Request for Annuity Service - NestEgg Builders

The Lincoln National Life Insurance Company (LNL)
Lincoln Life & Annuity Company of New York (LLANY)
RPS Changes
PO Box 7809
Fort Wayne IN, 46801-7809
Phone - 1-800-487-1485
FAX - 260-455-4578
Request for Annuity Service
Owner(s) Name Telephone Number Policy* Number Social Security Number
Owner's Street Address
Owner's City, State, Zip
1. Change Of Address
Owner
Annuitant
Payee
Street
City State Zip
2. Change Of Beneficiary
The following will replace all prior beneficiary designations.
Name Relationship Date of Birth
1.
Address
Primary 2.
Address
3.
Address
Name Relationship Date of Birth
1.
Address
Contingent 2.
Address
3.
Address
3. Change Of Name Owner
Annuitant
Copy of legal document needed (divorce decree, marriage license, etc.)
Previous Full Name
New Full Name
4. Miscellaneous Service Request
• If Joint Ownership, both Owners must sign. • If Corporation is Owner, signatures and titles of two Corporate officers are required.
Owner's Signature Date Joint Owner's Signature Date
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
*Policy may be referred to as "contract" or "certificate" in certain states.
Page 1 of 4
AN07048 4/08

The Lincoln National Life Insurance Company (LNL)
Lincoln Life & Annuity Company of New York (LLANY)
RPS Changes
PO Box 7809
Fort Wayne IN, 46801-7809
Phone - 1-800-487-1485
FAX - 260-455-4578
Owner(s) Name Telephone Number Policy* Number Social Security Number
Owner's Street Address
Owner's City, State, Zip
5. Withdrawal or Surrender
(also complete #7 below)
Please withdraw the maximum free partial surrender available.
Please withdraw the amount necessary to net _______________ after any applicable surrender charges and/or taxes.
Please fully surrender my policy. As consideration for this payment:
• I am attaching my policy and releasing the Company from any and all claims or demands which arise under the policy.
• I state that my policy has been lost or destroyed and that I have no knowledge as to its whereabouts. No person or persons, corporation
or association, has any claim or interest in said annuity, by virtue of any sales, assignment or pledge thereof; and no bankruptcy
proceedings are pending or threatened against me; except as follows: (Give names and addresses. If no exceptions,
insert, "No Exceptions.")
‣ ____________________________________________________________________________________________
6. Systematic Withdrawals
(also complete #7 below)
Please note this feature is not available on all annuity plans and may be
subject to policy limitations.
The minimum account value must be $20,000 to process on a monthly basis. The minimum account value must be $10,000 to
process on a quarterly, semi-annual or annual basis.
Payment Amount: Interest Only _________ % of accumulated value Other $ ______________
Payment Frequency: Monthly Quarterly Semi-Annual Annual
Begin Date:
______________________ (cannot be 29th, 30th or 31st of the month)
Payment Method: Check Direct Deposit: Checking (attach voided check) Savings (attach voided deposit slip)
All interest rates are expressed as annual effective interest rates. Options other than annual will total less than annual withdrawals
because of the interruption of interest compounding.
7. Tax Information and Withholding Election
Required before any distribution is made.
The Federal Tax Law provides that any distribution to you from an annuity policy is subject to Federal income tax withholding. There will be
no withholding on the portion of distribution that represents the return of your non-qualified premium payments. Please Note: If no election is
indicated, we are required to withhold 10% of the taxable amount for Federal income taxes.
You may elect to have no withholding apply to your distribution; however, you may be responsible for payment of any estimated tax due on
the distribution. You may also incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient.
Anyone under the age of 59 1/2 may be subject to a 10% Federal tax penalty on the taxable portion of the distribution.
Instructions: Check Box A, B, C or D below to indicate whether you want Income Tax withheld from your withdrawal.
A. I do not want to have any Income Tax withheld from my withdrawal.
B. I want Federal Income Tax withheld from my withdrawal at the 10% rate.
C. I want Federal Income Tax withheld from my withdrawal but not at the 10% rate. Withhold $ ______________ or _________ % for
Federal Income Tax from my withdrawal.
Note: If you are a resident of any state requiring withholding, by checking B or C, you are electing to also withhold state income
taxes, unless you specifically indicate otherwise below.
D. Do NOT withhold STATE income tax.
• If Joint Ownership, both Owners must sign. • If Corporation is Owner, signatures and titles of two Corporate officers are required.
Owner's Signature Date Joint Owner's Signature Date
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
*Policy may be referred to as "contract" or "certificate" in certain states.
Page 2 of 4
AN07048 4/08

The Lincoln National Life Insurance Company (LNL)
Lincoln Life & Annuity Company of New York (LLANY)
RPS Changes
PO Box 7809
Fort Wayne IN, 46801-7809
Phone - 1-800-487-1485
FAX - 260-455-4578
Owner(s) Name Telephone Number Policy* Number Social Security Number
Owner's Street Address
Owner's City, State, Zip
8. Annuitization
Payment: Income for Fixed Period (5 to 15 years) Guaranteed for __________ Years
Life Only Income
Life Income with Guaranteed Period (5, 10, 15, 20 years) Guaranteed for __________ Years
Other _______________________________________________________
_______________________________________________________
Begin Date:
___________________________________________ (cannot be 29th, 30th or 31st of the month)
Frequency: Monthly Quarterly Semi-Annual Annual
Payment Method:
Check
Direct Deposit _______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
The Federal Tax Law provides that any distribution to you from an annuity policy is subject to Federal income tax withholding.
There will be no withholding on the portion of distribution that represents the return of your non-qualified premium payments.
You may elect to have no withholding apply to your distribution; however, you may be responsible for payment of any estimated
tax due on the distribution. You may also incur penalties under the estimated tax rules if your withholding and estimated tax
payments are not sufficient. Anyone under the age of 59 1/2 may be subject to a 10% Federal tax penalty on the taxable portion
of the distribution.
I elect not to have any income tax withheld from any distributions made from my annuity.
I want my withholding from each periodic pension or annuity payment to be calculated using the number of allowances
and marital status shown. Number of allowances: ___________
Marital status: Single Married
• If Joint Ownership, both Owners must sign. • If Corporation is Owner, signatures and titles of two Corporate officers are required.
Owner's Signature Date Joint Owner's Signature Date
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
*Policy may be referred to as "contract" or "certificate" in certain states.
Page 3 of 4
AN07048 4/08

The Lincoln National Life Insurance Company (LNL)
Lincoln Life & Annuity Company of New York (LLANY)
RPS Changes
PO Box 7809
Fort Wayne IN, 46801-7809
Phone - 1-800-487-1485
FAX - 260-455-4578
Owner(s) Name Telephone Number Policy* Number Social Security Number
Owner's Street Address
Owner's City, State, Zip
9. Change of Owner(s)
Owner Full Name
The following will replace all prior Owner and Joint Owner designations.
Joint Owner Full Name
Street
Street
City, State, Zip
City, State, Zip
Social Security Number Date of Birth Male Social Security Number Date of Birth Male
Female
Female
Please note, a change of ownership may result in tax consequences.
Certification:
Under penalties of perjury, I certify that: (1) The number shown on this form is my correct Social Security Number or Taxpayer
Identification Number (or I am waiting for one to be issued to me) and (2) I am not subject to backup withholding either because I have not
been notified by the Internal Revenue Service ("IRS") that I am subject to backup withholding as a result of failure to report all interest or
dividends, or the IRS has notified me that I am no longer subject to backup withholding.
Certification Instructions:
You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because of under reporting interest or dividends on your tax return.
Owner's Signature Date Joint Owner's Signature Date
New Owner Signature
Date
10. Change of Annuitant(s) The following will replace all prior Annuitant and Joint Annuitant designations.
Annuitant Full Name
Joint Annuitant Full Name
Street
Street
City, State, Zip
City, State, Zip
Social Security Number Date of Birth Male Social Security Number Date of Birth Male
Female
Female
Annuitant's Signature Date Joint Annuitant's Signature Date
• If Joint Ownership, both Owners must sign.
• If Corporation is Owner, signatures and titles of two Corporate officers are required.
Owner's Signature Date Joint Owner's Signature Date
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
*Policy may be referred to as "contract" or "certificate" in certain states.
Page 4 of 4
AN07048 4/08