Non-Qualified Annuity / Deposit Agreement Distribution Request

1. Account Information

Certificate (Policy)/ Account Number

2. Annuitant / Depositor Information

Depositor Name*:

Address*:

State:—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Home Phone Number*:
() - x

Work Phone Number:
() - x

E-Mail Address*:

Social Security Number/TIN*:

Date of Birth*:
/ /

3. Distribution Instructions - Choose only one

4. Frequency of Distribution

MonthlyQuarterlySemi-AnnuallyAnnuallyOne-Time

Beginning month and year distribution(s): /

5. Tax Withholding Election - Choose only one

The distributions you take from your IRA are subject to federal income tax withholding unless you elect not to have withholding apply. If you do not select a box below, you are deemed to elect 20% tax withholding.

I elect NOT to have federal income tax withholding. I understand that I am still liable for payment for federal income tax on the distribution received. I also understand that I may be subject to federal income tax penalties under the estimated tax payment rules if my payments of the estimated tax and withholding are insufficient.

Withhold federal income tax rate of % from distributions.

Withhold federal income tax amount of $

6. Payment Information - Choose only one

By check to the mailing address currently on file for this account.By ACH/EFT (Complete Form ACH1)

By check to a third party address(Payable to the owner(s) or FBO the owner(s)):

State:—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Apply proceeds into my existing PRCUA mortgage account:

Apply proceeds into my existing PRCUA non qualified account:

Deposit proceeds into a new PRCUA non qualified account(please include a completed Annuity Application which is available for download here).

7. Signatures

This form must be signed by the IRA Annuitant (or Beneficiary or Executor for Death Benefits only).

By checking this box, you hereby affirm that the information you have provided is true and correct and that you are aware of all the consequences affecting the distribution requested by this form. This authority is to remain in full force and effect until PRCUA has received written notification from me (or either of us) of its termination in such time and manner as to afford PRCUA a reasonable opportunity to act on it.

Today's Date*:
/ /

Witness

This form requires a witness ONLY if your distribution is to be sent to a third party or to an address different from what we currently have on file for your annuity. Please note that for those types of distributions, the form will not be processed unless a witness signs and dates in the appropriate areas below.

By checking this box, you hereby affirm that you are the witness mentioned above.

* Please verify you are a human:

Submit Application