Sheila McCorriston Withdrawal

Please contact AXA Equitable at (800) 789-7771 before requesting
a withdrawal if you would like to maintain your benefit base at

a certain level and prevent an excess withdrawal.
Do not use this form for a Transfer or Exchange to Another Company
Return:
Express Mail:
AXA Equitable Life Insurance Company
Retirement Service Solutions
500 Plaza Drive, 6th Floor
AXA Advisors, LLC Secaucus, NJ 07094
AXA Distributors, LLC Regular Mail:
Accumulator® AXA Equitable Life Insurance Company

Retirement Service Solutions
Disbursement P.O. Box 1547

Secaucus, NJ 07096-1547
Variable Annuity Series Fax Number:
(816) 701-8040
This form is only applicable to contracts purchased prior to
10/10/2011. For Assistance:
DO NOT USE THIS FORM IF YOU RECEIVED AN AUTOMATED QUOTE/WITHDRAWAL Call:
FORM UNDER THE DOLLAR FOR DOLLAR WITHDRAWAL SERVICE TO MAXIMIZE OR (800) 789-7771
PRESERVE GUARANTEED INCOME AND/OR DEATH BENEFITS
Instead, please submit the automated quote/withdrawal form you received from us. To Sign Up For eDelivery:
If you would like to receive an automated withdrawal quote under the Dollar for Dollar Visit us at
Withdrawal service, please call (800) 789-7771. www.axa.com
Please note that use of this form will NOT guarantee that your withdrawal is not an
excess withdrawal or that your benefit base will be preserved at a certain dollar
amount for any guaranteed benefits under your contract.
PLEASE REVIEW THE IMPORTANT INFORMATION BEGINNING ON PAGE 12 BEFORE
REQUESTING A WITHDRAWAL TO DETERMINE HOW THE WITHDRAWAL MIGHT AFFECT
ANY OPTIONAL GUARANTEED BENEFITS UNDER YOUR CONTRACT.
1. Type of Request
Please contact your Financial Professional if you need assistance completing
this form.
Please complete the sections listed if you are requesting a:
• One-Time Withdrawal — Sections 2, 3, 4, 10, 11
• Systematic Withdrawal — Sections 2, 3, 5, 10, 11
• 72(t) Exception Withdrawal — Sections 2, 3, 6, 10, 11
• Principal Protector (GWB) Withdrawal — Sections 2, 3, 7, 10, 11
• Guaranteed Withdrawal Benefit for Life Payment Plan — Sections 2, 3, 8, 10, 11
2. Owner’s Information (Please print and fill in all information)

Certificate/Contract Number(s):
318042586
Owner’s Name: Sheila Christine McCorriston

First Middle/MI Last
Joint Owner’s Name:

First Middle/MI Last
Owner’s/Joint Owner’s Daytime Phone Number(s) 215-285-1948

Owner’s Email Address: phillygirl72@yahoo.com
Series 9.0 and Earlier

Page 1 of 13 E14638 Cat. #148485 (January 2018)
3. How To Receive Your Distribution
PLEASE COMPLETE THIS SECTION. IF YOU DO NOT COMPLETE THIS SECTION, WE WILL DEFAULT TO THE ADDRESS OF
RECORD AND SEND YOU A CHECK VIA FIRST CLASS MAIL.
PLEASE PROVIDE A VOIDED CHECK FOR THE DIRECT DEPOSIT OR WIRE TRANSFER OPTION. IF YOU DO NOT, WE WILL DEFAULT TO
THE ADDRESS OF RECORD AND SEND YOU A CHECK VIA FIRST CLASS MAIL.
 First Class Mail No Fee – Please allow 5-10 business days for delivery of your check.
 Direct Deposit No Fee – Please enter your bank account information on lines below. Your bank or financial institution may take up to
2 or more business days to credit the funds to your account.
 This bank account has been previously used by me to electronically receive funds from AXA. I acknowledge that for my own
security, if this cannot be verified, a check payable to me will be mailed to my address of record.
 This bank account has not been used previously for electronic transfer of funds with AXA. I acknowledge that for my own security,
AXA will attempt to validate the bank account, and if this cannot be verified, a check payable to me will be mailed to my address
of record.
PLEASE NOTE: If we are unable to verify the bank account information based on the information you provided, a check will be mailed to
your address of record.
Routing Number (9 digits):
Account Number
Account Holder Name
Bank Name (Required)
Address of Bank
 Brokerage Account*
Brokerage Account Number
Financial Institution’s Name (Required)
*A CHECK WILL BE SENT IN THE FOLLOWING CASES: Not all brokerage accounts accept electronic payments. A check will be mailed to the client’s
address of record if the electronic payment is unable to successfully process. Distributions on custodial owned contracts will be sent to the custodian.
If you are taking a Immediate One-Time Withdrawal or Full Surrender, the options below are also available:
The Express Delivery and Wire Transfer fees will be deducted from the net proceeds of the withdrawal.
 Express Delivery $35 fee – Allow 3 business days for delivery of your check.
 Wire Transfer $90 fee – Please enter your bank account information on the lines below. Allow for next day delivery of your funds. You must
✔
attach a voided personal check for wire transfer requests. We cannot process your request without it.
Routing Number (9 digits):
236084285
Account Number: 42084951
Payee Name: Sheila McCorriston
Financial Institution’s Name (Required):
Police & Fire Federal Credit Union
For Further Credit to:
Name of Client:
Account Number
Please attach a VOID check (Not a deposit slip)

3. How to Receive Your Distribution (continued)
Direct Deposit Agreement
By my signature in Section 7 I consent to the following:
• I certify that the bank account referenced above is under the same Ownership and Title as the annuity contract that is processing the
withdrawal(s).
• By submitting the form with a voided check and signing below you are certifying that the bank routing number and bank account number
provided are accurate. You should confirm these with your financial institution prior to submitting the form to ensure that you have the
correct information for direct deposit. Incorrect information may misdirect and/or delay receipt of your funds.
• I certify that the above account(s) bears my name, that I am an unrestricted and authorized signor on each account and that the funds are being
deposited to a financial institution within the US and will remain in a US bank. The funds will not be credited further into an bank located outside
the U.S.. I authorize AXA Equitable Life Insurance Company (“AXA Equitable”) above to deposit the amount of my withdrawal automatically into
my savings or checking account(s).
• Any person who knowingly and with the intent to defraud any insurance company or other person files a statement of claim containing
any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and may subject such person to criminal and civil penalties.
• I hereby authorize AXA Equitable to directly deposit the amount of my withdrawal in the account listed above at the above-named
bank/financial institution. This authorization will become effective only upon acceptance by AXA Equitable. This agreement will remain in
full force and effect until AXA Equitable has received written notification from me of its termination in such time and in such manner as to
afford AXA Equitable and my bank or financial institution a reasonable opportunity to act on it.
• the event that AXA Equitable notifies the financial institution that funds to which I am not entitled have been deposited to my account,
In
in error, I hereby authorize and direct the financial institution to return said funds to AXA Equitable as soon as possible. If the funds
erroneously deposited to my account have been drawn from that account so that return of those funds by the bank to AXA Equitable
is not possible, I authorize AXA Equitable to recover those funds by off-setting the amount erroneously paid to me from any future
payments from AXA Equitable until the amount of the erroneous deposit has been recovered, in full. It is understood that I will be notified
by AXA Equitable when this condition occurs.
4. One-Time Withdrawal
Please see Important Information about your Guaranteed Benefits to consider before taking a withdrawal,
on Page 12.
Please note that if you request a one-time withdrawal, the amount you request may reduce your GMIB and/
or GMDB benefit bases by an amount greater than your requested withdrawal amount. This could result in a
significant negative impact on the value of your guaranteed benefit. If you’re not certain what impact the one-time
withdrawal will have on your benefit base, please call AXA Equitable at (800) 789-7771 for a customized one-time
withdrawal quote that does not result in an Excess Withdrawal and/or maintains your benefit base as of your last
contract date anniversary.
• Minimum withdrawal amount is $300.
• WITHHOLDING: You must complete Section 10.
• You must select a delivery option in Section 3 or your distribution will be delayed.
IMPORTANT NOTICE
A. We will not process the withdrawal request UNLESS the box is checked below, if the requested
withdrawal will result in an Excess Withdrawal. If the requested withdrawal will NOT cause an Excess
Withdrawal the withdrawal instructions will be processed accordingly. (Not applicable for Series 06 and 07
contracts with GWBL)
Process the withdrawal request even if the withdrawal will result in an Excess Withdrawal.
B. Please choose one:

✔ Withdraw Dollar Amount $ 22,000.00
This amount must be less than 90% of current account value or your contract will be terminated.
Withdraw a Percentage (Please use whole number, maximum 90%) % of Current Account Value
(This is NOT a % of the Benefit Base)
Full Surrender. By surrendering this contract I understand that AXA Equitable is discharged from all
other obligations under the contract and that the contract is no longer inforce. All applicable charges
will be assessed. Please return the original certificate/contract and any other forms required by AXA
Equitable with this request. If you do not return the original certificate/contract, it will be considered
lost or destroyed.
4. One-Time Withdrawal (continued)
Please call AXA Equitable at (800) 789-7771 before requesting a withdrawal under the following
circumstances:
• You would like to maintain your GMIB and/or GMDB benefit base at a certain level, and you are not certain
what impact the withdrawal you have requested will have on your benefit base;
• Your contract’s issue date is between 4/1/02 and 12/9/04 and it has the annual ratchet or standard
death benefit instead of the roll-up death benefit; or
• You want more information about determining the effect of a withdrawal on your contract or you have any
other questions.
• You would like a customized withdrawal quote that does not result in an Excess Withdrawal.
Oregon RMD only: Check this box if your contract was issued in Oregon and the withdrawal request above
is to satisfy your Required Minimum Distribution calculated solely on the basis of this contract. This
withdrawal is for taxable year .
5. Systematic Withdrawals
Please see Important Information, about your Guaranteed Benefits to consider before setting up a
systematic withdrawal, on Page 12.
Please note that if you request a systematic withdrawal, the amount you request may reduce your GMIB and/
or GMDB benefit bases by an amount greater than your requested withdrawal amount. This could result in
a significant negative impact on the value of your guaranteed benefit. If you’re not certain what impact the
systematic withdrawals will have on your benefit base, please call AXA Equitable at (800) 789-7771 for a
customized systematic withdrawal quote that does not result in an Excess Withdrawal and/or maintains your
benefit base as of your last contract date anniversary.
• Available for all Contracts/Certificates except Inherited IRA and QP; Not available for contracts with
GWBL or PGB.
• Withdrawals may not exceed the following percentages of the account value: For Accumulator Series 04,
06, 07 and 8.0 contracts and all Accumulator Elite contracts: 0.8% monthly, 2.4% quarterly and 10%
annually. For other Accumulator Series contracts: 1.2% monthly, 3.6% quarterly and 15% annually.
• Series 8.0 and 9.0 contracts that have no Contingent Withdrawal Charges (CWCs) can elect percentages
greater than 10% or 15% of the account value, depending on the contract terms, up to an annual
maximum of 90% of the account value as of the transaction date (excludes Accumulator Select). Electing
an annual maximum percentage greater than 90% will result in the surrendering of the contract. If a
subsequent contribution is made to the contract after you have elected a Systematic Withdrawal
percentage greater than 0.8% monthly, 2.4% quarterly and 10% annually as of the beginning of the
contract year in which the subsequent contribution is made, the Systematic Withdrawal Option (“SWO”)
will be terminated automatically. A new SWO with percentages within the contract’s threshold may be
reestablished using this form.
• Your withdrawals will be taken from your account on a pro rata basis from the Variable Investment
Options (VIO) and the Guaranteed Interest Option (GIO). For Series 8.0 contracts and earlier ONLY: If you
wish to have your SWO payment withdrawn from specific investment options, please use the Withdrawal
Instructions in Section # 9 to specify from which investment options you would like your SWO funds
withdrawn. Once the requested amount is greater than your annuity account value, we will terminate your
SWO program.
IMPORTANT NOTICE
_Withdrawal the withdrawal instructions will be processed accordingly. (Not applicable for Series 06 and 07
5. Systematic Withdrawals (continued)
B. This is a Request to: Start a NEW Program Change a Current Program Stop a Program
Please choose one:

Not to exceed 10% or 15% of the value at the beginning of the contract year.
Withdraw Dollar Amount $ per period
Withdraw a Percentage % of Current Account Value. (This is NOT a % of the
Benefit Base.)
Systematic Withdrawals will continue until we are notified in writing to stop them.
Choose a Frequency: Monthly Quarterly Annually
Start Date: On (Month/Day/Year) May not start sooner than 28 days
after issue of the contract and may not start later than the 28th day of the month.
• Systematic withdrawals scheduled within three days of any Contract Date Anniversary when it occurs on a
non-business day may be processed in the following contract year and may have an adverse impact on the
optional benefits on your contract. If you wish to preserve your guaranteed income benefits, please call
(800) 789-7771 to receive an automated withdrawal quote under the Dollar for Dollar Withdrawal service.
Please call AXA Equitable at (800) 789-7771 before requesting a withdrawal under the following
circumstances:
• You would like to maintain your benefit base at a certain level, and you are not certain what impact the
withdrawal you have requested will have on your benefit base;
• Your contract’s issue date is between 4/1/02 and 12/9/04 and it has the annual ratchet or standard
death benefit instead of the roll-up death benefit; or
• You want more information about determining the effect of a withdrawal on your contract or you have any
other questions.
• You would like a customized systematic withdrawal quote that does not result in an Excess Withdrawal.
6. 72(t) Exception Withdrawals — Substantially Equal Withdrawals

Please note if you request a withdrawal from our Automatic 72(t) Exception Withdrawal Service, the amount
you request may reduce your GMIB and/or GMDB benefit bases by an amount greater than your requested
withdrawal amount. This could result in a significant negative impact on the value of your guaranteed benefit.
In addition, 72(t) withdrawals may cause your benefit base to be less on your next contract date anniversary
than in previous years. Please see Important Information on page 12 for a further explanation.
• Regardless of the calculation method you use, you may owe additional taxes or penalties if you stop,
change or roll over the annual withdrawals from the contract or make additional contributions or
rollovers to the contract before the later of 59½ or five years from the date of the first distribution.
Please note that the 1099 form at the end of the calendar year will reflect that the 72(t) exception
is no longer applicable if you make any such change or additional contribution.
•Y
our withdrawals will be taken from your account on a pro rata basis from the Variable Investment Options
(VIO) and the Guaranteed Interest Option (GIO). For Series 8.0 contracts and earlier ONLY: If you wish to
have your 72(t) payment withdrawn from specific investment options, please use the Withdrawal
Instructions in Section # 8 to specify from which investment options you would like your 72(t) funds
withdrawn.
• For all IRA Certificates/contracts except Inherited IRA; Not available for Guaranteed Withdrawal Benefit
for Life (GWBL) or Principal Guaranteed Benefit (PGB).
• This option may be elected at any time before attaining age 59½. Once this form is received in our
processing office, your 72(t) distribution payments will begin on the day you selected below.

6. 72(t) Exception Withdrawals — Substantially Equal Withdrawals (continued)
•C
lients over 59½ who began receiving 72(t) withdrawals from contracts issued by a prior carrier and who
are establishing new AXA Equitable contracts may request to continue their 72(t) withdrawal programs with
AXA Equitable. In order for us to properly complete your request you must provide documentation from the
prior carrier (amount / frequency / duration) about your 72(t) withdrawal program to the AXA Equitable
Processing Office.
• Select only one calculation method.
IMPORTANT NOTICE
Withdrawal the withdrawal instructions will be processed accordingly. (Not applicable for Series 06 and 07
B. Select Only One Calculation Method Below.
Fixed Annuitization Calculation Method:
Pay the level annual withdrawal amount the processing office calculates to me each year as follows:
Please make distribution amount of $ payable on the of the applicable month.
• If a quote is provided, we will process the request for the requested amount. If you would like us to
calculate the withdrawal for you, we will calculate it off the maximum amount available. If the
maximum amount will result in an excess withdrawal, the amount will be reduced as to not cause an
excess withdrawal, unless the check box is checked.
• The date selected may also not be later than the 28th day of the month.
• The date selected may not be within 3 days prior to the Contract Anniversary Date.
Fixed Amortization Calculation Method:

Pay the level annual withdrawal amount to me each year as follows:
Please make distribution amount of $ payable on the of the applicable month.
• A quote must be provided, we will process the request for the requested amount. If the amount
indicated will result in an excess withdrawal, the amount will be reduced as to not cause an excess
withdrawal, unless the check box is checked.
• The date selected may also not be later than the 28th day of the month.
• The date selected may not be within 3 days prior to the Contract Anniversary Date.
MD Calculation Method — I understand that I must calculate and submit a request for my distribution
R
amount annually.
My substantially equal withdrawal amount for taxable year is $ .
This amount I have provided for this taxable year should be divided and distributed to me as follows:
Choose a Frequency: Monthly Quarterly One Time Payment

7. Principal Protector (Guaranteed Withdrawal Benefit (GWB) Withdrawals)
• T his withdrawal option is available only if you elected Principal Protector (GWB) when your Accumulator
Series 04 contract was issued.
•A
mounts withdrawn in excess of your GWB Annual withdrawal amount may be subject to a withdrawal
charge (if applicable).
•W
ithdrawing more than your GWB Annual withdrawal amount will cause a GWB Excess withdrawal to occur
which can cause a significant reduction in both your GWB benefit base and your GWB Annual withdrawal
amount.
Please choose one:
One time withdrawal: $
Systematic withdrawals:
Amount of withdrawal: $ (The total amount calculated over the payment frequency
you elect, together with any other withdrawals during the contract year must not exceed your GWB Annual
Withdrawal amount.)

after issue of the contract and may not start later than the 28th day of the month
8. Guaranteed Withdrawal Benefit for Life (GWBL) Withdrawals

Available only for Series 06 and 07 contracts with GWBL, if elected.
•A mounts withdrawn in excess of your GWBL Annual withdrawal amount may be subject to a withdrawal
charge (if applicable).
• If you request a one-time withdrawal while you are enrolled in Customized or Maximum Payment Plan,
that payment plan will terminate.
• To enroll in the Automatic Required Minimum Distribution (RMD) Withdrawal Service with GWBL, complete
the Automatic RMD Withdrawal Service form (Cat. # 130888) please.
Automated Withdrawal Options (choose either A, B or C)
A. Maximum Payment Plan:
•W e will calculate and distribute to you the maximum amount you are entitled to withdraw each contract
year — your Guaranteed Annual Withdrawal amount — in scheduled payments.
•E
ach scheduled payment will be equal to your Guaranteed Annual Withdrawal amount divided by the
number of scheduled payments per year.
• T he payment amount may increase if your GWBL Benefit Base increases.

8. Guaranteed Withdrawal Benefit for Life (GWBL) Withdrawals (continued)
B. Customized Payment Plan:
• Your withdrawals will be taken from your account on a pro rata basis from the Variable Investment
Options (VIO) and the Guaranteed Interest Option (GIO). If you wish to have your payment withdrawn from
specific investment options, please use the Withdrawal Instructions in Section # 9 to specify from which
investment options you would like your funds withdrawn.
• You must provide a fixed dollar amount below that reflects the amount you want to receive for each
scheduled payment.
• Cumulative payments in a contract year must be less than or equal to your Guaranteed Annual
Withdrawal amount for each contract year.
• Your scheduled withdrawals will not automatically increase if there is an increase in your GWBL Benefit Base.
• If you take any lump sum distribution in the same contract year the program is scheduled to begin (but
prior to the commencement of the program), the lump sum payment will not be factored into your
scheduled payment requests for that contract year and may cause an Excess Withdrawal to occur.
• An Excess Withdrawal may cause a significant reduction in both your GWBL Benefit Base and your
Guaranteed Annual Withdrawal amount.
Amount for each scheduled payment: $
C. To Re-enroll in a GWBL Payment Plan:
• Please check one box below and complete the information above if you are enrolling in one of the Payment
Plans because your previous enrollment in either the Maximum Payment Plan or Customized Payment Plan
was terminated due to a one-time withdrawal.
• Your new scheduled payments will not begin until after your next contract anniversary.
Please choose one:
Re-enroll me in the Customized Payment Plan. I understand that my scheduled payments will not resume
until after my next contract anniversary.
Re-enroll me in the Maximum Payment Plan. I understand that my scheduled payments will not resume
until after my next contract anniversary.
9. Withdrawal Instructions
•U nless you specify otherwise on the lines below, the withdrawals will be taken from your account value on
a pro rata basis from the variable investment options, and if applicable, from the Guaranteed Interest
Option (GIO). Series 8.0 contracts and earlier are eligible to have systematic 72(t) and customized
payment plan withdrawals taken from specific investment options.
• If there is insufficient value in the variable investment options and the GIO, any additional amounts
required will be withdrawn from the fixed maturity options in order of the earliest maturity date first.
For Systematic withdrawals, 72(t) withdrawals, and Customized Payment Plan withdrawals from Series 8.0
contracts and earlier ONLY:
• If you choose specific investment options, and the value in the selected investment options(s) drops
below the requested withdrawal amount, the requested amount will be taken on a pro rata basis from all
investment options in the contract on the business day after the withdrawal was scheduled to occur. All
subsequent periodic withdrawals will be processed on a pro-rata basis from all investment options and
will be processed on the day of the month you elected.
Specific Withdrawal Instructions

10. Important Tax Notification & Withholding Election
• We will automatically withhold 10% Federal Income Tax from the taxable portion (NQ contracts) or the
gross amount (all IRAs) of your withdrawal unless you check option A below.
• If this is a Roth IRA, even though your distribution may not be taxable, we are required to withhold
Federal Income Tax from the gross amount of distribution, unless you elect out, as shown below. You will
be able generally to compute the taxable amount, if any, of your Roth IRA withdrawal on your own tax
return. We do not have to withhold if the distribution is clearly tax-free (for example, you have held this
Roth IRA for more than 5 years and you are older than age 59½).
• If this is a TSA or QP contract and this is an eligible rollover distribution, we will withhold 20% and you
cannot elect out. If this is not an eligible rollover distribution, 10% withholding applies.
• Some states require us to withhold state income tax if Federal Income Tax is withheld.
• If you are a US citizen/legal resident and the check is sent abroad, we must withhold tax.
• If you are not a US citizen/legal resident we require additional information. In addition to this form,
please send us a letter requesting this withdrawal, indicating your current residence and citizenship
status, along with an IRS Form W-8BEN. We will withhold 30% tax unless your Form W-8BEN properly
indicates to us that we may withhold at a different rate.
• Please be advised: Due to IRS implementation of the Foreign Account Tax Compliance Act (FATCA),
taxable disbursements made to entity (business or trust) owners/payees may be subject to 30%
withholding if proper documentation is not on file. Proper documentation is considered to be a properly
completed and signed IRS Form W-9 for domestic entities. Foreign entities are expected to submit a
properly completed and correct type of IRS Form W-8. In the event proper documentation is not on file
with AXA US (AXA Equitable, MLOA & USFL), we will withhold the required 30% upon disbursement. For
further details regarding the FATCA rules and regulations and how disbursements may be affected,
please contact your tax advisor.
• Please consult your tax advisor for rules that apply to you.
Withholding Election:
A. I do NOT want Federal Income Taxes (and state income tax, if applicable) withheld from my withdrawal or
surrender. I have provided my U.S. residence address and correct Taxpayer Identification Number below. I
have provided the correct Social Security Number for an individual or Employer Identification Number for a
non-natural owner. I understand that I am responsible for the payment of estimated taxes, and that I may
incur penalties if my payments are not enough. Under penalty of perjury, I certify that the following
Taxpayer Identification Number is correct:
Social Security Number / EIN / Other
B. ✔ I WANT to have 10% Federal Income Tax withheld from the taxable amount of my withdrawal or surrender
(you may also designate an additional percentage below).
C. I want an additional percentage of federal income tax withheld from my withdrawal or surrender:
% + 10% = %.
11. Signatures
• Please consult your prospectus for restrictions, minimum or maximum limitations, fees and other
applicable information relating to your request.
• Withdrawals from contracts with optional benefits in excess of the limits expressed in the contract may
significantly reduce the value of those benefits.
• All transactions will be processed effective with the business date this form is received (if all required
information is provided) in the processing office. Note: The business day generally ends at 4 PM Eastern Time.
• If we do not have an original signature on file, we will require a signature guarantee in order to process this
transaction. You can call Customer Service at (800) 789-7771 to confirm whether we have your original
signature on file.
• Direct Deposit: By my signature below I agree to the statement in the Direct Deposit Agreement in Section 3.

11. Signatures (continued)
I (We) hereby certify the following: (I) no bankruptcy proceeding, attachment, or other lien or claim is now
pending against the owner(s), (II) the Taxpayer Identification Number(s) (Social Security Number(s) or Employer
Identification Number(s), as applicable) on this form is correct, and (III) the owner(s) and annuitant are U.S.
citizens, or are U.S. non-citizens who are legal residents or “resident aliens.” (IV) If (III) is not true, I/we have
provided appropriate documentation as to citizenship and residence.
Any person who knowingly and with the intent to defraud any insurance company or other person files a
statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may
subject such person to criminal and civil penalties.
All contract owners must sign and date this form.
Signature:
Owner (if owned by an entity, show title) Current Date (mm/dd/yyyy)
Signature:
Joint Owner (if applicable) Current Date (mm/dd/yyyy)
Signature:
Custodial Owner Current Date (mm/dd/yyyy)
Signature:
Assignees (if any) or Authorized Representative (include title) Current Date (mm/dd/yyyy)
Medallion Signature Guarantee: (Please place medallion Each signature must be guaranteed by a bank,
signature guarantee stamp below.) broker-dealer, savings and loan association, credit
union, national securities exchange or other “eligible
guarantor institution” as defined in rules adopted by
the Securities and Exchange Commission. Signatures
may also be guaranteed with a medallion stamp of the
STAMP program or the NYSE Medallion Signature
Program, provided that the amount of the transaction
does not exceed the relevant surety coverage of the
medallion. A medallion signature guarantee may
NOT be obtained through a notary public.
Note: Endorsement guarantee is not acceptable.
12. Special Instructions

IMPORTANT INFORMATION ABOUT YOUR GUARANTEED BENEFITS TO CONSIDER BEFORE TAKING A ONE-TIME
WITHDRAWAL (SECTION 4) OR SETTING UP A SYSTEMATIC WITHDRAWAL (SECTION 5) OR 72(t) EXCEPTION
WITHDRAWALS (SECTION 6)
• In general, when you take money out of your contract, you also reduce the GMIB/GMDB roll-up benefit bases in the same amount as the
amount withdrawn (“Dollar for Dollar Reduction”). However, if your total withdrawals in a contract year exceed a certain amount
(“Excess Withdrawal”), your roll-up benefit bases are reduced pro-rata (“Pro Rata Reduction”).
• Under most contracts, an Excess Withdrawal occurs when your withdrawals in a contract year exceed your roll-up rate times your roll-up
benefit base as of your most recent contract date anniversary.
• A Pro Rata Reduction means that we calculate the percentage of your account value that is being withdrawn and reduce your roll-up base by
that percentage.
• When your account value is less than your roll-up benefit base, an Excess Withdrawal can significantly reduce your roll-up benefit base by an
amount that is greater than the requested withdrawal; conversely, when your account value is greater than your roll-up benefit base, an Excess
Withdrawal will result in a reduction to your roll-up benefit base that is less than your requested withdrawal amount. The effect of an Excess
Withdrawal is determined using your account value on the withdrawal transaction date when we process the withdrawal.
• For example, if your account value at the time of an Excess Withdrawal is $100,000 and your roll-up benefit base is $200,000, and you
withdraw $40,000 in cash, your roll-up benefit base would be reduced by 40%, or $80,000; however, if your account value is, instead,
$400,000, your benefit base would be reduced by 10% or $20,000.
• Please note that certain guaranteed benefits are calculated using a benefit base that is not based on a roll-up amount. Generally, these
benefit bases are reduced on a pro rata basis.
• If your contract was issued between 4/1/2012 and 12/9/2014 and the standard death benefit or annual ratchet death benefit was elected
without the GMIB, an Excess Withdrawal may occur when withdrawals in a contract year exceed the rate specified in the contract times the
death benefit as of the most recent contract date anniversary. These contracts do not have a roll-up benefit base. However, the amount shown
above as a reduction to the roll-up benefit base is the reduction to your death benefit.
• As a reminder, the guaranteed benefit charges and the annual administrative charge, if applicable, are deducted from the Annuity Account
Value (AAV) on the contract date anniversary, and you can exercise the GMIB, if eligible, only during the 30 day period following the contract
date anniversary. If you plan to exercise your GMIB, please ensure that your AAV will have a value that is greater than 0 after the annual fees
are deducted on the contract date anniversary, before you exercise.
SECTION 5 - SYSTEMATIC WITHDRAWALS (Also see above)
• Your first check will be sent on the specified start date and will be sent monthly/quarterly/annually thereafter.
Withdrawals may not exceed the following percentages of your account value:
For Accumulator Series’ 04, 06, 07, 8.0 and 9.0 and all Accumulator Elite contracts:
• 0.8% monthly, 2.4% quarterly and 10.0% annually
All other Accumulator Series contracts:
• 1.2% monthly, 3.6% quarterly and 15.0% annually
• Series 8.0 and 9.0 contracts that have no Contingent Withdrawal Charges (CWCs) can elect percentages greater than 10% or 15% of the
account value, depending on the contract terms, up to an annual maximum of 90% of the account value as of the transaction date (excludes
Accumulator Select). Electing an annual maximum percentage greater than 90% will result in the surrendering of the contract. If a subsequent
contribution is made to the contract after you have elected a Systematic Withdrawal percentage greater than 0.8% monthly, 2.4% quarterly
and 10% annually, as of the beginning of the contract year in which the subsequent contribution is made, the Systematic Withdrawal Option
will be terminated automatically. A new SWO with percentages within the contract’s threshold may be reestablished using this form.
Your withdrawals will be taken from your account on a pro rata basis from the Variable Investment Options (VIO) and the Guaranteed Interest
Option (GIO). For Series 8.0 contracts and earlier ONLY: If you wish to have your SWO payment withdrawn from specific investment
options, please use the Withdrawal Instructions in Section # 8 to specify from which investment options you would like your SWO funds
withdrawn. Once the requested amount is greater than your annuity account value, we will terminate your SWO program.
SECTION 6 - 72 (t) Exception Withdrawals-Substantially Equal Withdrawals (Also see above)
• Withdrawals prior to age 59½ from IRAs are subject to an additional 10% federal income tax early distribution penalty under Section 72(t),
unless an exception applies. One exception applies to withdrawals which are part of a series of substantially equal periodic payments (the
“Section 72(t) SEPP exception”). There are three IRS-approved methods that can be used when calculating Section 72(t) SEPP exception
payments. They are the fixed annuitization method, the fixed amortization method, and the required minimum distribution (RMD) method. The
three methods are described in Rev. Rul. 2002-62. For more information or to obtain a copy of Rev. Rul. 2002-62 please call (800) 789-7771;
it is also available on the IRS website.

Important Information (Continued)
• If you would like us to calculate the withdrawal for you, we use the fixed annuitization method. You can calculate your withdrawal using one of the
other methods. In order to report the payments on Form 1099-R with the penalty exception code, we need to have a record of which IRS-approved
calculation method you are using. If you choose the fixed amortization method, you must provide an illustration of your calculation with your
request. If you choose the RMD method, you will be responsible for calculating the amount each year and requesting the withdrawals.
• Your withdrawals will be taken from your account on a pro rata basis from the Variable Investment Options (VIO) and the Guaranteed Interest
Option (GIO). For Series 8.0 contracts and earlier ONLY: If you wish to have your 72(t) payment withdrawn from specific
investment options, please use the Withdrawal Instructions in Section # 8 to specify from which investment options you
would like your 72(t) funds withdrawn.
Fixed Annuitization Calculation Method
• You may not elect to receive the first payment in the same contract year in which a lump sum withdrawal was taken, nor can this option be
elected while special dollar cost averaging (where applicable) is in effect.
• If you stop or change the withdrawals, or if a lump sum withdrawal is taken while this option is chosen, it will cancel this election. In that event,
you may be liable for an additional tax penalty on Substantially Equal Withdrawals taken before cancellation.
RMD Calculation Method
• You must calculate and submit a request for your distribution amount annually.
• Check the box in this section only if you want to use the Required Minimum Distribution (RMD) calculation method or you elected the one time
change to the RMD method of calculation on the 72(t) Penalty Exception Substantially Equal Periodic Payment (SEPP) Change Form (Cat. No.
132042).
• Accumulator does not use the RMD calculation method for automatic distribution for its Substantially Equal Withdrawal program. You are
responsible for the manual calculation for this distribution option and you must send us your requested amount each year as this distribution
method will produce a different payment amount every year.
• If this request is not received each year, no amount will be disbursed to you. By your signature in section 10, you tell us that this current
payment and future payments are not subject to the additional 10% federal income tax penalty.
• If this exception to the penalty becomes invalid at any time, you agree to advise us of this change in writing.
SECTION 7 - Guaranteed Withdrawal Benefit (GWB): Accumulator Series 04 Only
• The dollar amount you indicate in this section, together with any other withdrawals you take during the contract year should not exceed your
GWB Annual withdrawal amount (5% of your initial GWB benefit base adjusted thereafter for additional contributions, an optional step up or
for GWB Excess withdrawals).
• Withdrawing more than your GWB Annual withdrawal amount will cause a GWB Excess withdrawal to occur which can cause a significant
reduction in both your GWB benefit base and your GWB Annual withdrawal amount.
• Please note that amounts withdrawn in excess of your GWB Annual withdrawal amount may be subject to a withdrawal charge (if applicable).
• All withdrawals that you make count towards the free corridor amount available under your contract.
SECTION 8 - Guaranteed Withdrawal Benefit for Life (GWBL) Accumulator Series 06 and Series 07 Only
• If you take a lump sum withdrawal, this program will be terminated and amounts withdrawn in excess of your Guaranteed Annual Withdrawal
amount may be subject to a withdrawal charge (if applicable).
• All withdrawals that you make count towards the free corridor amount available under your contract.
• You must choose the Maximum or the Customized Payment Plan.
• Under Maximum Payment Plan
• We will calculate and distribute to you the maximum amount you are entitled to withdraw each contract year — your Guaranteed Annual
Withdrawal amount — in scheduled payments.
• Each scheduled payment will be equal to your Guaranteed Annual Withdrawal amount divided by the number of scheduled payments per year.
• The payment amount may increase if your GWBL Benefit Base increases.
• If scheduled payments begin in the middle of a contract year, we will make as many periodic payments in the amount determined at the
start date until the next contract anniversary. So for that contract year, you may not receive the full Guaranteed Annual Withdrawal amount.
• Under Customized Payment Plan
• Your withdrawals will be taken from your account on a pro rata basis from the Variable Investment Options (VIO) and the Guaranteed
Interest Option (GIO). If you wish to have your payment withdrawn from specific investment options, please use the
Withdrawal Instructions in Section # 9 to specify from which investment options you would like your funds withdrawn.

Page 12 of 13 E14638
Cat. #148485 (January 2018)
Important Information (Continued)
• You must provide a fixed dollar amount that reflects the amount you want to receive for each scheduled payment.
• Cumulative payments in a contract year must be less than or equal to your Guaranteed Annual Withdrawal amount for each contract year.
• Your scheduled withdrawals will not automatically increase if there is an increase in your GWBL Benefit Base.
• If you take any lump sum distribution in the same contract year the program is scheduled to begin (but prior to the commencement of the program),
the lump sum payment will not be factored into your scheduled payment requests for that contract year and may cause an Excess Withdrawal to occur.
• An Excess Withdrawal may cause a significant reduction in both your GWBL Benefit Base and your Guaranteed Annual Withdrawal amount.
SECTION 9 - Withdrawal instructions
• Unless you specify otherwise, withdrawals will be taken from your account value on a pro rata basis from the variable investment options, and
if applicable, from the Guaranteed Interest Option. Series 8.0 contracts and earlier are eligible to have systematic, 72(t), and
customized payment plan withdrawals taken from specific investment options.
• If there is insufficient value, in the variable investment options and the GIO, any additional amounts required will be withdrawn from the fixed
maturity options in order of the earliest maturity date first.
For Systematic withdrawals, 72(t) withdrawals, and Customized Payment Plan withdrawals from Series 8.0 contracts and
earlier ONLY: If you choose specific investment options, and the value in the selected investment options(s) drops below the requested
withdrawal amount, the requested amount will be taken on a pro rata basis from all investment options in the contract on the business day after
the withdrawal was scheduled to occur. All subsequent periodic withdrawals will be processed on a pro-rata basis from all investment options
and will be processed on the day of the month you elected.
Cat. #148485 (January 2018)
Page 13 of 13 E14638

Sheila McCorriston Withdrawal

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Sheila McCorriston Withdrawal

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Please contact AXA Equitable at (800) 789-7771 before requesting

a withdrawal if you would like to maintain your benefit base at

Accumulator® AXA Equitable Life Insurance Company

Disbursement P.O. Box 1547

2. Owner’s Information (Please print and fill in all information)

Owner’s Name: Sheila Christine McCorriston

Joint Owner’s Name:

Owner’s/Joint Owner’s Daytime Phone Number(s) 215-285-1948

Owner’s Email Address: phillygirl72@yahoo.com

Series 9.0 and Earlier

Routing Number (9 digits):

Account Holder Name

Bank Name (Required)

Financial Institution’s Name (Required)

For Further Credit to:

Please attach a VOID check (Not a deposit slip)

Series 9.0 and Earlier

B. Please choose one:

Please choose one:

6. 72(t) Exception Withdrawals — Substantially Equal Withdrawals

Series 9.0 and Earlier

Fixed Amortization Calculation Method:

Series 9.0 and Earlier

• WITHHOLDING: You must complete Section 10.

Please choose one:

One time withdrawal: $

Start Date:  On (Month/Day/Year) May not start sooner than 28 days

8. Guaranteed Withdrawal Benefit for Life (GWBL) Withdrawals

Series 9.0 and Earlier

Series 9.0 and Earlier

Series 9.0 and Earlier

All contract owners must sign and date this form.

Note: Endorsement guarantee is not acceptable.

12. Special Instructions

Series 9.0 and Earlier

Cat. #148485 (January 2018)

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Start Date: On (Month/Day/Year) May not start sooner than 28 days