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ANNUITY DISTRIBUTION REQUEST - Marketing …

Lincoln Financial Group is the Marketing name for Lincoln National Corporation and its affiliates. page 1 of 3AN07301 4/12 The Lincoln National Life Insurance Company ( Company )Lincoln Life & ANNUITY Company of New York ( Company )Servicing Office: PO Box 2348, Fort Wayne IN 46801-2348 Fax Number 260 Address: Lincoln Financial Group, Inforce - IA1300 S Clinton St., Fort Wayne IN 46802-3506 ANNUITY DISTRIBUTION * REQUESTThis form should be used for the following markets: IRA/Roth/SEP/SARSEP/Non-QualifiedFor contracts** with the Lincoln Lifetime IncomeSM Edge living benefit riders, please use form AN10100 for CONTRACT INFORMATIONC ontract Number _____Contract Owner s Name _____Issued by h The Lincoln National Life Insurance Company h Lincoln Life & ANNUITY Company of New YorkSocial Security Number (Last 4 digits) _____ Date of Birth _____Telephone Number Daytime _____ Evening _____IMPORTANT INFORMATIONd The information contained on this form is based on the Company s understanding of curr

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 3 AN07301 4/12 The Lincoln National Life …

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Transcription of ANNUITY DISTRIBUTION REQUEST - Marketing …

1 Lincoln Financial Group is the Marketing name for Lincoln National Corporation and its affiliates. page 1 of 3AN07301 4/12 The Lincoln National Life Insurance Company ( Company )Lincoln Life & ANNUITY Company of New York ( Company )Servicing Office: PO Box 2348, Fort Wayne IN 46801-2348 Fax Number 260 Address: Lincoln Financial Group, Inforce - IA1300 S Clinton St., Fort Wayne IN 46802-3506 ANNUITY DISTRIBUTION * REQUESTThis form should be used for the following markets: IRA/Roth/SEP/SARSEP/Non-QualifiedFor contracts** with the Lincoln Lifetime IncomeSM Edge living benefit riders, please use form AN10100 for CONTRACT INFORMATIONC ontract Number _____Contract Owner s Name _____Issued by h The Lincoln National Life Insurance Company h Lincoln Life & ANNUITY Company of New YorkSocial Security Number (Last 4 digits) _____ Date of Birth _____Telephone Number Daytime _____ Evening _____IMPORTANT INFORMATIONd The information contained on this form is based on the Company s understanding of current federal tax laws and regulations and is not intended to serve as legal or tax advice.

2 You should consult your attorney or tax advisor as to any tax, accounting or legal statements made on this form. d Surrender Charges and a Market Value Adjustment (MVA), if any, may apply if the withdrawal amount is greater than the free partial withdrawal amount as stated in the DISTRIBUTION requests from any indexed contract will be withdrawn from the Fixed Account first. Only after the Fixed Account has been exhausted, will any remaining withdrawals be made from the indexed accounts. Withdrawals from the indexed accounts will be made pro-rata based on the indexed account values at the time of the withdrawal. d Variable products may specify the subaccount to be used.

3 If the dollar value of a specified subaccount is reduced below the requested amount, the DISTRIBUTION will be changed to pro-rata based on current All declared interest rates are expressed as annual effective interest rates. Any DISTRIBUTION taken during the contract year will reduce the actual amount earned because of interruption of interest This form should not be used to REQUEST a Required Minimum TYPE OF DISTRIBUTIONS elect Type of DISTRIBUTION : h T otal Surrender (full surrender) h P artial Withdrawal (partial surrender)If Partial Withdrawal - Select ONE type of withdrawal - A, B, or C (Required)h A. Withdraw $ _____ h Yes h No If Surrender Charges, MVA, tax and/or mailing fee are applicable and are withheld, do you want the amount received to equal the amount requested?

4 H B. Withdraw the annual free partial withdrawal amount as stated in the C. Withdraw the remaining available Lifetime Benefit Amount allowed pursuant to the terms of my Lincoln Living IncomeSM Advantage rider for this benefit year. Please note: If you have an Automatic Withdrawal Service it will be stopped for the rest of this benefit year and resume after your rider anniversary. If your remaining amount allowed is $0, no withdrawal will be processed. For options A and B Excess withdrawals may substantially deplete or eliminate the guarantees allowed under your Lincoln Living IncomeSM Advantage rider and may result in the termination of the rider and contract.

5 Please contact your Financial Advisor, ANNUITY Customer Service or refer to your Contract for additional : Specify a dollar amount in option A, if not requesting the entire DISTRIBUTION amounts in options B and C. If an Automatic Withdrawal program is in effect, it may be impacted by DISTRIBUTION requests. Contact your Representative/Agent for additional information.* DISTRIBUTION may be referred to as Payment , Withdrawal or Surrender. ** Contract may be referred to as Policy or Certificate. XXX-XX- Page 2 of 3AN07301 4/12** Lincoln reserves the right to assess a fee; fees are subject to Product Requests Only Dollar Amount/% Variable Subaccount_____ from _____ from _____ from _____ from _____(If the dollar value of a specified subaccount is reduced below the requested amount, the payments will be changed to pro-rata based on the current allocations.)

6 3. FEDERAL/STATE INCOME TAX WITHHOLDING (Required)If tax information is NOT provided, 10% federal income tax and applicable state income tax WILL be will be withheld from this DISTRIBUTION as indicated below. If you elect not to have federal income tax withheld, you will remain liable for payment of federal income tax on your DISTRIBUTION . You may also be subject to tax penalties under the estimated tax payment rules if your payment of estimated tax and withholding, if any, are not adequate. You may wish to discuss your withholding election with your attorney or tax Income Tax Withholding Options: (Select One)h Do NOT withhold federal income taxh Withhold 10% federal income taxh Indicate the total amount or percentage of federal income tax to be withheld.

7 $ _____ or _____% (The amount must be greater than 10%.)If federal income tax is withheld, state income tax may be withheld, depending on your state of residence. The following states mandate state tax withholding if federal income tax is withheld: Iowa, Maine, Massachusetts, Nebraska, Oklahoma, Vermont, and Virginia. If you are a resident of Arkansas, California, Georgia, or Oregon, and federal tax is withheld, you may opt out of state you are a resident of Delaware, Kansas, North Carolina, and are subject to mandatory Federal tax withholding, then state income tax is also required. Otherwise you may opt out of state income tax you are resident of California or Vermont and elect federal and state tax withholding, the state tax will be a percentage of the federal amount withheld as your state Income Tax Withholding Options: (Select One)State of residence _____ (Michigan residents MUST elect state income tax withholding on form MI W-4P.)

8 H V oluntary state income tax amount of $ _____ or _____%h Do not withhold state income tax (Opt Out)Note: The dollar amount or percent withholding must meet the minimum withholding guidelines for your state. If tax information is not provided, federal taxes and applicable state taxes will be withheld using married and 3 METHOD OF DISTRIBUTION - Select ONE DISTRIBUTION method - A, B, C, or D (Required)h A. Direct Deposit (no fee) h B. Wire Deposit ($25 fee for domestic wires; $40 fee for foreign wires)**h C. 100% of Disbursement sent to Brokerage Account h D. Mail Check (no fee)**h E. Overnight Check ($25 fee)**If A or B is selected (Direct Deposit or Wire Deposit), complete this information:Name of Financial Institution _____Telephone Number _____Address _____City _____State _____Zip _____Type of Account: h Checking Account (must attach a voided check) h Savings AccountAccount Number _____ABA/Transit Routing Number (Contact your Financial Institution for this.)

9 _____Note: The DISTRIBUTION will be sent Direct Deposit if bank information is provided but no selection is marked C is selected complete this information:Client Brokerage Account number: _____ Note: Disbursements to a brokerage account must be sent electronically to an account held at the broker/dealer of record on the contract. Acceptance of electronic payments may vary by firm. If an electronic option is not available, a check will be sent to the client s address of D or E is selected (Mail Check or Overnight Check), complete this information:h Address on recordh Alternate Address Send check to _____ Make check payable to _____ If this is a direct transfer to an IRA, SEP or SARSEP, provide account number.

10 _____ Alternate Address _____ City _____State _____Zip _____ Telephone Number _____IMPORTANT TAX INFORMATIONThe IRS issued guidance in 2008 that affects your ability to take distributions from an ANNUITY that is funded by a tax-free partial exchange from another contract. Under the 2008 IRS guidance, if you take a DISTRIBUTION from either your prior contract or your new contract within 12 months of the exchange, the tax-free status of the exchange could be lost. Certain limited exceptions apply that would allow you to take a DISTRIBUTION within the 12 month period; and you should consult your attorney or tax advisor to determine if any of those exceptions currently apply to SPECIAL INSTRUCTIONS_____6.


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