TIAA 1035 EXCHANGE AUTHORIZATION
TO ALTERNATE INVESTMENT COMPANY
TRANSFER PAYOUT ANNUITY FOR ATRA
Page 3 of 3
TADTEM/OPYXFRATRA
F10926 (7/18)
6. YOUR AUTHORIZATION AND SIGNATURE
By signing below, you agree that:
You will return your completed Authorization with a 1035 Exchange form from the insurance company that
is accepting your initial transfer;
The date your Transfer Payout Annuity contract is issued cannot be prior to the receipt of all necessary papers;
Once your Transfer Payout Annuity contract is issued, it cannot be revoked nor can the amount be changed;
You authorize the continuation of the beneficiaries under the original contract listed in Section 2. Once the
contract is issued, you reserve the right to change this designation at any time.
You hereby authorize this payment and a partial surrender of the above-referenced contract accumulation
to the designated accepting insurance company;
You intend this transfer to be part of an exchange under Internal Revenue Code Section 1035; no part of
the contract accumulation shall be received actually or constructively by you;
You represent and warrant that no person, firm or corporation has an interest in the captioned contract
except the undersigned, and that no proceedings of either a legal or equitable nature are pending which
might affect said contract;
You represent that a copy of this original assignment shall be as valid as original;
As the insurance company accepting this transfer the alternate investment company requests full
surrender of the above-referenced contract. The surrender represents the transfer of funds in 10 payments
over 9 years to the alternate investment company and qualifies as a 1035 Exchange.
For your protection, TIAA may require additional verification of your identity before accepting your transaction
as in good order. You agree that your transaction will be valued as of the market close on the business day
that all of the steps necessary to verify your identity and the transaction to be in good order have been
completed. You also agree that in the event these steps are completed after the market close on a business
day, then your transaction will be valued as of the market close on the next business day. The amount
of money that you receive will depend on the share or unit price on the day on which your transaction is
deemed to be in good order. Due to market fluctuations, the price your shares or units ultimately receive
could be less than the share or unit price when you initiated this transaction. It is also possible that if we
are unable to reach you to verify this transaction within 5 days, this transaction may be canceled.
Please sign your full
legal name with suffix, if
applicable, using black
or dark blue ink, or online
using TIAA’s digital signing
experiences. Non-TIAA digital
signatures, such as signing
with Adobe Acrobat, are
not accepted.
Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer
identification number (or I am waiting for a number to be issued to me); and (2) I am not subject to
backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified
by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure
to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup
withholding; and (3) I am a U.S. citizen or other U.S. person; and (4) The FATCA code(s) entered on this
form (if any) indicating that I am exempt from FATCA reporting is correct.
Your Signature Today’s Date (mm/dd/yyyy)
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