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FULL OR PARTIAL WITHDRAWAL REQUEST INSTRUCTIONS

FIXED/VARIABLE ANNUITIES

ReliaStar Life Insurance Company (Home Office: Minneapolis, MN)

ReliaStar Life Insurance Company of New York (Home Office: Woodbury, NY)
(the “Company”)
Members of the Voya® family of companies
Customer Service: PO Box 1559, Hartford, CT 06144-1559
Phone: 877-884-5050
Use this form to request a withdrawal under the provisions of your annuity contract. Do not use this form to request a rollover,
transfer, or exchange to another company. Please follow instructions to avoid delays in processing your request. A distribution is
a tax reportable event that may not be reversed. Check boxes are provided below to guide you as you complete each section of
the form.
c Good Order
Please refer to this section of the form for important information. For Employee Retirement Security Income (ERISA) plans only,
complete and attach a Spousal Consent form. If the appropriate documentation or information is not received, your request may
be considered not in good order, e.g., Hardship withdrawal documentation. Future dated requests will not be accepted.

c RETURN COMPLETED FORMS

Complete the form and mail or fax it to the Customer Service. Choose only one submission method. Multiple submissions may
result in processing delays and/or duplicate withdrawals.

c CONTRACT OWNER INFORMATION

Please print clearly and complete the information requested in its entirety. If you are an Alternate Payee you are not required to
complete this section.

c ALTERNATE PAYEE INFORMATION

Complete this section if you are an Alternate Payee requesting a withdrawal due to a Qualified Domestic Relations Order.

c WITHDRAWAL AMOUNT
Select option A, B, or C and specify the applicable dollar amount or percentage. The Amount Available Free of Withdrawal Charge
option refers to the free amount as defined by the contract or prospectus.
Please review your contract and/or prospectus for detailed information regarding withdrawal charges and other withdrawal provisions,
as some products limit the number of withdrawals that can be requested.
Net or Gross Options – Select one option if you are requesting a Partial Withdrawal or Hardship Withdrawal.

c PARTIAL WITHDRAWAL TO REPAY OUTSTANDING LOAN(S)

Complete this section only if you are requesting a Partial Withdrawal and want to repay an active or defaulted outstanding loan
balance(s) with amounts deducted from your contract value. If completing this section, do not complete section 3.

c WITHDRAWAL CHARGE/MARKET VALUE ADJUSTMENT ACKNOWLEDGMENT

Prior to processing your request, we require written acknowledgement of any withdrawal charge and/or market value adjustment
of $500 or more. If not provided, your request will be returned for completion and re-submission.

c VARIABLE ANNUITY FUND SELECTION FOR PARTIAL WITHDRAWALS

If you have a variable annuity contract and wish to have your partial withdrawal from a specific investment option, you may do so
by specifying in this section.

c REASON FOR WITHDRAWAL

Complete this section if the contract is a 403(b) or 401(a), or if the withdrawal is subject to a waiver of withdrawal charge due to
disability or termination of employment as defined by the contract or prospectus. Also complete this section if you are requesting
a withdrawal to repay a loan on your contract.

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c EMPLOYER CONTRIBUTIONS
This section is to be completed by the Plan Sponsor or Third Party Administrator (TPA) for 403(b) contracts subject to ERISA or that
have Employer contributions subject to vesting. Contact your Employer to verify if your plan is subject to ERISA or has Employer
contributions subject to vesting.

c TAX WITHHOLDING
Please read the Tax Withholding section carefully for important information. Read the attached State Income Tax Withholding
Notification to determine your available state withholding options.

c CONTRACT OWNER, SPOUSE AND ALTERNATE PAYEE AUTHORIZED SIGNATURES AND TAX WITHHOLDING
CERTIFICATION
The Owner’s or Alternate Payee’s, and if applicable the Joint Contract Owner and/or Spouse’s signature is required on Page 6. If
the Owner lives in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI), the Spouse’s signature is required.

c Conservatorship/Guardianship and Date

The Conservator/Guardian signature is required on page 7 if there is an active Conservatorship/Guardianship on file.

c EMPLOYER, PLAN SPONSOR OR NAMED FIDUCIARY AUTHORIZED SIGNATURE AND CERTIFICATION and
THIRD PARTY ADMINISTRATOR AUTHORIZED SIGNATURE AND CERTIFICATION
All 403(b) and 401(a) withdrawals will require certification and signature by your Employer or an authorized Third Party Administrator
with few exceptions. Please contact your Employer, Plan Administrator, or TPA for their authorization and signature in section 12
and/or 13 before submitting your form.

Mail or fax your completed form to Customer Service. Keep a copy for your records.

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FULL OR PARTIAL WITHDRAWAL request
FIXED/VARIABLE ANNUITIES
ReliaStar Life Insurance Company (Home Office: Minneapolis, MN)
ReliaStar Life Insurance Company of New York (Home Office: Woodbury, NY)
Members of the Voya® family of companies
(the “Company”)
Customer Service: PO Box 1559, Hartford, CT 06144-1559
Phone: 877-884-5050
GOOD ORDER
Use this form to request a withdrawal under the provisions of your annuity contract. Do not use this form to request a rollover,
transfer, or exchange to another company.
All transactions will be processed upon completion and receipt of this form and any other required document in good order. Good
order is defined as receipt of any required information at our Service Center accurately and entirely completed, with any applicable
signatures. If this form is not received in good order, including any required Employer, Plan Sponsor, or Third Party Administrator
signature, a new form will be sent to you for completion and re-submission. If additional required documents are not properly
executed and received within 30 days of receipt of the initial documentation, the entire submission will be closed and new
paperwork will be required. To allow adequate time for processing and reporting of your distribution in the current tax year, please
return this form in good order by December 15. Sections 12 and 13 are not applicable to IRA or Non-qualified annuity contracts.
For ERISA Plans only, complete and attach a Spousal Consent form.
Reminder to Insurance Producer regarding New York Issued Annuity Contracts: Before making any recommendation, you must
have adequate knowledge of the transaction you’re recommending and provide your client with the relevant features of the
annuity contract and potential consequences of the transaction, both favorable and unfavorable. If you have any questions about
the annuity contract or transaction prior to making a recommendation, please contact the Company.
RETURN COMPLETED FORMS
Choose only one submission method. Multiple submissions may result in processing delays and/or duplicate withdrawals.
Important Note: All 403(b) and 401(a) withdrawals will require signature and certification by your Employer or an authorized
Third Party Administrator in section 12 or 13 with few exceptions. Please contact your Employer or Plan Administrator for their
signature and certification before submitting your form to the following address or fax number.
Regular Mail: Overnight Delivery: Fax:
Customer Service Customer Service Customer Service
PO Box 1559 One Orange Way Toll-Free Fax: 800-382-5744
Hartford, CT 06144-1559 Windsor, CT 06095
1. Contract owner information (Please print.)
Contract Number (Required)
(Financial transactions require a separate form for each contract.)
Contract Owner Name (Required) SSN/TIN (Required)
c Check here if the address provided below is your current permanent mailing address. We will update our records to reflect
this address if not currently on file.
Address (Required)
City State ZIP Phone
If the above box is not checked and the address provided above does not match the address we have on file, your request will
be considered not in good order and a new form will be required.
Resident state for tax purposes: (If your current physical and/or mailing address is outside of your
state of legal residence for tax purposes, please enter your tax state here and in section 9.)

Joint Contract Owner Name SSN/TIN (Required)

MAIL CHECK TO:
c Above address
c Alternate address (Please complete the following.)
Address
City State ZIP
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2. ALTERNATE PAYEE information (Please print. Complete this section if you are an alternate payee requesting a
withdrawal due to a Qualified Domestic Relations Order.)

Contract Number (Required)

Alternate Payee Name (Required) SSN/TIN (Required)

Address (Required)

City State ZIP Phone

Resident state for tax purposes: (If your current physical and/or mailing address is outside of your
state of legal residence for tax purposes, please enter your tax state here and in section 9.)

3. Withdrawal amount (Select one option. Continue to section 4 if requesting a Partial Withdrawal to repay loans. Do
not complete this section if completing section 4.)

Minimum withdrawal limits apply. Any withdrawal may be subject to a withdrawal charge and/or positive or negative market
value adjustment (MVA). Please refer to your contract for more detailed information regarding the impact of withdrawals from
your annuity.
If the amount available for withdrawal is less than the dollar amount you are requesting, the transaction will be processed for the
maximum amount available.
c A. Partial Withdrawal (Do not complete this section to request a Partial Withdrawal to repay an outstanding loan. Select one.)
c Specific Dollar Amount $ _______________________
c Percentage of Contract Value _________%
c Amount Available Free of Withdrawal Charge $ _________________________ (If no amount is provided, the maximum
amount available with no withdrawal charge will be withdrawn. If the full contract value is available free of withdrawal
charge and no amount is provided, a full withdrawal will be processed.)
c B. Full Withdrawal (Prior to processing a full withdrawal, all loans will be paid with amounts deducted from your contract value.
The outstanding principal loan balance and accrued interest, if not previously reported, will be reported to the IRS as a taxable
distribution on IRS Form 1099-R.)
c C. Hardship Withdrawal
c Specific Dollar Amount $ _________________________
c Maximum hardship amount available

Net or Gross Options (Complete the following if you have selected option A. Partial Withdrawal or C. Hardship Withdrawal
above.)
Is the amount you have requested to be the Net or Gross amount withdrawn?
c Net (Your check will be for the amount requested. Your contract value will be reduced by this amount plus any applicable
withdrawal charge/MVA, federal/state tax.)
c Gross (Your check will be for the amount requested less any applicable withdrawal charge/MVA, federal/state tax. Your
contract value will be reduced by the amount requested.)
If “Net” or “Gross” is not selected, we will default to processing a Gross amount.

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4. PARTIAL WITHDRAWAL TO REPAY OUTSTANDING LOAN(S) (Select A. or B. Complete this section only if you are
requesting a Partial Withdrawal and want to repay an active or defaulted outstanding loan balance(s) with amounts deducted
from your contract value. If completing this section, do not complete section 3.)
An eligible Reason for Withdrawal must be selected in section 7. Please note financial hardship is not an eligible reason for a
withdrawal to repay a loan.
If you request a partial withdrawal to repay a loan(s), qualify for a withdrawal, and the amount available for distribution is enough
to cover a) the entire outstanding loan(s) (principal plus accrued interest), and b) any withdrawal charge due and Market Value
Adjustment (MVA) if applicable on the outstanding loan balance, then the sum of a) and b) is deducted from your Contract Value
and the loan is paid off. The outstanding principal loan balance and accrued interest, if not previously reported, will be reported
to the IRS as a taxable distribution on IRS Form 1099-R.
A withdrawal to repay an active loan is considered taxable income. Mandatory 20% federal income tax withholding applies. If
applicable, any mandatory state tax will also be withheld. Consult your tax advisor for additional information.
c A. Partial Withdrawal to Repay Outstanding Loan(s). (You will not receive a check.)
I elect to:
c Repay all loans.
c Repay the following Loans (5-digit loan number(s))
Note: A defaulted loan will remain outstanding on your account and will reduce the availability of future loans. A defaulted
loan will continue to accrue interest which includes a spread charge owed to Voya. As a result, not repaying a defaulted
loan will decrease your contract value. It remains your responsibility to continue remitting loan repayments if any of the
following statements are true: this section 4 is not completed; you do not qualify for a withdrawal; you elect NOT to repay
all outstanding loan balances; no loan numbers are provided; and/or the amount available for distribution is not enough to
fully repay the balance of the specified loan(s). Your loan payoff may qualify for a Qualified plan loan offset. For further
details, please see the section in the Special Tax Notice entitled “If you have an outstanding loan that is being offset” or
refer to IRS Regulation for Qualified plan loan offset in IRC §402(c)(3)(C)(ii).
c B. Partial Withdrawal to Repay Outstanding Loan(s) and Receive a Check. (You will receive a check. Enter the total amount
of the partial withdrawal, i.e., the amount you want to receive as a check, plus the amount necessary to repay the loan(s).
Example: $500 to repay loan(s) + $500 received as a net check = $1,000 entered in Specific Dollar Amount.)

Specific Dollar Amount $ __________________________

I elect to:
c Repay all loans.
c Repay the following Loans (5-digit loan number(s))
Note: A defaulted loan will remain outstanding on your account and will reduce the availability of future loans. A defaulted
loan will continue to accrue interest which includes a spread charge owed to Voya. As a result, not repaying a defaulted loan
will decrease your contract value. It remains your responsibility to continue remitting loan repayments if any of the following
statements are true: this section 4 is not completed; you do not qualify for a withdrawal; you elect NOT to repay all outstanding
loan balances; no loan numbers are provided; and/or the amount available for distribution is not enough to fully repay the
balance of the specified loan(s). Your loan payoff may qualify for a Qualified plan loan offset. For further details, please see
the section in the Special Tax Notice entitled “If you have an outstanding loan that is being offset” or refer to IRS Regulation
for Qualified plan loan offset in IRC §402(c)(3)(C)(ii).

Net or Gross Options (Complete the following if you have selected option B. Partial Withdrawal to Repay Outstanding Loan(s)
and Receive a Check above.)
Is the amount you have requested to be the Net or Gross amount withdrawn?
c Net (Your check will be for the amount requested. Your contract value will be reduced by this amount plus any applicable
withdrawal charge/MVA, federal/state tax.)
c Gross (Your check will be for the amount requested less any applicable withdrawal charge/MVA, federal/state tax. Your
contract value will be reduced by the amount requested.)
If “Net” or “Gross” is not selected, we will default to processing a Gross amount.

5. WITHDRAWAL CHARGE/MARKET VALUE ADJUSTMENT ACKNOWLEDGMENT (Prior to processing your request, we

require written acknowledgement of any withdrawal charge and/or market value adjustment of $500 or more. If not provided,
your request will be returned for completion and re-submission.)
Withdrawal Charge/Market Value Adjustment Acknowledgement

$ Amount of Withdrawal Charge and/or Market Value Adjustment incurred for the withdrawal.

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6. VARIABLE ANNUITY FUND SELECTION FOR PARTIAL WITHDRAWALS
Amounts will be withdrawn from each investment option on a pro rata basis. If, however, you wish to have your partial withdrawal
from a specific investment option, you may do so by specifying below. Each percentage must be rounded to the nearest whole
percent (Example: 15%, not 15.5%). If the fund name and number do not match, your request will be considered not in good order
and a new form will be required.

Fund Name Fund # Amount Or % Fund Name Fund # Amount Or %

(Required) (Required)

7. REASON FOR WITHDRAWAL (Complete this section if your contract is a 403(b) or 401(a), or if your withdrawal is subject
to a waiver of withdrawal charge due to disability or termination of employment.)
Some 403(b) products provide a waiver of the withdrawal charge due to disability or if the contract is at least five years old
and you terminate from employment after the age of 55. See your contract provisions, and if applicable, select and complete
B. or C. below.
 A. Attainment of Age 59 1/2
 B. Termination of Employment - Date (Required): ______ / ______ / ______  Prior to Age 55  On or After Age 55
 C. Disability - Date of Disability: ______ / ______ / ______ (As defined by Internal Revenue Code Section 72(m)(7).)
 D. Qualified Domestic Relations Order (QDRO) Proceeds from Divorce (QDRO Certification required. Only available to an
Alternate Payee.)
 E. Financial Hardship
I certify this distribution is necessary to meet the following financial need:
c Tax-deductible medical expenses incurred by you, your spouse or your dependent, or if permitted by the plan, a primary
beneficiary designated by you under the plan.
c The purchase (excluding mortgage payments) of your principal residence.
c Payment of college tuition, related educational fees, and room and board expenses for the next 12 months for you, your
spouse, your children, your dependents, or if permitted by the plan, a primary beneficiary designated by you under the plan.
c Payments necessary to prevent eviction from your principal residence or foreclosure on the mortgage of your principal
residence.
c Payments for burial or funeral expenses for your deceased parent, spouse, children or dependents, or if permitted by
the plan, a primary beneficiary designated by you under the plan.
c Tax-deductible casualty expenses for the repair of your principal residence that are not covered by insurance. A casualty
is the damage, destruction, or loss of property resulting from an identifiable event that is sudden, unexpected, or unusual
such as, but not limited to earthquakes, fires, floods, terrorist attacks, vandalism and storms.
c Expenses and Loss (including Loss of Income) due to FEMA disaster impacting principal residence or place of employment.
 F. Plan Termination (The Company must have prior notice of your Employer’s intent to terminate the 403(b) Plan.)
 G. Qualified Reservist Distribution (As defined by Internal Revenue Code Section 403(b)(11)(C) for distributions to which section
72(t)(2)(G) applies.)

8. EMPLOYER CONTRIBUTIONS (To be completed by Plan Sponsor or TPA.)

If the Contract Owner is separated from service and the Employer contributions subject to vesting are not 100% vested, the
requested withdrawal should be disbursed as follows:
Disbursement to Participant: ________%
Disbursement to Employer: ________%

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9. TAX WITHHOLDING
Federal Withholding
Regardless of whether or not federal or state income tax is withheld, you are liable for taxes on the taxable portion of the payment.
If you do not have a sufficient amount withheld, you may be subject to tax penalties under the Estimated Tax Payment rules.
An election made for a single non-recurring distribution applies only to the payment for which it is being made. For recurring
payments, your withholding election will remain in effect until it is changed or revoked. You may change or revoke your election
at any time prior to a payment being made by submitting IRS form W-4P. U.S. persons having their payment delivered outside the
U.S. or its possessions may not make an election of NO withholding. In this case, if you choose no withholding, the default rate
will be applied. Non-resident aliens are subject to a mandatory 30% withholding rate unless they are eligible for a reduced rate or
exemption under a tax treaty and the required documentation is submitted.
Eligible rollover distribution – 20% withholding: (See the attached Special Tax Notice.) Distributions you receive from qualified
pension or annuity plans that are eligible to be rolled over tax free to an IRA or another qualified plan are subject to a flat 20%
federal withholding rate. The 20% withholding rate is required, and you cannot choose not to have income tax withheld from
eligible rollover distributions. You may elect withholding in excess of the mandatory 20% rate.
Non-periodic payments – 10% withholding: Non-periodic, non-rollover eligible payments from pensions, annuities, IRA’s and life
insurance contracts are subject to a flat 10% federal withholding rate unless you choose not to have federal income tax withheld.
These include for example, required minimum distributions, hardship withdrawals, and distributions from IRA’s that are payable on
demand. You can choose not to have withholding applied to your non-periodic distribution by checking the applicable box below.
You may also elect withholding in excess of the flat 10% rate.
Payments to a participant in a non-qualified deferred compensation plan (409A or non-governmental 457(b)): Withholding
from your payment will be based on the IRS wage withholding tables and is determined by the marital status and other information
you specify on IRS Form W-4. You may also elect an additional amount to be withheld from your payment. You must submit an IRS
Form W-4 to make your election. To obtain IRS Form W-4 please go to www.IRS.gov or call 800-829-3676. This election CANNOT
be made below. If you do not submit a Form W-4, withholding will occur as if you had checked the “Single or Married Filing
separately” box on Form W-4 and made no other elections.
Distributions from a non-qualified deferred compensation plan that exceed $1,000,000 during a calendar year are subject to a
flat supplemental rate as specified in IRS Publication 15 (Circular E), Employer’s Tax Guide. For these distributions, no other rate
is allowed and additional withholding is not an option.
Note: Payments made to beneficiaries of a non-qualified deferred compensation plan are NOT subject to withholding and do not
require submission of IRS Form W-4.

Federal Withholding Instructions:

 DO NOT withhold any federal income tax unless mandated by law
 DO withhold federal taxes

Additional amount you want withheld from your payment(s) $ (Note: This amount is in addition to the
standard federal withholding rate applicable to your distribution.)

State Withholding Instructions:

Payments to a participant in a non-qualified deferred compensation plan (409A or non-governmental 457(b)): If you participated
in a non-qualified deferred compensation plan, state income tax withholding may be required to be withheld from our distribution.
If applicable, please submit your state’s Form W-4 to specify your marital status and allowances for state tax withholding purposes.
This election CANNOT be made below. If you do not provide your state’s Form W-4, withholding will be applied according to the
state default.

Resident state for tax purposes: (If your current physical and/or mailing address is
outside of your state of legal residence for tax purposes, please enter your tax state here. If no U.S. state or territory is on
record and one is not specified, we will presume this income is not reportable to any U.S. state or territory.)
c DO NOT withhold any state income tax unless mandated by law.
c DO withhold state taxes in the amount of $ or % (If you make this election, a dollar amount or
percentage must be specified and cannot be less than any required withholding.)

If you do not make an election or if your state requires a greater amount of withholding, we will withhold at the rate specified by
your state of residence for the type of payment you are receiving. In some cases, your state specific withholding election form is
required to opt out of withholding or to choose a rate other than the state’s default rate. Refer to the attached State Income Tax
Withholding Notification and/or your State Department of Taxation for details.

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10. CONTRACT OWNER, spouse and alternate payee AUTHORIZED signatures and TAX WITHHOLDING
certification
Under penalties of perjury, I declare that I have examined the tax withholding for state and federal purposes and to the best of my
knowledge and belief it is true, correct and complete, including state and federal opt out elections, as applicable.

By signing this form, I acknowledge the following:

• The information provided is complete and accurate.
• I have read and understand the terms and conditions of this withdrawal request and agree to be bound by its terms.
• All withdrawals may be subject to maintenance fees, early withdrawal charges, and/or market value adjustments (as stated
in section 3).
• If I have ceased employment with the Employer and my rights under the contract or certificate are not 100% vested, they
may be forfeitable under the Plan. If my rights are forfeitable, the Plan Sponsor may instruct the Company to pay the amount
forfeited and pay that amount less withdrawal charges to the Plan Sponsor.
• If I am currently receiving a series of substantially equal payments (in accordance with IRC 72(q)(t)), taking an additional
withdrawal will modify my original agreement.

If I have requested a hardship withdrawal, I understand I may be asked to provide additional documentation to support the
hardship request. I declare the following:
• There is an immediate and heavy financial need;
• The distribution is necessary to meet such a need; and
• I considered all non-taxable loans if required under the plan(s) maintained by my employer; however, such loan would
increase the amount of my financial need and/or create an adverse financial situation;
• There are no other non-hardship distributions available to me under the plan(s) maintained by my employer;
• I have exhausted all other means available and meet the Plan requirements.
If this contract is subject to Employee Retirement Income Security Act (ERISA), I have included a completed Spousal Consent.
I, the Participant, certify that the information provided on the Spousal Consent (if applicable) is accurate. I further certify that if I
have indicated that I am legally separated or abandoned, I have the necessary court order. I understand that if I receive a payment
as a complete or partial withdrawal of my account (other than a joint and survivor annuity), the value of benefits payable to my
Spouse either under a QPSA or QJSA will be reduced or eliminated. I understand that once payment representing complete or
partial withdrawal of my account has been made, my election to waive QPSA and QJSA is irrevocable with respect to the value of
amounts paid pursuant to my request.
I understand that the Company reserves the right to directly or through a third party recover any payments made in excess of
amounts to which I am entitled under the terms of the Contract regardless of the method of payment.
Note to Owner regarding New York Issued Annuity Contracts: If your insurance producer is providing a recommendation regarding
this transaction, the insurance producer is required to provide you with the relevant features of the annuity contract and potential
consequences of the transaction, both favorable and unfavorable.

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10. CONTRACT OWNER, spouse and alternate payee AUTHORIZED signatures and TAX WITHHOLDING
certification (continued)

U.S. TAXPAYER CERTIFICATIONS

Under penalties of perjury, I certify that:

1. The Taxpayer Identification Number that appears on this form is correct,
2. I am not subject to backup withholding due to failure to report interest and dividend income1, and
3. I am a U.S. person
1
If you are subject to back-up withholding, you must strike through statement number 2.

NON-RESIDENT ALIEN STATUS

If you are a Non-Resident Alien, please check the box and provide your country of residence below.
c Under penalties of perjury, I certify that I am a Non-Resident Alien and my country of residence is .
The amount paid to you will be subject to 30% withholding, unless you submit an IRS Form W-8, and are entitled to claim a reduced
rate of withholding under the applicable U.S. tax treaty.

I certify that I have received and understand the Special Tax Notice Regarding Important Tax Information and, if applicable, waive
the 30 day notice requirement.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
(in bold above) required to avoid backup withholding.

 Contract Owner Signature  Date 

 Contract Owner SSN/TIN 

 Joint Contract Owner Signature  Date 

 Joint Contract Owner SSN/TIN 

 Alternate Payee Signature  Date 

If the Owner lives in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI), the spouse’s signature is required.

 Signature of Spouse 
IMPORTANT NOTICE: PLEASE NOTE THAT A DISTRIBUTION IS A TAX REPORTABLE EVENT THAT MAY NOT BE REVERSED.
Date 

Please note that duplicate requests for distribution, such as a fax followed by a mailed original, may result in multiple distributions.
The Company will not be responsible for any gain/loss or charges that arise from multiple submissions.

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11. CONSERVATOR/GUARDIAN SIGNATURE AND DATE
By signing below, you certify that you have read, understand and agree to be bound by, the provisions of this form as well as
(and without limitation) the terms and conditions governing Voya’s relationship with the account holder as currently set forth in
the contract, the Plan document and/or our Services Agreement (if applicable), which may be amended in the future. By signing
below, you also certify the following:
• You are the individual/entity named in the document(s) appointing the Conservatorship/Guardianship of the Estate for the
Account Holder for the accounts identified on this form.
• You certify that the Account Holder is not deceased.
• You agree to identify yourself as Conservator/Guardian when signing documents on behalf of the Account Holder, using [YOUR
NAME] as Conservator (or Guardian, if applicable) for [ACCOUNT HOLDER NAME]. All distribution checks will be made payable
to you as Conservator/Guardian for [ACCOUNT HOLDER NAME].
• You indemnify and hold Voya harmless from and against any and all losses, liabilities, claims, and costs resulting from
transactions made in accordance with your instructions. You further agree that the indemnifications are in addition to, and do
not limit, any rights that Voya may have under any other agreement with you.
• You agree to notify Voya and cease acting as Conservator/Guardian if you know or have reason to know that your capacity to
act as Conservator/Guardian has been limited or terminated for any reason.
• You agree and represent that if there are multiple Conservators/Guardians authorized with respect to the Plan accounts/
contract(s) listed on this form, you will act in accordance with the Letters of Conservatorship/Guardianship, including acting
independently, acting together or acting in majority as so indicated in the Letters of Conservatorship or Guardianship.
• Ongoing, it is your responsibility to provide Voya with current Letters of Conservatorship/Guardianship, or a court order of
appointment and, ongoing you may be asked to provide updated Letters/Court Orders, etc., if so authorized and/or required,
in order for you to conduct transactional activities and/or make account modifications. Account access will be granted to you
only through our Call Center.
• You agree that it is your responsibility as Conservator/Guardian to notify Voya if your Conservatorship/Guardianship either
changes or terminates which may require additional documentation.
• You understand that in the event of any conflict between instructions given by Conservators/Guardians or by an account
holder, Voya may restrict the account until it has received joint written instructions that it finds satisfactory.

 Conservator/Guardian Signature  Date 

12. Employer, plan sponsor or named fiduciary authorized Signature and Certification
This section must be completed by the Employer or its designee if required by a contract between the Company and the
Employer.
I am an Employer, Plan Sponsor, or Named Fiduciary of the Plan identified above and certify the following:
• I have read and agree to the terms of the requested withdrawal;
• I have verified the Participant’s eligibility for such withdrawal and have not relied solely on information provided by the
Participant in this form in order to make this determination;
• The requested benefits are permitted in accordance with the terms of the Plan document;
• The information provided in this document is complete and accurate to the best of my knowledge. If any information provided
by the Participant to the Company is in conflict with the information provided by me to the Company, I acknowledge that the
Company will rely conclusively on the information provided by me;
• I have amended my Plan document to reflect all applicable federal tax legislation and IRS guidance, including the Pension
Protection Act of 2006, in accordance with the IRS’s remedial amendment period; and
• If applicable, the requested withdrawal should be disbursed as set forth in Section 8 and such disbursement is consistent with
the terms of the Plan.

Employer Name

Authorized Signer Name (Please print.)

 Signature  Date 

Page 8 of 9 – Incomplete without all pages Order #119324 07/12/2021

TM: DISTRIBMNT
13. Third party administrator authorized Signature and Certification
This section must be completed if required by the Employer.
I am employed as a Third Party Administrator of the Plan identified above and certify the following:
• I have read and agree to the terms of the requested withdrawal;
• I have verified the Participant’s eligibility for such withdrawal and have not relied solely on information provided by the
Participant in this form in order to make this determination;
• The requested benefits are permitted in accordance with the terms of the Plan document;
• The information provided in this document is complete and accurate to the best of my knowledge. If any information provided
by the Participant to the Company is in conflict with the information provided by me to the Company, I acknowledge that the
Company will rely conclusively on the information provided by me; and
• If applicable, the requested withdrawal should be disbursed as set forth in Section 8 and such disbursement is consistent with
the terms of the Plan.

Name of TPA Firm

Authorized Signer Name (Please print.)

 Signature  Date 

Page 9 of 9 – Incomplete without all pages Order #119324 07/12/2021

TM: DISTRIBMNT
State Income Tax Withholding Notification
401, 403(b), 408 and Governmental 457 Plan Distribution

Notification
If you are a resident of Arkansas, California, Connecticut, Delaware, District of Columbia, Georgia, Iowa, Kansas, Maine, Maryland1,
Massachusetts, Michigan, Nebraska2, North Carolina3, Oklahoma, Oregon, Vermont, or Virginia1, your state requires state income
tax withholding on the taxable portion of your distribution from your 401, 403(b), 408 Individual Retirement or Governmental
457 Plan. This state income tax withholding is in addition to the mandatory 20% (or, in some cases, 10%) federal income tax
withholding. Please note, when a state cost basis differs from federal, the federal cost basis will be used in determining taxability
for state income tax withholding purposes.
• If you are a resident of California or Oregon state income tax withholding will be calculated unless you elect “out” of state
income tax withholding.
• If you are a resident of Arkansas, North Carolina3 or Vermont, state withholding will be automatically calculated when federal
income tax withholding applies. If you do not elect “out” of 10% federal income tax withholding, you can still choose to elect out
of state withholding. Requesting North Carolina withholding over mandatory amounts requires their Form NC-4P, Withholding
Certificate for Pension or Annuity Payments.
• If you are a resident of Iowa, Maine, Massachusetts, Nebraska2, or Oklahoma, state income tax withholding will be automatically
calculated as these states do not allow an election “out” of state income tax withholding when federal income tax withholding
applies.
• If you are a resident of Delaware, Kansas or Maryland1 and are subject to mandatory 20% federal income tax withholding,
state income tax withholding will be automatically calculated. State withholding is not required when 10% federal income tax
withholding applies.
• If you are a resident of Virginia1 or Michigan, state income tax withholding will be calculated automatically unless you meet
certain criteria and claim an exemption from withholding. To claim an exemption or to request withholding over mandatory
amounts, complete Form VA-4P for Virginia or Form MI-W4P for Michigan, and return the appropriate form to us with, and to the
same designated location as, your Withdrawal Request.
• If you are a resident of the District of Columbia and are receiving a total distribution of your account balance, state income tax
withholding will be automatically calculated. State withholding is not required for partial distributions.
• If you are a resident of Georgia and are receiving periodic payments, state income tax withholding will be automatically
calculated unless you elect out.
• If you are a resident of Connecticut and are receiving partial non-periodic payments, state income tax withholding will be taken
at the highest marginal rate unless you claim exemption from withholding and/or request additional withholding by completing
Form CT-W4P. If you are receiving a total payment of your account balance, state income tax withholding will be taken at the
highest marginal rate unless you request additional withholding by completing Form CT-W4P. You cannot claim exemption
from withholding for a total payment. If you are receiving a periodic payment, state income tax withholding will be taken at
the highest marginal rate unless you complete Form CT-W4P. Form CT-W4P must be returned to us with, and to the same
designated location as, your Withdrawal Request.
1
Maryland and Virginia state income tax withholding is not required for distributions from 408 Plans.
2
Nebraska state income tax withholding is not required for premature distributions from 408 Plans.
3
North Carolina does not apply to distributions from NC state and local government or federal retirement systems for those vested as of 8/12/89.

KEEP A COPY FOR YOUR RECORDS

Order #143703 Form #83006 04/01/2019

TM: MYOUTBCKUP
Special Tax Notice
REGARDING PAYMENTS FROM AN ACCOUNT
OTHER THAN A DESIGNATED ROTH ACCOUNT
ReliaStar Life Insurance Company (RLIC), Minneapolis, MN
ReliaStar Life Insurance Company of New York (RLNY), Woodbury, NY
RLIC and RLNY (“RLSTR”) affiliated
Security Life of Denver Insurance Company (SLD), Denver, CO
Midwestern United Life Insurance Company (MULIC), Indianapolis, IN
SLD and MULIC (“SLD/MULIC”) affiliated
Customer Service: PO Box 1559, Hartford, CT 06144-1559
Phone: 877-884-5050
SLD/MULIC and RLSTR may provide administrative services to each other, but are otherwise unaffiliated. All contractual obligations
under each insurance policy or contract are the sole responsibility of the issuing insurance company.
YOUR ROLLOVER OPTIONS
You are receiving this notice because all or a portion of a payment you are receiving is eligible to be rolled over to an IRA or an
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 from the Plan that are not from a designated Roth account (a type
of account in some employer plans that is subject to special tax rules). If you also receive a payment from a designated Roth account
in the Plan, you will be provided a different notice for that payment, and the Plan administrator or the payor will tell you the amount that
is being paid from each account.
Rules that apply to most payments from a plan 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 Plan 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 (generally, distributions made before age 59½), 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 to the 10% additional income tax 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 an employer plan
(a tax-qualified plan, section 403(b) plan, or 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 may not provide 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, the Plan 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, the Plan is
required to withhold 20% of the payment for federal income taxes (up to the amount of cash and property received other than
employer stock). 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 Plan 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 joint lives or joint life
expectancies of you and your beneficiary);
• Required minimum distributions after age 70½ (if you were born before July 1, 1949), after age 72 (if you were born after
June 30, 1949), or after death;
• Hardship distributions;
• Payments of employee stock ownership plan (ESOP) dividends;
• 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);
• Cost of life insurance paid by the Plan;

Page 1 of 10 Order #119381 04/01/2021

GENERAL INFORMATION ABOUT ROLLOVERS (Continued)
• Payments of certain automatic enrollment contributions that you request to withdraw within 90 days of your first contribution;
• Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there generally
will be adverse tax consequences if you roll over a distribution of S corporation stock to an IRA); and
• Distributions of certain premiums for health and accident insurance.
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.
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 Plan
(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 Plan:
• 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;
• Payments of ESOP dividends;
• Corrective distributions of contributions that exceed tax law limitations;
• Cost of life insurance paid by the Plan;
• 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;
• 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; and
• 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:
• The exception for payments made after you separate from service if you will be at least age 55 in the year of the separation (or
age 50 for qualified public safety employees) does not apply;
• 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); and
• 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.
Additional exceptions apply for payments from an IRA, including:
• Payments for qualified higher education expenses;
• Payments up to $10,000 used in a qualified first-time home purchase; and
• 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 rules (including withholding rules).

Page 2 of 10 Order #119381 04/01/2021

Special rules and options
If your payment includes after-tax contributions
After-tax contributions included in a payment are not taxed. If you receive a partial payment of your total benefit, an allocable portion
of your after-tax contributions is included in the payment, so you cannot take a payment of only after-tax contributions. However, 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 Plan 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 $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 your payment includes employer stock that you do not roll over
If you do not do a rollover, you can apply a special rule to payments of employer stock (or other employer securities) that are either
attributable to after-tax contributions or paid in a lump sum after separation from service (or after age 59½, disability, or the
participant’s death). Under the special rule, the net unrealized appreciation on the stock will not be taxed when distributed from the
Plan and will be taxed at capital gain rates when you sell the stock. Net unrealized appreciation is generally the increase in the value
of employer stock after it was acquired by the Plan. If you do a rollover for a payment that includes employer stock (for example, by
selling the stock and rolling over the proceeds within 60 days of the payment), the special rule relating to the distributed employer
stock will not apply to any subsequent payments from the IRA or, generally, the Plan. The Plan administrator can tell you the amount
of any net unrealized appreciation.
If you have an outstanding loan that is being offset
If you have an outstanding loan from the Plan, your Plan benefit 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 an 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 Plan is 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 Plan even if you are under age 59½ (unless the payment is
from a separate account holding rollover contributions that were made to the Plan from 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 your payment includes employer stock that you do not roll over” and “If you were born on or before January 1, 1936” do not apply.

Page 3 of 10 Order #119381 04/01/2021

Special rules and options (Continued)
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 Plan is 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 Plan 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 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 distributing Plan. If you roll over a payment from the Plan to a designated Roth account
in the 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 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 Plan participant
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 Plan as the surviving spouse of a deceased participant, you have
the same rollover options that the participant would have had, as 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 70½ (if you were born before July 1, 1949) or age 72 (if you were born after
June 30, 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 Plan,
you will not have to start receiving required minimum distributions from the inherited IRA until the year the participant would have
been age 70½ (if the participant was born before July 1, 1949) or age 72 (if the participant was born after June 30, 1949).
If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan 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 QDRO. If you are the spouse or former spouse of the participant who receives a payment from the Plan 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.

Page 4 of 10 Order #119381 04/01/2021

Special rules and options (Continued)
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%, the
Plan is 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 in the Plan), the Plan is not
required to allow you to do a direct rollover and is 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 the payor. 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 payor, or a professional tax advisor, before taking a payment from the Plan.
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.

Page 5 of 10 Order #119381 04/01/2021

Special Tax Notice
REGARDING PAYMENTS FROM A
DESIGNATED ROTH ACCOUNT
ReliaStar Life Insurance Company (RLIC), Minneapolis, MN
ReliaStar Life Insurance Company of New York (RLNY), Woodbury, NY
RLIC and RLNY (“RLSTR”) affiliated
Security Life of Denver Insurance Company (SLD), Denver, CO
Midwestern United Life Insurance Company (MULIC), Indianapolis, IN
SLD and MULIC (“SLD/MULIC”) affiliated
Customer Service: PO Box 1559, Hartford, CT 06144-1559
Phone: 877-884-5050
SLD/MULIC and RLSTR may provide administrative services to each other, but are otherwise unaffiliated. All contractual obligations
under each insurance policy or contract are the sole responsibility of the issuing insurance company.
YOUR ROLLOVER OPTIONS
You are receiving this notice because all or a portion of a payment you are receiving is eligible to be rolled over to a Roth IRA or
designated Roth account in an employer plan. This notice is intended to help you decide whether to do a rollover.
This notice describes the rollover rules that apply to payments from the Plan that are from a designated Roth account. If you
also receive a payment from the Plan that is not from a designated Roth account, you will be provided a different notice for that
payment, and the Plan administrator or the payor will tell you the amount that is being paid from each account.
Rules that apply to most payments from a designated Roth account 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?
After-tax contributions included in a payment from a designated Roth account are not taxed, but earnings might be taxed. The tax
treatment of earnings included in the payment depends on whether the payment is a qualified distribution. If a payment is only part
of your designated Roth account, the payment will include an allocable portion of the earnings in your designated Roth account.
If the payment from the Plan is not a qualified distribution and you do not do a rollover to a Roth IRA or a designated Roth account in
an employer plan, you will be taxed on the portion of the payment that is earnings. If you are under age 59½, a 10% additional income
tax on early distributions (generally, distributions made before age 59½) will also apply to the earnings (unless an exception applies).
However, if you do a rollover, you will not have to pay taxes currently on the earnings and you will not have to pay taxes later on
payments that are qualified distributions.
If the payment from the Plan is a qualified distribution, you will not be taxed on any part of the payment even if you do not do a rollover.
If you do a rollover, you will not be taxed on the amount you roll over and any earnings on the amount you roll over will not be taxed
if paid later in a qualified distribution.
A qualified distribution from a designated Roth account in the Plan is a payment made 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 the 5-year rule, you count from
January 1 of the year your first contribution was made to the designated Roth account. However, if you did a direct rollover to a
designated Roth account in the Plan from a designated Roth account in another employer plan, your participation will count from
January 1 of the year your first contribution was made to the designated Roth account in the Plan or, if earlier, to the designated Roth
account in the other employer plan.
What types of retirement accounts and plans may accept my rollover?
You may roll over the payment to either a Roth IRA (a Roth individual retirement account or Roth individual retirement annuity) or a
designated Roth account in an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457 plan) that will
accept the rollover. The rules of the Roth IRA or employer plan that holds the rollover will determine your investment options, fees,
and rights to payment from the Roth IRA or employer plan (for example, Roth IRAs are not subject to spousal consent rules, and Roth
IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the Roth IRA or the
designated Roth account in the employer plan. In general, these tax rules are similar to those described elsewhere in this notice, but
differences include:
• If you do a rollover to a Roth IRA, all of your Roth IRAs will be considered for purposes of determining whether you have satisfied
the 5-year rule (counting from January 1 of the year for which your first contribution was made to any of your Roth IRAs).
• If you do a rollover to a Roth IRA, you will not be required to take a distribution from the Roth IRA during your lifetime and you
must keep track of the aggregate amount of the after-tax contributions in all of your Roth IRAs (in order to determine your taxable
income for later Roth IRA payments that are not qualified distributions).
• Eligible rollover distributions from a Roth IRA can only be rolled over to another Roth IRA.
How do I do a rollover?
There are two ways to do a rollover. You can either do a direct rollover or a 60- day rollover.
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GENERAL INFORMATION ABOUT ROLLOVERS (Continued)
If you do a direct rollover, the Plan will make the payment directly to your Roth IRA or designated Roth account in an employer plan.
You should contact the Roth 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 (generally within 60 days) into a Roth IRA, whether
the payment is a qualified or nonqualified distribution. In addition, you can do a rollover by making a deposit within 60 days into a
designated Roth account in an employer plan if the payment is a nonqualified distribution and the rollover does not exceed the
amount of the earnings in the payment. You cannot do a 60-day rollover to an employer plan of any part of a qualified distribution. If
you receive a distribution that is a nonqualified distribution and you do not roll over an amount at least equal to the earnings allocable
to the distribution, you will be taxed on the amount of those earnings not rolled over, including the 10% additional income tax on early
distributions if you are under age 59½ (unless an exception applies).
If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you at the same time, the portion
directly rolled over consists first of earnings.
If you do not do a direct rollover and the payment is not a qualified distribution, the Plan is required to withhold 20% of the earnings
for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll
over the entire payment in a 60-day rollover to a Roth IRA, you must use other funds to make up for the 20% withheld.
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 Plan 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 joint lives or joint life
expectancies of you and your beneficiary);
• Required minimum distributions after age 70½ (if you were born before July 1, 1949), after age 72 (if you were born after June 30,
1949), or after death;
• Hardship distributions;
• Payments of employee stock ownership plan (ESOP) dividends;
• 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);
• Cost of life insurance paid by the Plan;
• Payments of certain automatic enrollment contributions that you request to withdraw within 90 days of your first contribution; and
• Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there generally will
be adverse tax consequences if S corporation stock is held by an IRA); and
• Distributions of certain premiums for health and accident insurance.
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.
If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?
If a payment is not a qualified distribution and you are under age 59½, you will have to pay the 10% additional income tax on early
distributions with respect to the earnings allocated to the payment that you do not roll over (including amounts withheld for income
tax), unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the earnings not rolled over.
The 10% additional income tax does not apply to the following payments from the Plan:
• 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;
• Payments of ESOP dividends;
• Corrective distributions of contributions that exceed tax law limitations;
• Cost of life insurance paid by the Plan;
• 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;
• Payments of certain automatic enrollment contributions that you request to withdraw within 90 days of your first contribution; and
• Payments excepted from the additional income tax by federal legislation relating to certain emergencies and disasters.
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GENERAL INFORMATION ABOUT ROLLOVERS (Continued)
If I do a rollover to a Roth IRA, will the 10% additional income tax apply to early distributions from the IRA?
If you receive a payment from a Roth IRA when you are under age 59½, you will have to pay the 10% additional income tax on early
distributions on the earnings paid from the Roth IRA, unless an exception applies or the payment is a qualified distribution. In general,
the exceptions to the 10% additional income tax for early distributions from a Roth IRA listed above are the same as the exceptions for
early distributions from a plan. However, there are a few differences for payments from a Roth IRA, including:
• The exception for payments made after you separate from service if you will be at least age 55 in the year of the separation (or
age 50 for qualified public safety employees) does not apply;
• 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 a Roth IRA of a spouse or former spouse); and
• 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.
Additional exceptions apply for payments from an IRA, including:
• Payments for qualified higher education expenses;
• Payments up to $10,000 used in a qualified first-time home purchase; and
• 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 rules (including withholding rules).

SPECIAL RULES AND OPTIONS

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 your payment includes employer stock that you do not roll over
If you receive a payment that is not a qualified distribution and you do not roll it over, you can apply a special rule to payments of
employer stock (or other employer securities) that are paid in a lump sum after separation from service (or after age 59½, disability,
or the participant’s death). Under the special rule, the net unrealized appreciation on the stock included in the earnings in the
payment will not be taxed when distributed to you from the Plan and will be taxed at capital gain rates when you sell the stock. If you
do a rollover to a Roth IRA for a nonqualified distribution that includes employer stock (for example, by selling the stock and rolling
over the proceeds within 60 days of the distribution), you will not have any taxable income and the special rule relating to the
distributed employer stock will not apply to any subsequent payments from the Roth IRA or, generally, the Plan. Net unrealized
appreciation is generally the increase in the value of the employer stock after it was acquired by the Plan. The Plan administrator can
tell you the amount of any net unrealized appreciation.
If you receive a payment that is a qualified distribution that includes employer stock and you do not roll it over, your basis in the stock
(used to determine gain or loss when you later sell the stock) will equal the fair market value of the stock at the time of the payment
from the Plan.
If you have an outstanding loan that is being offset
If you have an outstanding loan from the Plan, your Plan benefit 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. If the distribution attributable to the offset is not a qualified distribution and you do not roll over
the offset amount, you will be taxed on any earnings included in the distribution (including the 10% additional income tax on early
distributions, unless an exception applies). You may roll over the earnings included in the loan offset to a Roth IRA or designated Roth
account in an employer plan (if the terms of the employer plan permit the plan to receive plan loan offset rollovers). You may also roll
over the full amount of the offset to a Roth IRA.
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
repayments that results in a deemed distribution), then you have 60 days from the date the offset occurs to complete your rollover.
If you receive a nonqualified distribution and 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 is not a qualified distribution and that you do
not roll over, special rules for calculating the amount of the tax on the earnings in 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 Plan is 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 receive a payment that is
Page 8 of 10 Order #119381 04/01/2021
Special rules and options (Continued)
not a qualified distribution and you do not roll it over, you will not have to pay the 10% additional income tax on early distributions
with respect to the earnings allocated to the payment that you do not roll over, even if you are under age 59½ (unless the payment
is from a separate account holding rollover contributions that were made to the Plan from 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 that is not a qualified distribution made before age 59½ will be subject to the 10% additional income tax on earnings
allocated to the payment (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 your payment includes employer stock that you do not roll over”
and “If you were born on or before January 1, 1936” do not apply.
If you receive a nonqualified distribution, 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 Plan is 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 nonqualified distributions 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 are not a Plan participant
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, whether the payment is a
qualified distribution generally depends on when the participant first made a contribution to the designated Roth account in the Plan.
Also, 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 receive a nonqualified distribution and 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 Plan as the surviving spouse of a deceased participant, you have
the same rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do
a rollover to a Roth IRA, you may treat the Roth IRA as your own or as an inherited Roth IRA.
A Roth IRA you treat as your own is treated like any other Roth IRA of yours, so that you will not have to receive any required
minimum distributions during your lifetime and earnings paid to you in a nonqualified distribution before you are age 59½ will be
subject to the 10% additional income tax on early distributions (unless an exception applies).
If you treat the Roth IRA as an inherited Roth IRA, payments from the Roth IRA will not be subject to the 10% additional income tax
on early distributions. An inherited Roth IRA is subject to required minimum distributions. If the participant had started taking required
minimum distributions from the Plan, you will have to receive required minimum distributions from the inherited Roth IRA. If the
participant had not started taking required minimum distributions, you will not have to start receiving required minimum distributions
from the inherited Roth IRA until the year the participant would have been age 70½ (if the participant was born before July 1, 1949)
or age 72 (if the participant was born after June 30, 1949).
If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan 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 Roth IRA. Payments from the inherited Roth IRA, even if made in a nonqualified distribution, will not be subject to the 10%
additional income tax on early distributions. You will have to receive required minimum distributions from the inherited Roth IRA.
Payments under a QDRO. If you are the spouse or a former spouse of the participant who receives a payment from the Plan 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 Roth IRA or to a designated Roth account in an eligible employer plan that will accept it).
If you are a nonresident alien
If you are a nonresident alien, you do not do a direct rollover to a U.S. IRA or U.S. employer plan, and the payment is not a qualified
distribution, the Plan is generally required to withhold 30% (instead of withholding 20%) of the earnings 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 (only including payments from the designated Roth account in the Plan) are less than $200, the Plan is not
required to allow you to do a direct rollover and is not required to withhold federal income taxes. However, you can do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout from the designated Roth account in the Plan of more than $1,000 will be directly
rolled over to a Roth IRA chosen by the Plan administrator or the payor. 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.

Page 9 of 10 Order #119381 04/01/2021

FOR MORE INFORMATION
You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan.
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.

Page 10 of 10 Order #119381 04/01/2021