WITHDRAWAL/SURRENDER REQUEST FORM
If the policy contract is not returned, by signing this surrender request form the owner certifies under penalties of perjury that the policy contract has been lost or destroyed,
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Request for Disbursement / Systematic Withdrawal Form for ...
mrannuity.comFGLI 4913 (12-2004) Original: Company Copy: Agent Copy: Client Page 1 of 5 Request for Disbursement / Systematic Withdrawal Form for Qualified Annuities INSURER Fidelity and Guaranty Life Insurance Company Americom Life and Annuity Insurance Company
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