Incoming Funds Transfer - Security Benefit

Questions? Call our National Service Center at 1-800-888-2461.®Security Benefit Total Value AnnuityIncoming Funds RequestInstructionsUse this form to transfer funds from your current carrier to Security Benefit. Complete the entire form. Please typeor print.1. The Owner should complete this Incoming Funds Request form and any applicable state-required replacementforms.2. Please contact your current carrier for any requirements it may have for transferring money to another company.3. Obtain Signature Guarantee if required by your current carrier.4. Upon receiving this material Security Benefit will send an acceptance letter to the carrier.1. Provide Client and Account Information❑ Application Attached or Contract Number __________________________________________________________________________Name of Owner __________________________________________________ ______ ___________________________________________First MI LastSocial Security Number/Tax I.D. Number ___________________________________Name of Joint Owner_______________________________________________ ______ _________________________________________(if applicable) First MI LastSocial Security Number/Tax I.D. Number ___________________________________Name of Annuitant___________________________________________ ______ ________________________________________________(if different from Owner) First MI LastSocial Security Number/Tax I.D. Number ___________________________________The account to which the funds are being transferred is a:(please select only one)❍ Roth IRA ❍ Traditional IRA ❍ SEP-IRA ❍ Non-qualified Annuity2. Provide Your Current Carrier InformationCurrent Carrier’s Name ______________________________________________________________________________________________Mailing Address _________________________________________________ _____________________ ______ ______________________Street Address City State ZIP CodePhone Number _________________________________ Account Number for Current Carrier _______________________________Please indicate the current account type (i.e., IRA, 403(b), or Non-qualified): ________________________________________________Please indicate the current investment vehicle (i.e., CD, Mutual Fund, 401(k), etc.): __________________________________________If this request involves your entire account balance, please check one of the following. My policy is:❍ Enclosed❍ Lost/destroyedPlease Continue IM-32300-00 2015/01/12 (1/3)

3. Set Up Transfer/Exchange/Rollover OptionType of Transfer/Rollover❍ 1035 Exchange:I hereby make complete and absolute assignment and transfer all or the portion specified of my rights, title and interest of every nature andcharacter in and to the Current Carrier Account in Section 2 to Security Benefit Life Insurance Company (SBL) in an exchange intendedto qualify under Section 1035 of the Internal Revenue Code. I understand that by executing this assignment, I irrevocably waive all rights,claims and demands under the above policy for the portion specified.If you effect, or have effected, a partial exchange from a previously existing annuity contract with another carrier to an annuity contract withSBL under IRC Section 1035, any withdrawals from or changes in ownership to your SBL contract within 180 days of such partial exchangemay have adverse tax consequences. Please consult your tax advisor.❍ Rollover (not like-to-like, i.e., 457 to IRA, etc.)❍ Transfer (like-to-like, i.e., IRA to IRA, etc.)Please transfer these funds ❑ immediately or ❑ on maturity date: ______________________If neither indicated, funds should be transferred immediatelyDate (mm/dd/yyyy)Amount❍ Liquidate my entire Account: Estimated Value $ ___________________❍ Liquidate a specified amount: Amount to Transfer $ ___________________❍ Transfer over ________ years❑ Monthly ❑ Quarterly ❑ Semi-annually ❑ AnnuallyDistribution Requirements (if applicable)I certify that applicable requirements have been met for distribution. Check all that apply:❑ Age 59 1 /2 ❑ Disabled ❑ Severance from employment on ______________________Date (mm/dd/yyyy)Required Minimum Distribution (if applicable)❍ Current carrier should distribute my RMD to me prior to transferring/rolling over my account.❍ Current carrier should proceed with the transfer/rollover because the requirements for the current year havebeen met.NOTE TO TRANSFERRING COMPANY: Do NOT transfer ownership of stock to Security Benefit.Notice to Current CarrierPlease make check(s) payable to Security Benefit for the benefit of the Owner listed on this form and mail to:Security Benefit - regular mailSecurity Benefit - overnight mailP.O. Box 750500 Mail Zone 500Topeka, Kansas 66675-0500One Security Benefit PlaceTopeka, Kansas 66636-0001Please Continue IM-32300-00 2015/01/12 (2/3)

4. Provide SignaturesAs the Owner, I understand, acknowledge and certify that:– I am responsible for tax consequences which could include the imposition of penalties, additional taxes andinterest. Security Benefit assumes no responsibility or liability for any effects of this transaction.– I am aware of my right to receive information regarding my current contract, including contract values.– I certify that the information provided is correct and complete.x_______________________________________ ________________ ________________________________________ _________________Signature of Owner Date (mm/dd/yyyy) Signature of Joint Owner (if applicable) Date (mm/dd/yyyy)x_______________________________________ ________________ _________________________________________________________Signature of Plan Sponsor or Date (mm/dd/yyyy) TitleThird Party Administrator(if applicable – Please consult your financial advisor or employer)x_______________________________________ ________________ __________________________________________________________Signature of Agent Date (mm/dd/yyyy) Print Name of AgentSpousal Consent for Community Property States: If the owner/participant is a resident of AZ, CA, ID, LA, NM, NV,TX, WA or WI, spousal consent is required, unless the owner/participant has no legal spouse.x____________________________________________________________________________________________________ ________________Signature of SpouseDate (mm/dd/yyyy)5. Obtain Signature GuaranteePlease obtain a Signature Guarantee ONLY if required by your Current Carrier.You can obtain a Signature Guarantee from a bank, broker or other acceptable financial institution. A Notary Publiccannot provide a Signature Guarantee.x_________________________________________ ________________ _________________________________________________________Signature of Guarantor Date (mm/dd/yyyy) Title or Name of InstitutionPlace Signature Guarantee Stamp Here6. Security Benefit AcceptanceTo be completed by Security Benefit. Security Benefit hereby agrees to accept the transfer of the proceeds identifiedon this form.x_________________________________________ ________________ _________________________________________________________Signature of Accepting Carrier Date (mm/dd/yyyy) TitleMail to: Security Benefit • PO Box 750497 • Topeka, KS 66675-0497 orFax to: 1-785-368-1772Visit us online at www.securitybenefit.comIM-32300-00 2015/01/12 (3/3)

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