NO.: _________________________________________________________________________________________ ---------------------------------------------------------------------------------------------------------------------
Page 1 of 3 AGLC0222 Rev0715 D. SIGNATURE This request must be dated and all required signatures must be written in ink, using full legal names by the AND DATE person or persons who have rights of ownership under the terms of the contract. Acknowledgement of this change is not an admission that the policy/contract is in benefit or that the person(s) signing the change request is/are the owner(s). A recorded change, not signed by the owner(s), may not constitute a valid change. ---------------------------------------------------------------------------------------------------------------- IRS CERTIFICATION: Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding (enter exempt payee code*, if applicable:____), OR (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person*, and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct (enter exemption from FATCA reporting code, if applicable:____). **Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For contributions to an individual retirement arrangement (IRA) and, generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct ITIN. *See General Instructions provided on the IRS Form W-9 available from IRS.gov. **If you can complete a Form W-9 and you are a U.S. citizen or U.S. resident alien, FATCA reporting may not apply to you. Please consult your own tax advisors. ---------------------------------------------------------------------------------------------------------------- THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING. CO-OWNER SIGNATURE (Or Other Party Interested in OWNER SIGNATURE Policy) ------------------------------------------------------------- ------------------------------------------------- X X ------------------------------------------------------------- ------------------------------------------------- OWNER SIGNED ON (date) _____________________________________ CO-OWNER SIGNED ON (date) ____________________ ___________________________________________________________ ASSIGNEE, IRREVOCABLE BENEFICIARY, OTHER SIGNATURE (if required) ------------------------------------------------------------- X ------------------------------------------------------------- OTHER SIGNED ON (date) _____________________________________ COMPLETE THIS SECTION IF THIS POLICY IS OWNED BY A TRUST OR BUSINESS. [_] Trust Owned: (Complete the Certification of Trust) [_] Business Owned: (Complete the Business Certification) OWNER SIGNATURE AUTHORIZED SIGNATURE (required) Print full name of Company: ________________________________ ------------------------------------------------- ____________________________________________________________ X ------------------------------------------------- Print full name and title of authorized signer:_____________ SIGNED ON (date) _____________________________ ____________________________________________________________
------------------------------------------------------------------------------------------------------------------------------- E. AIGFN USE Local Office _______________ Agency ___________________ Local Office Approval ________________________ ONLY Verification Local Office Stamp Verified [_] Yes [_] No _______________ ________________ Initial Date ------------------------------------------------------------------------------------------------------------------------------- RETURN COMPLETED FORM TO THE ADDRESS OF THE COMPANY CHECKED ABOVE.
Page 2 of 3 AGLC0222 Rev0715 --------------------------------------------------------------------------------------------------------------------------- INSTRUCTIONS AND CONDITIONS --------------------------------------------------------------------------------------------------------------------------- This page is for informational purposes only and does not need to be returned with the form. --------------------------------------------------------------------------------------------------------------------------- POLICY Complete all policy information in this section. You may use this form for multiple policies that have the INFORMATION same policyowner and require the same signatures. --------------------------------------------------------------------------------------------------------------------------- NAME Check the box of the person whose name is to be changed. Check the reason for the name change. CHANGE --------------------------------------------------------------------------------------------------------------------------- ADDRESS Check the box of the person whose address is to be changed. Indicate the new address. CHANGE --------------------------------------------------------------------------------------------------------------------------- SIGNATURE Please elect ownership type and fill out all applicable information. All required signatures must be written AND DATE in ink, using full legal names. The request must be signed by: the person or persons who have the rights of ownership under the terms of the Policy, by an assignee, or by any other party who may have an interest in the Policy by legal proceedings or statutes. . If the owner is a trust, complete the Certification of Trust. . If the owner is a business, complete the Business Certification --------------------------------------------------------------------------------------------------------------------------- ADDITIONAL GUARDIANSHIP/CONSERVATORSHIP - Signature of the current guardian is required along with the current REQUIREMENTS Guardianship Papers or Letter of Conservatorship. The signature must be dated within one year of the request. POWER OF ATTORNEY - Request must be signed by the attorney-in-fact. A copy of the applicable Power of Attorney document is required. A completed, signed, dated, and notarized Power of Attorney Affidavit and Indemnity Agreement is required when the disbursement will be $100,000 or over and/or the face amount of the policy is $1,000,000 or over. ---------------------------------------------------------------------------------------------------------------------------
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