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Phoenix Life Insurance Company Mail to: Full Surrender Request

PHL Variable Insurance Company PO Box 8027


Phoenix Life and Annuity Company Boston MA 02266-8027 OR
Fax: 816-221-9674

A. Account Information
Policy/Contract Number Insured/Annuitant Name(s): Please print full name
11188147 Gerald & Sue Friedman
Daytime Telephone Number (Include area code) Advisors Telephone Number (Include area code)

B. Transaction Type
Full Surrender
Direction to Pay A Third Party (Financial Institution Only. This does not constitute a 1035 Exchange.)
Please indicate name and address of Financial Institution

Name ______________________________________________________________________________________

Address ____________________________________________________________________________________

City/State/ZIP Code ____________________________________________________________________________

C. Taxes (If no election is made we will withhold Federal taxes at a minimum rate of 10%)
Do Not withhold taxes Withhold taxes at 10% Withhold taxes at a rate of ______% (minimum of 10%)
The distributions paid from your contract may be subject to Federal Income Tax. The Company is required by the Internal
Revenue Code to withhold 10% Federal Income Tax on distributions deemed to be taxable, unless you meet certain
requirements and elect not to have withholding apply. If you do not have sufficient Federal Income Tax withheld from your
distribution, you may incur penalties under the estimated tax rules. Phoenix will not withhold Federal Taxes on Pensions, Profit
Sharing, Keogh Plans or Annuities owned in IRA accounts outside Phoenix.
I am aware that there may be tax consequences resulting from this transaction. Under penalty of perjury, I certify that the
correct Social Security/Taxpayer Identification Number is shown below.

Your Social Security / Taxpayer Identification Number is REQUIRED;


Social Security Number: _____ / ____ / _________ or Taxpayer Identification Number: _____ / _______________
D. Tax-Sheltered Annuity Contract Additional Requirements
(Must be completed for all Section 403(b) Tax-Sheltered Annuities)
The Internal Revenue Code limits the conditions under which a distribution may be made from a Section 403(b) annuity
contract. Surrender or partial withdrawal is only permitted when: (please check one)
The employee attains age 59, has a severance from employment, dies or becomes disabled. (Documentation and
completed form OL3049 required.)
(Documentation for age includes birth certificate, passport, drivers license; documentation for severance from employment
includes written materials from employer sponsoring 403(b) Plan referencing severance, resignation, retirement.)
A hardship exists. (Employer approval and completed form OL4395 required.)
(The amount distributed in a hardship case cannot include any income earned under the contract.)
Distributions not paid directly to an eligible retirement plan (including an IRA) in a direct rollover are subject to 20-percent
mandatory income tax withholding. See Special Tax Notice Regarding Section 403(b) Tax-Sheltered Annuity Plan Payments
for more information and other exceptions relating to the withholding requirement. The mandatory withholding and
surrender/partial withdrawal restrictions are required under the Internal Revenue Code and Phoenix is required to abide by
these guidelines.

20150617141545823000
Business Use Only: __________________________________________

11188147
Policy/Contract Number: ______________________________________

Form Void If Altered


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