NON-QUALIFIED ANNUITIES - Request for
Disbursement/Systematic Withdrawal Form
INSURER: FIDELITY & GUARANTY LIFE INSURANCE COMPANY
ADMIN 5587 (01-2011) Fidelity & Guaranty Life Insurance Company Des Moines, IA Rev. 06-2015
SECTION 4 -When this section is complete, please proceed to Section 5.
LOST POLICY CERTIFICATION
By checking this box, I hereby represent that the above-referenced policy has been lost, mislaid, or destroyed, as I have
been unable to find it after careful search and inquiry. By my signature below, I agree to hold the Company harmless
from all loss, expense and liability for which the Company may become liable as a direct or indirect result of accepting
this transaction without requiring the return of the policy.
SECTION 5 – NOTICE OF TAX AND WITHHOLDING ELECTION (MUST BE COMPLETED)
x
The Company will withhold, as required by law, federal income tax from the taxable portion of your withdrawal unless
you elect not to have any withholding.
x Federal income tax withholding is generally at a 10% rate, but you may elect not to withhold any taxes. PLEASE
CONSULT A TAX ADVISOR REGARDING YOUR SPECIFIC SITUATION PRIOR TO MAKING YOUR ELECTION.
x The election to have no withholding is available only to individuals who are U.S. Citizens or residents and have a mailing
address in the United States. If the distribution is being delivered outside the United States, or in care of a person in the
U.S., additional withholding requirements apply.
x If you are not a U.S. Citizen or U.S. person, the federal income tax withholding rate is 30%. A valid, accurate and
complete W-8BEN form must be submitted in order to claim treaty exemption and must include a Taxpayer Identification
Number along with date of birth.
x If you elect not to have federal or state income tax withheld, you may still be liable for payment of federal income and, if
applicable, state income tax on the taxable portion of the distribution.
x You may be subject to tax penalties under the Estimated Tax Payment Rules if any payments of estimated tax and
withholding are insufficient (IRS Publication 505 explains federal estimated tax requirements and penalties).
x The Internal Revenue Service may impose tax penalties for distributions prior to age 59 ½.
x In states where state income tax is not required or is voluntary for the Company, we DO NOT withhold state income
taxes.
x State income tax will be withheld in states where it is mandatory, unless you elect not to have withholding.
x You may revoke your Federal withholding election at any time by filing IRS Form W-4P. Your election will remain
in effect until revoked.
Check one:
DO NOT withhold Federal Income Tax
Withhold Federal Income Tax- (The maximum amount may not exceed the taxable amount) $ .
You are required to furnish your state’s withholding form where applicable, please contact your tax advisor or your
state’s taxing authority for questions. AZ, AR, CA, CT, IN, IA, KY, ME, MD, MA, NY, NC, OH, WV, MS, NC.
DO NOT withhold State Income Tax
Withhold State Income Tax – minimum required - Certain States allow you to specify the amount if applicable please
specify desired amount. ___________________________ % or $ _______________________________________ .
SECTION 6 – SIGNATURE & CERTIFICATION
1. I have read and understand all sections of this form that are applicable to my request.
2. I understand that the distributions will be taken proportionately from all interest crediting options.
3. I understand that if my withdrawal(s) exceed(s) the free withdrawal amount specified in my policy, the withdrawal(s) will
be subject to Surrender Charges and any applicable Market Value Adjustment.
4. All information and certifications provided by me are true and complete to the best of my knowledge and belief. I am
aware that there may be tax consequences associated with this transaction.
5. I am aware that Fidelity & Guaranty Life Insurance Company, affiliates and representatives cannot give tax advice and I
have been advised to consult an independent tax advisor.
6. I certify that my Social Security/Taxpayer Identification Number on this form is correct, that I am a U.S. person (U.S.
citizen or resident alien).
7. I certify that I am not subject to backup withholding due to failure to report interest and dividend income.
8. I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting.
9. By not furnishing the correct Taxpayer Identification Number, I may be subject to additional penalties imposed by the
Internal Revenue Service.
