Required Minimum Distribution Election Form - Penn Mutual

Required Minimum Distribution Election Form
Instructions
• To elect a Required Minimum Distribution complete sections: 1, 2, 3, 4, 5 and 7.
• If you would like Direct Deposit of your payments under any option, complete section 6.
• Please note that it is your responsibility to ensure that your overall Required Minimum Distribution is satisfied.
• If you have any questions regarding how to complete this form, please contact Customer Service at
1-800-523-0650, Monday through Friday.
• For Inflation Protector and Guaranteed Growth & Income Benefits use Form # KA9216.
1. Account Information
Name of Contract Owner
Contract Number
2. RMD Information
RMD Year
RMD Amount
Please provide date of birth and daytime phone number.
Date of Birth (mm/dd/yyyy)
/ /
Daytime Phone Number
( ) —
Note: The Required Minimum Distribution (RMD) amount stated above is based on your life expectancy using the
IRS Uniform Life Expectancy Table. If your contract is a Stretch IRA, the RMD is calculated using the Single Life Table.
3. RMD Calculation Method (please select only one option)
Please choose one of the following Required Minimum Distribution calculation methods below:
Uniform Distribution Table (select if your spouse is not your sole beneficiary or is not more than 10 years
younger than you)
Single Life Table (for Stretch IRAs Only)
Joint Life Expectancy (select only if your spouse is sole beneficiary and is more than 10 years younger than you)
Name of Beneficiary (First) (Middle) (Last)
/ /
Spouse's Date of Birth (mm/dd/yyyy)
KA9223 10/12 The Penn Mutual Life Insurance Company, 600 Dresher Road
Page 1 of 4
Horsham, PA 19044, www.pennmutual.com

4. RMD Withdrawal Schedule Selection (please select only one option). Option 1 is a Withdrawal
Schedule and Option 2 is a One-Time Distribution.
If you would like to start having your Required Minimum Distribution amount automatically withdrawn from your
contract, please complete this section.
Option 1. RMD Withdrawal Schedule - If you choose a monthly, quarterly or semi-annual frequency, we
will divide the payments by the remaining months in the calendar year.
RMD Withdrawal Frequency Monthly Quarterly Semi - Annual Annual
RMD Withdrawal Start Date(s)
You must specify the start date for your RMD automatic withdrawals in section A below. If you
become 70 ½ this year and are an IRA or retired 403(b) owner, you have the option to defer your
first RMD payment until April 1st of the following year. To select the deferral option, complete
section B only.
Must Select A or B.
A. RMD Automatic Withdrawal Start Date (mm/dd/yyyy)
OR
B. April 1st Lump Sum Distribution Date (mm/dd/yyyy)
RMD Automatic Withdrawal Start Date (mm/dd/yyyy)
/ /
/ /
/ /
Notes:
• Non-spousal Stretch IRA holders must begin RMD by December 31st of the year following the date of death.
• Spousal Stretch IRA holders can postpone RMD until the decedent would have been age 70 ½.
• Do not specify the 29th, 30th or 31st day of the month since these dates do not occur every month.
• For withdrawals to be sent via Electronic Funds Transfer (EFT) to your bank, your withdrawal effective date
must be the 2nd, 8th, 15th, or 28th of a given month. (Note: It will take a minimum of 2 business days for the
transfer to process.)
• Because of calculations that occur on your policy anniversary, systematic withdrawals cannot be scheduled
on the "day" of contract issue. For example, if your contract issue date is 03/19/1997 you cannot elect to start
withdrawals on the 19th day of any month.
For IRAs and retired 403(b) owners only: if you become 70 ½ this year you can defer your first payment until
April 1st of the following year. However, if you do so, you must satisfy both distributions - one for the year you
turned 70 ½ and another for the following year.
• The first distribution must be taken by April 1 of next year, in one lump sum payment and the second
distribution must be taken by December 31st of the same year.
• If you choose to defer your payment, please select the dates in which you want to satisfy both of your
distributions in Option B above.
Option 2. One-Time Distribution
At this time, I do not want to set up an automatic Required Minimum Distribution payout. I would
like to take a one-time distribution to satisfy my Required Minimum Distribution for this year only.
I understand that this distribution will be effective as of the date Penn Mutual receives this form.
KA9224 10/12 Page 2 of 4

5. W-4P Notice of Federal and State Tax Withholding (select one)
Do not withhold federal income tax from the taxable portion of my withdrawal payment(s). I understand that
if I do not have federal income tax withheld, I may be responsible for payments of estimated tax and penalties
if I fail to make such payments.
Please withhold % for federal withholding and/or % for state withholding.
Important Information Regarding Your Withholding:
• If you do not specify a withholding election percentage, we are required by the IRS to withhold 10% of the
taxable portion of your distribution.
• If you elect federal withholding, the minimum amount of withholding elected must be at least 10% of the
taxable portion of your distribution.
• Please note that some states require mandatory state withholding if you elect federal withholding.
• Distributions from your annuity may have tax implications. You may wish to consult your financial professional.
• You may change your withholding election for future withdrawals by completing a new W-4P.
6. Direct Deposit Banking Information
Please complete the following information, to set up direct deposit for your withdrawal payments.
Note: If you do not select direct deposit, we will mail a check to your address of record. The check will be made
payable to the contract owner of record.
1. Type of Account Checking Account Savings Account
2. Name of Account
3. ABA Routing Transit No.
4. Account No.
5. Bank Phone Number with Area Code
( ) —
If you have elected to have your withdrawal payments transferred electronically, please include a copy of a voided
check for verification purposes. Your check must be pre-printed with your name and the bank's name. You may
submit written verification from your financial institution if you have a Savings Account or do not have pre-printed
checks for your account. Please attach below.
Attach check here:
KA9225 10/12 Page 3 of 4

7. Signatures
There may be contractual charges for taking a withdrawal from your annuity contract. If you have any
questions, please consult your contract prospectus, your financial professional, or one of our Customer
Service Representatives.
• I represent that no bankruptcy or insolvency proceeding is pending with respect to me.
• My signature below indicates I have read and understand the preceding information and elect to proceed
with this transaction.
Contract Owner Signature
/ /
Date (mm/dd/yyyy)
Contract Co-Owner Signature (if applicable)
/ /
Date (mm/dd/yyyy)
Please return form to Penn Mutual Life Insurance Company, Annuity Services
P.O. Box 178, Philadelphia, PA 19105-0178, or fax to 215-956-7699
If you have questions please call Customer Service, Monday through Friday at 1-800-523-0650
KA9226 10/12 Page 4 of 4