Professional Documents
Culture Documents
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 ____________________________________________________________________________________
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.
20150617141545823000
Business Use Only: __________________________________________
11188147
Policy/Contract Number: ______________________________________