AB2151 (Rev.

6/1/21)

Withdrawal/Surrender Request Form

for fixed, fixed-indexed and registered index-linked annuities

Fixed and fixed-indexed annuities: PO Box 5420, Cincinnati OH 45201 / 800-854-3649 / 800-482-8126 Fax
Registered index-linked annuities: PO Box 5423, Cincinnati OH 45201 / 800-789-6771 / 800-807-9777 Fax
Overnight Address: 10th Floor, 301 E Fourth St, Cincinnati OH 45202
Website: GAIGannuities.com

To help ensure your request is processed timely and accurately, please print clearly and only in the spaces
provided. Do not write outside of the boxes. If you need to provide additional information or special
instructions, please attach a separate sheet of paper.

Contract Number

Contract Owner Information (or Annuitant/Participant for Group Contracts)

First Name Middle Initial Last Name

OR Business/Organization/Trust Owner

Home/Business Phone Number Cell Phone Number

Social Security/Tax ID Number Email

If you provided an email above or we have an email address on record, you will receive status updates. Email
notifications will be sent from no-reply@gaig.com. Please remove this address from your list of blocked senders.

Street Address (If address differs from what we have on file, we will update our records to reflect what is entered.)

City State Zip

Joint Contract Owner Information (if applicable)

First Name Middle Initial Last Name

Affiliate: Annuity Investors Life Insurance Company®

Administrator for Life Insurance and Annuities: Loyal American Life Insurance Company® Continental General Insurance Company®
Great American® appearing with the Great American Logo is a registered trademark of Great American Insurance Company and is used under license.

Page 1 of 7
Amount of Distribution (select only one) AB2151 (Rev. 6/1/21)

All withdrawals will include the contract’s penalty free amount, if available. The minimum partial withdrawal amount is
$500.00 net of contract charges. The maximum amount cannot reduce the surrender value below the policy minimum value
as stated in the contract. The actual amount paid could be less than requested due to other limits imposed by the contract.

o Full surrender and termination of the annuity contract (please return the annuity contract with the request form)
o Partial withdrawal from the annuity contract:
o Gross withdrawal (before all charges and taxes) for $

o Net withdrawal (after all charges and taxes) for $

o Gross withdrawal for contract’s free withdrawal amount (before taxes)

Distribution Type (select only one)

o Distribution to owner/annuitant/participant
o Distribution to brokerage account
Non-qualified contracts only. Although funds are being directed to the Brokerage Account for your benefit, the
distribution is a taxable and reportable event to the contract owner.

o Direct transfer, direct rollover or 1035 exchange

A Letter of Acceptance (LOA) from the new plan or provider is required. The LOA must be on company letterhead,
signed and dated by a company authorized representative along with a current corporate resolution, and indicate
the tax qualification of the new account. For partial 1035 exchanges, please review the “Important Notice
Concerning Partial Exchanges of Non-Qualified Annuity Contracts” form #X2664316NW for important information
concerning your request.

If a Direct Rollover (not a transfer) of qualified funds is requested for a year that you have a Required Minimum
Distribution (RMD) due, we will first pay to you any remaining RMD for this contract prior to the rollover unless
you check the box below. Any RMD payment will be subject to default federal and state income tax withholding
unless you complete the Income Tax Withholding section of the Withdrawal/Surrender Request Form.
o I certify that I have already taken my full RMD for this contract for the current year and all prior years in whole
or in part from another source.

Income Tax Withholding

For 403(b) TSA, 401 Pension/Profit Sharing/401(k), or a Governmental 457 tax qualified contract, a minimum of
20% federal income tax withholding is required by the IRS unless your distribution is a direct rollover, direct transfer,
RMD or due to financial hardship. Federal tax withholding is not mandatory. The default withholding amount is 10%.
Withholding will only apply to the portion of your distribution that is taxable. Whether or not taxes are withheld, you
will be liable for payment of all applicable federal and state income taxes on the taxable portion of the distribution. You
may also be subject to penalties under the estimated tax rules if your withholding and estimated tax payments, if any,
are not adequate. If no selection is made, we will withhold based on the default amount required. If federal income tax
withholding is elected, state income tax withholding may also apply due to state requirements.

Federal Income Tax Withholding (select one):

o 10% default amount o No withholding, unless required

o More than 10% default or required amount: %

State Income Tax Withholding (select one):

o Any required amount o No withholding, unless required

o More than required amount: %

Page 2 of 7
 AB2151 (Rev. 6/1/21)

Payee/Payment Instructions (complete section A or B)

A). For distributions to owner/annuitant/participant (select only one)
o Check via mail at address of record (no fee)
o Check via express delivery ($20 fee) o Check here to require your signature at delivery
Express deliveries cannot be sent to a PO Box address. The fee will be withheld from the distribution.

o Direct deposit to a personal checking or savings account (no fee)

Available for withdrawals up to $25,000. Once direct deposit is elected, all eligible future payments will be
paid via this method until you direct otherwise. If your account information cannot be verified, a check
will be sent to your address of record in place of the direct deposit.

o My checking or savings account information is on file.

o My checking or savings account information is not on file.
You must complete the information below. Please also include a voided check below or a copy of your
account statement or a letter from your financial institution confirming the information.

Account type: o Checking o Savings

Financial Institution Name Financial Institution Phone Number

Routing Number (9 digits required) Account Number

List Names of ALL Owners on the Financial Institution Account

Page 3 of 7
 AB2151 (Rev. 6/1/21)

B.) For distributions to a brokerage account or as a direct transfer/direct rollover/1035 exchange

Check will be sent via regular mail. To elect express delivery at yours or your new carrier’s expense,
please provide valid UPS or FedEx billing account information and a physical mailing address. If this
information is not provided, the check will be sent via regular mail. Important: If you have named an
insurance company, bank, brokerage firm or other financial institution as your payee, you are authorizing
us to follow the written instructions of that financial institution to make payment to any agent, custodian,
or clearing house, or to use an alternate mailing address.

Check Payee Brokerage Account Number (if applicable)

Check Payee’s Mailing Address

City State Zip

Special Tax Notice Regarding Plan Payments

This section only applies to withdrawals from a 403(b) TSA, 401 Pension/Profit Sharing/401(k), or a
Governmental 457 qualified contract unless the withdrawal from these types of qualified contracts is a required
minimum distribution (RMD), a hardship distribution or a direct transfer.

The Special Tax Notice contains information about rollover rights and tax treatment of eligible rollover
distributions from a 403(b) TSA plan, a 401 Pension/Profit Sharing/401(k) plan, or a Governmental 457 plan. It
is provided for your information. Please contact our office prior to submitting this form if your contract is under
one of these plans and you did not receive the Special Tax Notice.

For eligible rollover distributions from these plans, you have 30 days to consider your options.

Unless you check the box below, we will hold your request for this 30-day consideration period.

o I waive my 30-day consideration period.

Page 4 of 7
 AB2151 (Rev. 6/1/21)
For 403(b) TSA Contracts Only
If you do not have a 403(b) TSA, this section does not apply. I certify that these payments requested from my
403(b) TSA contract are permitted as a result of (MUST CHECK ONE):
o AGE 59½: I am now age 59½ or older
o SEVERANCE FROM EMPLOYMENT: I have severed employment with the employer through which 403(b) TSA
contributions were made.
Date of severance:
Name of
MM/DD/YYYY
employer:
o DISABILITY: I am unable to engage in customary or comparable substantial gainful activity by reason of medically
determinable physical or mental impairment expected to result in death or be of long-continued and indefinite duration.
Attach documentation if no plan administrator.
o QDRO: Payments will be made to an alternate payee under a qualified domestic relations order. Attach copy of court order.
o QUALIFIED RESERVIST: Payment to reservist called to active duty for 180+ days or indefinite period.
Attach copy of order if no plan administrator.

o BIRTH OR ADOPTION OF A CHILD: Date of Birth/Adoption (MM/DD/YYYY)

A child of mine has been born or I have legally adopted an eligible child (a child who is not the child of my spouse,
and who is under the age of 18 or physically/mentally incapable of self-support). I have not taken a qualified birth or
adoption distribution from any other qualified retirement plan or IRA.

o FINANCIAL HARDSHIP: Attach financial hardship documentation if no plan administrator.

An immediate and heavy financial need on account of (MUST CHECK ONE):
o Uninsured eligible medical expenses for me or my spouse, dependent, or designated beneficiary;
o Direct costs for purchase of my principal residence, excluding mortgage payments;
o Eligible post-secondary education expenses for me, my spouse, or my dependent;
o Threatened eviction from, or mortgage foreclosure on, my principal residence;
o Funeral expenses for my parent, spouse, children, dependents, or designated beneficiary;
o Expenses for repair of damage to my principal residence that qualifies as a casualty loss & is not covered by insurance.
By electing Financial hardship, you certify that the immediate and heavy financial need cannot reasonably be relieved (1) through
reimbursement or compensation by insurance or otherwise, (2) by liquidation of your assets, (3) by cessation of elective
contributions under this plan, (4) by currently available distributions and nontaxable loans under plans maintained by your
employer or any other employer, or (5) by borrowing from commercial sources on reasonable commercial terms in an amount
sufficient to satisfy the need. In addition, you agree to discontinue all elective contributions and employee contributions to the
plan and all other plans maintained by the employer for a period of at least six months after receipt of the hardship distribution.
Expenses for the repair of damage to my principal residence that qualifies as a casualty loss and is not covered by insurance.
Post-12/31/88 earnings cannot be distributed and rollovers are not allowed under financial hardship.
o CONTRACT EXCHANGE/DIRECT TRANSFER: Payment to be made as (MUST CHECK ONE):
o Contract exchange within the same employer 403(b) TSA plan.
o Direct transfer to governmental defined benefit plan for purchase of permissive service credit or as repayment
under IRC section 415(k)(3).
o Plan-to-plan direct transfer from one employer 403(b) TSA plan to another employer 403(b) TSA plan, either as
mandated by employer(s) in connection with corporate or plan reorganization or as otherwise allowed by the terms
of both plans.
o ROLLOVER ACCOUNT: Payment is only to be made FROM an existing 403(b) contract that was funded solely with
rollover contributions made into the existing 403(b) contract from a different employer retirement plan or IRA.

Page 5 of 7
 Owner/Annuitant/Participant Certification and Authorization AB2151 (Rev. 6/1/21)

I understand that:
• Withdrawals will adversely affect any benefits under a living benefit rider or a death benefit rider.
• Unless made in the form of a direct transfer, direct rollover, or 1035 exchange, distributions before age 59½ may
be subject to a 10% federal penalty tax (or 25% for some SIMPLE IRA distributions) in addition to other applicable
income taxes.
• Due to contract terms and tax laws, once the funds have been distributed the funds cannot be returned nor the
withdrawal transaction reversed.
• Pursuant to the transaction requested, the Company may use a third party service provider to verify your identity or
confirm your ownership of the account to which you are requesting funds to be transferred.
I agree and certify that the Company is authorized to process this withdrawal request, and will hold the Company
harmless against any and all claims made by reason of its compliance with this request.
Furthermore, if the contract is not returned for full surrenders, then by signing this request I certify under penalties of
perjury and insurance fraud that the contract has been lost and that it has not been assigned, transferred, or pledged,
and I agree to hold the insurance company harmless from any and all claims or loss which may occur directly or
indirectly on account of its acceptance of this certification.

o Check here if you are attaching any additional pages to this form.
Signature of Owner/Annuitant/Participant Date (MM/DD/YYYY)

Signature of Joint Owner (if applicable) Date (MM/DD/YYYY)

Signature of Power of Attorney(s)/Authorized Representative(s)

signing on behalf of Owner/Annuitant/Participant Date (MM/DD/YYYY)

For requests signed by a Power of Attorney (POA):

• Provide a copy of the POA document. The POA Certification (form AAG2816) must also be completed or on file.
• Payments can only be made to an account where the person who gave the POA is a named owner of the account.
• Payments will be made to the Principal (or transferred, rolled over, exchanged or deposited for his/her benefit) and not to or
for the POA.
For contracts owned by a Trust:
• The acting Trustee(s) must sign. If there has been a change of Trustee(s) from the Trustee(s) on file, then you must
submit a new Trust Certification (form X6017907NW).
• Payments can only be made to an account owned by the Trust unless additional documentation is provided showing
that these distributions from the Trust are permitted.
• Payments will be made to the Trust (or transferred, exchanged or deposited for its benefit).
Log into GAIGannuities.com if you need the POA or Trust Certification form.

Plan Administrator Certification and Authorization

This section only needs to be completed for withdrawals from 403(b) TSA, 401 Pension/Profit Sharing/401(k), or 457 tax
qualified contracts. The Plan Administrator should complete this section.
Name of Employer Plan Name of Plan Administrator Plan Administrator Phone

The Plan Administrator certifies that the withdrawal or surrender requested is permitted under the employer’s plan and
authorizes the Company to process the request as indicated above. In the case of a hardship distribution from a 403(b)
contract, the Plan Administrator agrees that the participant will be required to discontinue all elective contributions and
employee contributions to the plan and all other plans maintained by the employer for a period of at least six months
after receipt of the hardship distribution.

Plan Administrator Signature Date (MM/DD/YYYY)

Page 6 of 7
 AB2151 (Rev. 6/1/21)
Signature Notarization or Signature Guarantee (if applicable)
Your signature on this request must be notarized or signature guaranteed below if you purchased your contract
electronically with an electronic signature and you have not previously submitted a notarized or guaranteed signature, or
as requested by the Company.

Option 1: Notarized Signature

State of County of

Date (MM/DD/YYYY)

This Withdrawal/Surrender Request Form was acknowledged before me on

Name of Person who is acknowledging his/her signature

by

Signature of Notary Public

My Commission expires (MM/DD/YYYY) Seal

Option 2: Signature Guarantee

SIGNATURE GUARANTEED BY: Stamp or Seal of Eligible Guarantor Institution with Authorized Signature

You may have signature guarantee provided by a bank, savings and loan association, trust company, credit union, broker/dealer or any other
“eligible guarantor institution” as defined under the rules adopted by the Securities and Exchange Commission. These institutions often participate in
signature guarantee medallion programs such as the Securities Transfer Agent Medallion Program (STAMP).
Page 7 of 7
 SPECIAL TAX NOTICE
ABOUT YOUR ROLLOVER OPTIONS
FOR DISTRIBUTIONS FROM A TRADITIONAL
SECTION 403(b) TAX SHELTERED ANNUITY,
SECTION 401(a) PENSION, PROFIT-SHARING, OR 401(k) PLAN,
OR GOVERNMENTAL 457(b) PLAN

You are receiving this notice because all or a portion of a payment you are receiving from the annuity contract
(the “Contract”) is eligible to be rolled over to an IRA or another employer plan. This notice is intended to help
you decide whether to do such a rollover.
This notice describes the rollover rules that apply to payments that are not from a designated Roth account (a
type of account for after-tax contributions to some employer plans that is subject to special tax rules). If your
Contract is a designated Roth account, or if you also receive a payment from a designated Roth account, then
you need a different notice about your rollover options (Form N6060518NW ROTH).
Rules that apply to most payments are described in the GENERAL INFORMATION ABOUT ROLLOVERS
section. Special rules that only apply in certain circumstances are described in the SPECIAL RULES AND
OPTIONS section.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes? You will be taxed on a payment from the Contract if you do not roll it over.
If you are under age 59½ and do not do a rollover, you will also have to pay a 10% additional income tax on
early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until
you receive payments later and the 10% additional income tax will not apply if those payments are made after
you are age 59½ (or if an exception applies).
What types of retirement accounts and plans may accept my rollover? You may roll over the payment to
either an IRA (an individual retirement account or individual retirement annuity) or another employer plan (a
401(a) tax-qualified plan, a section 403(b) plan, or a governmental section 457(b) plan) that will accept the
rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options,
fees, and rights to payment from the IRA or employer plan (for example, IRAs are not subject to spousal consent
rules, and IRAs cannot make loans). Further, the amount rolled over will become subject to the tax rules that
apply to the IRA or employer plan.
How do I do a rollover? There are two ways to do a rollover. You can do either a direct rollover or a 60-day
rollover.
If you do a direct rollover, we will make the payment directly to your IRA or an employer plan. You should
contact the IRA sponsor or the administrator of the employer plan for information on how to do a direct
rollover.
If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible
employer plan that will accept it. Generally, you will have 60 days after you receive the payment to make the
deposit. If you do not do a direct rollover, we are required to withhold 20% of the payment for federal income
taxes. This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds
to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not
rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are
under age 59½ (unless an exception applies).
How much may I roll over? If you wish to do a rollover, you may roll over all or part of the amount eligible for
rollover. Any payment from the Contract is eligible for rollover, except:
• Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the
lives or joint life expectancy of you and your beneficiary)
• Required minimum distributions after age 72 (age 70½ if you were born before July 1, 1949) or after
death
• Hardship distributions
• Corrective distributions of contributions that exceed tax law limitations
• Loans treated as deemed distributions (for example, loans in default due to missed payments before your
employment ends
• Automatic enrollment contributions that you request to withdraw within 90 days of your first contribution
We can tell you what portion of a payment is eligible for rollover.
ADM2306 (Rev. 6/1/2021) Great American® appearing with the Great American Logo is a registered Page 1 of 5
trademark of Great American Insurance Company and is used under license.
If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions? If you are
under age 59½, you will have to pay the 10% additional income tax on early distributions for any payment from
the Contract (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions
listed below applies. This tax applies to the part of the distribution that you must include in income and is in
addition to the regular income tax on the payment not rolled over.
The 10% additional income tax does not apply to the following payments from the Contract:
• Payments made after you separate from service if you will be at least age 55 in the year of the separation
• Payments that start after you separate from service if paid at least annually in equal or close to equal
amounts over your life or life expectancy (or the joint lives or joint life expectancies of you and your
beneficiary)
• Payments from a governmental plan made after you separate from service if you are a qualified public
safety employee and you will be at least age 50 in the year of the separation
• Payments made due to disability
• Payments after your death
• Corrective distributions of contributions that exceed tax law limitations
• Payments made directly to the government to satisfy a federal tax levy
• Payments made under a qualified domestic relations order (QDRO)
• Payments of up to $5,000 made to you from a defined contribution plan if the payment is a qualified birth
or adoption distribution
• Payments up to the amount of your deductible medical expenses (without regard to whether you itemize
deductions for the taxable year)
• Certain payments made while you are on active duty if you were a member of a reserve component called
to duty after September 11, 2001 for more than 179 days
• Certain payments up to $5,000 made to you following the birth or qualified adoption of a child
• Payments of certain automatic enrollment contributions that you request to withdraw within 90 days of
your first contribution
• Payments excepted from the additional income tax by federal legislation relating to certain emergencies
and disasters
• Phased retirement payments made to federal employees
If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?
If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10% additional
income tax on early distributions on the part of the distribution that you must include in income, unless an
exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA
are the same as the exceptions listed above for early distributions from a plan. However, there are a few
differences for payments from an IRA, including:
• There is no exception for payments made after separation from service when you will be at least age 55
in the year of separation
• There is no exception for payments made after separation from service as a public safety employee when
you will be at least age 50 in the year of separation
• The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule
applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made
directly to an IRA of a spouse or former spouse)
• The exception for payments made at least annually in equal or close to equal amounts over a specified
period applies without regard to whether you have had a separation from service
• There are additional exceptions for payments from an IRA, including (1) payments for qualified higher
education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and (3)
payments for health insurance premiums after you have received unemployment compensation for 12
consecutive weeks (or would have been eligible to receive unemployment compensation but for self-
employed status)
Will I owe State income taxes? This notice does not address any State or local income tax or withholding rules.

ADM2306 (Rev. 6/1/2021) Page 2 of 5

 SPECIAL RULES AND OPTIONS
If your payment includes after-tax contributions: After-tax contributions included in a payment are not taxed.
If a payment is only part of your total plan benefit, an allocable portion of your after-tax contributions is generally
included in the payment, so you cannot take a payment of only after-tax contributions. However, if. If you have
pre-1987 after-tax contributions maintained in a separate account, a special rule may apply to determine whether
the after-tax contributions are included in the payment. In addition, special rules apply when you do a rollover,
as described below.
You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a
60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs
(in order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a
portion of the amount paid from the Contract and at the same time the rest is paid to you, the portion rolled over
consists first of the amount that would be taxable if not rolled over. For example, assume you are receiving a
distribution of $12,000 of which $2,000 is after-tax contributions. In this case, if you directly roll over $10,000 to
an IRA that is not a Roth IRA, no amount is taxable because the $10,000 that has been rolled over is treated as
the taxable portion and the $2,000 amount not rolled over is treated as being after-tax contributions. If you do a
direct rollover of the entire amount paid from the Plan to two or more destinations at the same time, you can
choose which destination receives the after-tax contributions. Similarly, if you do a 60-day rollover to an IRA of
only a portion of a payment made to you, the portion rolled over consists first of the amount that would be taxable
if not rolled over. For example, assume you are receiving a distribution of $12,000, of which $2,000 is after-tax
contributions, and no part of the distribution is directly rolled over. In this case, if you roll over $10,000 to an IRA
that is not a Roth IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is
treated as being after-tax contributions.
You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a
direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a
governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment that
includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled over.
If you miss the 60-day rollover deadline: Generally, the 60-day rollover deadline cannot be extended.
However, the IRS has the limited authority to waive the deadline under certain extraordinary circumstances, such
as when external events prevented you from completing the rollover by the 60-day rollover deadline. Under
certain circumstances, you may claim eligibility for a waiver of the 60-day rollover deadline by making a written
self-certification. Otherwise, to apply for a waiver from the IRS, you must file a private letter ruling request with
the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information,
see IRS Publication 590-A, Contributions to Individual Retirement Arrangements (IRAs).
If you have an outstanding loan that is being offset: If you have an outstanding loan under the Contract, your
Contract values may be offset by the outstanding amount of the loan, typically when your employment ends. The
offset amount is treated as a distribution to you at the time of the offset. Generally, you may roll over all or any
portion of the offset amount. Any offset amount that is not rolled over will be taxed (including the 10% additional
income tax on early distributions, unless an exception applies). You may roll over offset amounts to an IRA or
another employer plan (if the terms of the employer plan permit the plan to receive plan loan offset rollovers).
How long you have to complete the rollover depends on what kind of plan loan offset you have. If you have a
qualified plan loan offset, you will have until your tax return due date (including extensions) for the tax year during
which the offset occurs to complete your rollover. A qualified plan loan offset occurs when a plan loan in good
standing is offset because your employer plan terminates, or because you sever from employment. If your plan
loan offset occurs for any other reason (such as a failure to make level loan repayments that results in a deemed
distribution),, then you have 60 days from the date the offset occurs to complete your rollover.
If you were born on or before January 1, 1936: If you were born on or before January 1, 1936 and receive a
lump sum distribution that you do not roll over, special rules for calculating the amount of the tax on the payment
might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.
If your payment is from a governmental section 457(b) plan: If the Contract is under a governmental section
457(b) plan, the same rules described elsewhere in this notice generally apply, allowing you to roll over the
payment to an IRA or an employer plan that accepts rollovers. One difference is that, if you do not do a rollover,
you will not have to pay the 10% additional income tax on early distributions from the Contract even if you are
under age 59½ (unless the payment is from a separate account holding rollover contributions that were made to
ADM2306 (Rev. 6/1/2021) Page 3 of 5
the Contract from a 401(a) tax-qualified plan, a section 403(b) plan, or an IRA). However, if you do a rollover to
an IRA or to an employer plan that is not a governmental section 457(b) plan, a later distribution made before
age 59½ will be subject to the 10% additional income tax on early distributions (unless an exception applies).
Other differences include that you cannot do a rollover if the payment is due to an “unforeseeable emergency”
and the special rules under “If you were born on or before January 1, 1936” do not apply.
If you are an eligible retired public safety officer and your payment is used to pay for health coverage or
qualified long-term care insurance: If the Contract is under a governmental plan, you retired as a public safety
officer, and your retirement was by reason of disability or was after normal retirement age, you can exclude from
your taxable income plan payments paid directly as premiums to an accident or health plan (or a qualified long-
term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a
maximum of $3,000 annually. For this purpose, a public safety officer is a law enforcement officer, firefighter,
chaplain, or member of a rescue squad or ambulance crew.
If you roll over your payment to a Roth IRA: If you roll over a payment from the Contract to a Roth IRA, a
special rule applies under which the amount of the payment rolled over (reduced by any after-tax amounts) will
be taxed. In general, the 10% additional income tax on early distributions will not apply. However, if you take the
amount rolled over out of the Roth IRA within the 5-year period that begins on January 1 of the year of the
rollover, the 10% additional income tax will apply (unless an exception applies).
If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will
not be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a payment made
after you are age 59½ (or after your death or disability, or as a qualified first-time homebuyer distribution of up
to $10,000) and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from
January 1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that
are not qualified distributions will be taxed to the extent of earnings after the rollover, including the 10% additional
income tax on early distributions (unless an exception applies). You do not have to take required minimum
distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590-A, Contributions
to Individual Retirement Arrangements (IRAs), and IRS Publication 590-B, Distributions from Individual
Retirement Arrangements (IRAs).
If you do a rollover to a designated Roth account in the same plan: You cannot roll over a distribution to a
designated Roth account in another employer’s plan. However, you can roll the distribution over into a designated
Roth account in the same employer plan as your Contract. If you roll over a payment from the Contract to a
designated Roth account in the same plan, the amount of the payment rolled over (reduced by any after-tax
amounts directly rolled over) will be taxed. In general, the 10% additional income tax on early distributions will
not apply. However, if you take the amount rolled over out of the Roth IRA within the 5-year period that begins
on January 1 of the year of the rollover, the 10% additional income tax will apply (unless an exception applies).
If you roll over the payment to a designated Roth account in the same plan, later payments from the designated
Roth account that are qualified distributions will not be taxed (including earnings after the rollover). A qualified
distribution from a designated Roth account is a payment made both after you are age 59½ (or after your death
or disability) and after you have had a designated Roth account in the plan for at least 5 years. In applying this
5-year rule, you count from January 1 of the year your first contribution was made to the designated Roth
account. However, if you made a direct rollover to a designated Roth account in the plan from a designated Roth
account in a plan of another employer, the 5-year period begins on January 1 of the year you made the first
contribution to the designated Roth account in the plan or, if earlier, to the designated Roth account in the plan
of the other employer. Payments from the designated Roth account that are not qualified distributions will be
taxed to the extent of earnings after the rollover, including the 10% additional income tax on early distributions
(unless an exception applies).
If you are not a participant in the plan:
• Payments after death of the participant: If you receive a distribution after the participant’s death that
you do not roll over, the distribution generally will be taxed in the same manner described elsewhere in
this notice. However, the 10% additional income tax on early distributions and the special rules for public
safety officers do not apply, and the special rule described under the section “If you were born on or
before January 1, 1936” applies only if the deceased participant was born on or before January 1, 1936.
• If you are a surviving spouse: If you receive a payment from the Contract as the surviving spouse of
a deceased participant, you have the same rollover options that the participant would have had, as

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 described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat
the IRA as your own or as an inherited IRA.
An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before
you are age 59½ will be subject to the 10% additional income tax on early distributions (unless an
exception applies) and required minimum distributions from your IRA do not have to start until after you
are age 72 (age 70½ if you were born before July 1, 1949).
If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional
income tax on early distributions. However, if the participant had started taking required minimum
distributions, you will have to receive required minimum distributions from the inherited IRA. If the
participant had not started taking required minimum distributions from the Contract, you will not have to
start receiving required minimum distributions from the inherited IRA until the year the participant would
have been age 72 (age 70½ if the participant was born before July 1, 949).
• If you are a surviving beneficiary other than a spouse. If you receive a payment from the Contract
because of the participant’s death and you are a designated beneficiary other than a surviving spouse,
the only rollover option you have is to do a direct rollover to an inherited IRA. Payments from the
inherited IRA will not be subject to the 10% additional income tax on early distributions. You will have to
receive required minimum distributions from the inherited IRA.
Payments under a qualified domestic relations order (QDRO): If you are the spouse or former spouse of
the participant who receives a payment from the Contract under a QDRO, you generally have the same
options and the same tax treatment that the participant would have (for example, you may roll over the
payment to your own IRA or an eligible employer plan that will accept it). However, payments under the
QDRO will not be subject to the 10% additional income tax on early distributions.
If you are a nonresident alien: If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA
or U.S. employer plan, instead of withholding 20%, we are generally required to withhold 30% of the payment
for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a
60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-
S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax
treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publication 515,
Withholding of Tax on Nonresident Aliens and Foreign Entities.
Other special rules: If a payment is one in a series of payments for less than 10 years, your choice whether to
do a direct rollover will apply to all later payments in the series (unless you make a different choice for later
payments).
If your payments for the year are less than $200 (not including payments from a designated Roth account), we
are not required to allow you to do a direct rollover and we are not required to withhold federal income taxes.
However, you may do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a designated
Roth account in the plan) will be directly rolled over to an IRA chosen by the plan administrator or by us. A
mandatory cashout is a payment from a plan to a participant made before age 62 (or normal retirement age, if
later) and without consent, where the participant’s benefit does not exceed $5,000 (not including any amounts
held under the plan as a result of a prior rollover made to the plan).
You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information on
special rollover rights related to the U.S. Armed Forces, see IRS Publication 3, Armed Forces’ Tax Guide. You
also may have special rollover rights if you were affected by a federally declared disaster (or similar event), or if
you received a distribution on account of a disaster. For more information on special rollover rights related to
disaster relief, see the IRS website at www.irs.gov.

FOR MORE INFORMATION

You may wish to consult with the plan administrator, or a professional tax advisor, before taking a payment from
the Contract. Also, you can find more detailed information on the federal tax treatment of payments from
employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590-A, Contributions to
Individual Retirement Arrangements (IRAs); IRS Publication 590-B, Distributions from Individual Retirement
Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications
are available from a local IRS office, on the web at www.irs.gov, or by calling 1-800-TAX-FORM.
ADM2306 (Rev. 6/1/2021) Page 5 of 5
a