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OutgOing rOllOver/transfer/exchange request fixeD/variaBle ...

Instructions - Page 1 of 1 Order #144774 12/03/2022 TM: TRANSFMNTOUTGOING rOllOver/transfer/exchange REQUESTFIXED/VARIABLE ANNUITIES - CHECKLIST FOREMPLOYER FUNDED PLANSR eliaStar 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 companiesCustomer Service: PO Box 1559, Hartford, CT 06144-1559 Phone: 877-884-5050 Use this form to request a rollover, transfer, or exchange from your 403(b), Roth 403(b), 401, 401(k), or Pension plan to another company. Please follow the checklist to avoid delays in processing your request . A distribution is a tax reportable event that may not be COMPLETED FORMSS ection 1: CONTRACT OWNER INFORMATION Have you completed section 1?

established or maintained by private tax-exempt organizations are subject to ERISA. A Spousal Consent form is required (Form 149932) for contracts subject to ERISA. If you are unsure if your contract is subject to ERISA, please contact Customer Service at 1-877-884-5050 for assistance. • Have you completed section 3?

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