VL 19552 - 65886001
VL 19552 - 65886001
747- 999-7826
Daytime Phone: (_______)_________________________________ 12/13/1958
Date of Birth: ________________________________
2. DISTRIBUTION METHOD
Choose from one of the following distribution methods below. Please review the enclosed “SPECIAL TAX NOTICE” carefully.
OPTION A → WITHDRAWAL
• Distributes funds as requested and leaves account open
• Future contributions accepted if allowed by the plan
• No impact to outstanding loans
Please indicate Account(s) you wish to withdraw from.
500c155
Account #______________________________ Account #______________________________ Account #______________________________
$__75,000
________________ or_______________ % $__________________ or_______________ % $__________________ or_______________ %
Choose one: Choose one: Choose one:
l Distribute the amount pro-rata against l Distribute the amount pro-rata against l Distribute the amount pro-rata against
all available funds excluding Schwab all available funds excluding Schwab all available funds excluding Schwab
PCRA (default) PCRA (default) PCRA (default)
l Distribute the amount pro-rata against all l Distribute the amount pro-rata against all l Distribute the amount pro-rata against all
available funds including Schwab PCRA available funds including Schwab PCRA available funds including Schwab PCRA
l Distribute the amount or percentage from l Distribute the amount or percentage from l Distribute the amount or percentage from
each fund as specified below: each fund as specified below: each fund as specified below:
Fund Code Amount Fund Code Amount Fund Code Amount
OPTION B → SURRENDER
• Automatically closes the account
• Future contributions will not be accepted
• Any active outstanding loan(s) will be terminated and reported as taxable distribution(s)
Please indicate Account(s) you wish to surrender.
OPTION D → ANNUITY IF AVAILABLE UNDER THE PLAN (Please complete VALIC’s Annuity Benefits Form.)
6. SPOUSAL CONSENT
ERISA-covered and certain other employer plans require the client to state his/her marital status and the spouse to consent to this distribution. Not required
for 457 Deferred Compensation Plans. Please check the appropriate box below:
REQUIRED FOR CLIENT: Client Marital Status
l Not Married l Married
REQUIRED FOR SPOUSE: Spousal Consent
Under federal law, you have the right to receive a survivor benefit of at least 50% of the amount in this account if your spouse dies before you. As a result,
your spouse must have written consent before making withdrawals from his or her retirement account. If you consent to the withdrawal, you will not receive a
survivor benefit from the amount withdrawn. If you agree to the withdrawal, please read and sign the statement below and have your signature witnessed.
• I have read and understand the “Joint and Survivor Annuity and Qualified Annuity Benefit” section of the Information pages and I agree to the payment of
funds from my spouse’s retirement account.
• I understand and agree that I am giving up my right to receive a survivor benefit payment from VALIC Retirement Services Company for the amount being
paid and I release VALIC Retirement Services Company from all liability for making this payment.
__________________________________________________________________________________ 05/01/2023
________________________
Client Signature Date
__________________________________________________________________________________
Plan Administrator or Authorized Representative (Print Name)
__________________________________________________________________________________ ________________________
Plan Administrator or Authorized Representative Signature Date
AIG Retirement Services represents AIG member companies - The Variable Annuity Life Insurance Company (VALIC) and its subsidiaries, VALIC Financial Advisors, Inc. (VFA) and
VALIC Retirement Services Company (VRSCO). All are members of American International Group, Inc. (AIG).
VL 19552 VER 1/2022 2.0 DISBRSMNTM
page 3 of 3
Information
Monthly Payment
Annuitant Life
Only 39.62 35.35 32.38 30.27 28.75 27.61 26.76 26.13
Joint and
50% Survivor 35.47 33.65 30.21 29.26 27.53 26.99 26.07 25.76
Joint and
75% Survivor 33.71 32.86 29.23 28.78 26.95 26.70 25.73 25.58