EX-5.(C) 5 dex5c.txt ANNUITY MATURITY SERVICE REQUEST FORM
EXHIBIT 5(c) --- American Annuity Maturity Service Request |AIG| General --- American General Life Insurance Company Member of American International Group, Inc. Complete and Return to: Supplementary Contracts INSTRUCTIONS: Before completing this form, please read instructions below P.O. Box 1401 o Houston, TX 77251-1401 o 800-247-6584 and on reverse side. ------------------------------------------------------------------------------------------------------------------------------------ 1. Annuitant:_________________________________________________________________ Annuitant's Date of Birth:__________________________ Contract Owner(s):_________________________________________________________ Contract #:_________________________________________ Address:___________________________________________________________________ Annuitant's Sex: [_] Male [_] Female Contract Owner(s) Social Security (or Taxpayer I.D.) No.: _______/_____/___ Phone Number:( )_________________________________ ------------------------------------------------------------------------------------------------------------------------------------ 2. Extended Maturity Date This option stipulates that a maturity option may be Extend the maturity date to _____________________________________. requested anytime prior to the extended maturity date if desired. ------------------------------------------------------------------------------------------------------------------------------------ 3. [_] NOTICE AND DISCLAIMER | Section 401(a)(9) of the Internal Revenue Code and IRS regulations impose certain minimum OF REQUIRED | distribution requirements upon IRAs, tax sheltered annuities, and 401(k) plans. (See Proposed DISTRIBUTIONS FROM | Regulations(S)(S)1.401(a)(9)-1, (S)(S)1.401(a)(9)-2, (S)(S)1.403(b)-2, (S)(S)1.408-8, and IRS INDIVIDUAL RETIREMENT | Notice 88-38.) Generally, these rules require that distributions must commence after age 70 1/2. ANNUITIES AND TAX | Since AGL is not in a position to determine whether or not you are in compliance with these SHELTERED ANNUITIES | distribution requirements, please consult your tax advisor or trustee of your plan, ((S)(S)403(b) AND | if applicable, to ensure your compliance with these rules. 401(k) PLANS) | I have read the above notice and disclaimer and agree that AGL is not liable for any penalty | or any other liability I might incur due to my failure to satisfy the minimum distribution | requirements referred to above. | Initials of contract owner(s) ____________________ ------------------------------------------------------------------------------------------------------------------------------------ 4. Marital Status: [_]Single [_]Married [_]Widowed | 5. I certify that the policy has been: [_]Enclosed [_]Lost [_]Divorced | [_]Destroyed ------------------------------------------------------------------------------------------------------------------------------------ 6. Settlement Options a. TSA, CORPORATE, AND HR-10 PENSION OR PROFIT SHARING PLAN PARTICIPANTS: If you are married at the time you are eligible to receive payments, the Employee Retirement Income Security Act of 1974 stipulates you will automatically receive a Joint and Survivor Annuity unless you and your spouse elect NOT to receive this annuity form. No other settlement option will be valid unless the election statement below is completed: [_] We hereby elect not to receive benefits under a Joint and Survivor Annuity Form. ___________________________________________________________ ____________________________________________________________ ANNUITANT SIGNATURE DATE SPOUSE SIGNATURE DATE b. Elect one of the following settlement options: (Furnish proof of birth with election of Options 1-3. For election of Options 2-5, complete Section 9 for "Beneficiary/ Joint Annuitant".) Surrender charges may be applicable per the contract provisions. (All settlement options may not be available. Please refer to your contract.) [_] (1) Life Annuity [_] (3) Life Annuity with guaranteed monthly payments: [_] (5) Designated Amount____________ [_] 60 [_] 120 [_] 180 [_] (6) Lump Sum ____________________ [_] (2) Joint and Survivor [_] (4) Designated Period: [_] 60 [_] 120 [_] 180 [_] (7) Other _______________________ Annuity with benefits to survivor: [_] Full [_] 2/3 [_] 1/2 c. Payment frequency: [_] Monthly [_] Quarterly [_] Semiannually [_] Annually ------------------------------------------------------------------------------------------------------------------------------------ 7. Bank Agreement Authorization (for use when selecting Settlement Options 1-5 listed above) AGL is hereby authorized and directed to transfer funds in settlement of the annuity payments as they become due to me, to the order of the bank or institution named below. I hereby authorize and direct the Bank to correct erroneous credits to my account received for due dates after my death or due to erroneous duplicate transfers by refunding the amount(s) to AGL as being payments made under mistake of fact. I agree that AGL shall not be liable for loss of funds during the process of transfer to the bank (or for delay in any such transfer) except where due to the negligence of AGL. I reserve the right to revoke or cancel this bank authorization which must be made in writing to AGL. _____________________________________________________ |_|_|_|_|_|_|_|_|_| Type of bank account (check one): NAME OF BANK ABA ROUTING NUMBER [_] Savings [_] Checking* * Attach a blank "voided" check from your account. _____________________________________________________ ________________________________________________________________________ NAME ON BANK ACCOUNT BANK ACCOUNT NUMBER _____________________________________________________________________________ (______)____________________________________ ADDRESS CITY STATE ZIP PHONE NUMBER ------------------------------------------------------------------------------------------------------------------------------------ 8. Notice of Withholding Complete the following applicable lines when selecting a Settlement Option: 1. I elect not to have income tax withheld from my pension or annuity. (Do not complete lines 2 or 3.)............ [_] 2. I want my withholding from each periodic pension or annuity payment to be figured using the number of allowances and marital status shown. (You may also designate a dollar amount on line 3.) Marital status: [_] Single [_] Married [_] Married, but withhold at higher Single rate.....______________ (Enter Number of allowances.) 3. I want the following additional amount withheld from each pension or annuity payment. NOTE: For periodic payments, you cannot enter an amount here without entering the number (including zero) of allowances on line 2...........$____________ Under penalties of perjury, I certify: (1) that the Social Security (or taxpayer identification) number is correct as it appears in this application and; (2) that I am not subject to backup withholding under Section 3406 (a)(1)(C) of the Internal Revenue Code. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. PLEASE SIGN HERE.____________________________________________________________ Date ____________________________________________ ------------------------------------------------------------------------------------------------------------------------------------ 9. Joint Annuitant or Primary Beneficiary: __________________________________________________ [_] M [_] F Social Security (Taxpayer I.D.) No. _________/_______/________ LAST FIRST M. I. ____________________________________________________________________________ Date of Birth _________/_______/________ ADDRESS CITY STATE ZIP (MONTH/DAY/YEAR) 10. In accordance with the terms of the contract designated herein, I hereby elect the above option and agree that this election supercedes and revokes any prior election. _____________________________________________________________________ _________________________________________________________ SIGNATURE OF ANNUITANT DATE SIGNATURE OF CONTRACT OWNER DATE (AND JOINT ANNUITANT, IF APPLICABLE) (If other than Annuitant) _____________________________________________________________________ _________________________________________________________ SIGNATURE OF ASSIGNEE DATE SIGNATURE OF JOINT OWNER DATE ------------------------------------------------------------------------------------------------------------------------------------ L 5539 Rev1202 Page 1 of 2
INSTRUCTIONS The following information will assist you in completing the Maturity Service Request once you have selected a settlement option. OPTION SECTION ------------------ ---------------------- Settlement Option 1, 3, 4, 5, 6, 7, 8, 9 Extend Maturity Date 1, 2, 3, 9 -------------------------------------------------------------------------------- DEFINITIONS Contract Owner: The person, corporation, or trustee named in the contract or contract application as the policy owner Annuitant: The person named in the contract as the insured/annuitant or an employee eligible to participate in a retirement plan adopted by the Contract Owner Joint Annuitant: The person selected to receive payment after death of the annuitant when Option 2, Joint and Survivor Annuity, is elected Beneficiary: The person entitled to receive payment in the event benefits continue after death of annuitant -------------------------------------------------------------------------------- SETTLEMENT OPTIONS Life Only *This option provides for income that is guaranteed for life. Payments under this option are generally higher than those indicated below. However, there is no guaranteed minimum number of payments or any provision for a death benefit payable to your beneficiary. Life with Guaranteed Period *This option provides for equal periodic payments to be made during the lifetime of the Annuitant. If the Annuitant dies before the number of payments guaranteed have been paid, payments will be continued to the beneficiary of the Annuitant until all payments guaranteed have been paid. Designated Period This option provides for equal periodic payments for a specified number of years. Upon the death of the annuitant, payments will continue to the designated beneficiary through the end of the specified period. Designated Amount This option provides for equal periodic payments to the annuitant or designated beneficiary at the amount specified until the policy's proceeds and interest have been exhausted. Joint and Last Survivorship *This option guarantees an income for the joint lifetime of yourself and a designated second person (usually your spouse). Upon the death of one payee, payment will be continued in equal or lesser amounts to the survivor, as chosen by the owner. Review Your Policy Since your policy was selected for your particular needs and since products may vary, your policy may offer options in addition to the popular options mentioned above. *If you select any of these, you must also submit a copy of your birth certificate, valid driver's license, or current passport. Page 2 of 2 L 5539 Rev1202