SURRENDER REQUEST FORM - unifiedlife.com

1 SURRENDER REQUEST form Policy Number: _____ Insured: _____ _____ (First Name) (Last Name) The undersigned owner of the referenced policy hereby forwards the policy to and requests that the policy be canceled and the cash SURRENDER value of the policy, if any, be paid to the owner. The owner and any irrevocable beneficiary hereby indicate his/her understanding that the cancellation of the policy and withdrawal of the cash SURRENDER value terminates the insurance coverage provided under the policy as of the effective date of the SURRENDER , which is the date all requirements are received by the company.

2 Furthermore, all undersigned below acknowledge that the termination of this policy may be considered a taxable event which will be reported to the IRS. Each individual signing below certifies that he/she is of legal age, that the policy is not assigned and pledges that the policy is not subject to any bankruptcy proceeding, attachment, lien, or claim except as indicated on this form . The undersigned owner of the referenced policy hereby requests a policy SURRENDER (termination) be processed against the above policy number. Please return your original policy and/or any duplicate policies or certificates of insurance, or check the Lost Policy Affidavit below: LOST POLICY AFFIDAVIT: I hereby certify that the policy has been lost or destroyed, I have no knowledge of its whereabouts and said policy is not assigned, hypothecated or pledged.

3 If at any time the original policy certificate or duplicate is found, I will immediately destroy it or return it to the company. Under current federal income tax law, we are required to withhold 10% of the taxable portion of the cash SURRENDER value and pay it to the IRS UNLESS YOU TELL US IN WRITING NOT TO WITHHOLD TAX. Certain states also require us to withhold state income tax if we withhold federal tax. You are responsible for paying income tax on the taxable portion of our payment even if we do no withholding. You may be subject to tax penalties under the estimated tax payment rules if your payments of estimated tax and withholding, if any, are not adequate. Also, an additional 10% Federal Tax penalty may be imposed on your withdrawal.

4 In making your decision about withholding, you should consider that penalties under the estimated income tax rules may apply if your withholding and estimated income tax payments are not sufficient. WITHHOLDING ELECTION: Enter your Tax ID Number in section D below. Check A if you do not want any Federal/State Income Tax withheld from your withdrawal/ SURRENDER proceeds; check B to have taxes withheld by the company and forwarded to the IRS on your behalf. As stated above, you are liable for the accurate payment of the applicable Federal/State Income Tax on the taxable portion of your withdrawal. A. Do not withhold Federal/State Income Tax B. Withhold Federal Income Tax at 10% as well as applicable State Income Tax Name: _____ Payee s SS#: _____-_____-_____* Phone: (_____) _____- _____ Address: _____ X _____ Owner s SS#: _____-____-_____* Owner s Phone.

5 (_____) _____- _____ Signature of Current Policy Owner/Assignor (Required) (Required) (Required) X _____ X_____/_____/_____ X _____ Signature of Co-Owner/Spouse (If Applicable)** Primary Owner s Date of Birth (Required) Signature & Title of Assignee/Irrevocable Beneficiary (If Applicable) Date: _____/_____/_____X _____ Notary Stamp/Seal (If Applicable): (Required) Signature of Witness/Notary Public (If Applicable) * Social Security/Tax Identification Number Certification Under penalty of perjury, I certify that.

6 1) the tax ID number above is correct (or I am waiting for a number to be issued to me), 2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, 3) I am a person (including a resident alien), and 4) I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting. Please cross through item 2 if you have been notified by the IRS that you are subject to backup withholding because you have failed to report all interest and dividends on your return.

7 Cross through item 3 if you are not a person (including a resident alien) and complete and return to us the applicable IRS form W-8 BEN or form W-8 BEN-E. ** If you reside in one of the community property states listed, your spouse s signature is required. Community Property States: AZ, CA, GUAM, ID, LA, NV, NM, PR, TX, WA, WI. Unless we have been notified of a community or marital property interest in this contract, if this space is unsigned, we will rely on good faith that no such interest exists and will assume no responsibility for inquiry. Section B SURRENDER REQUEST and Withholding Election (You Must Complete This Section) Section A Policy Information (You Must Complete This Section) Section C Payee (You Must Complete This Section) Section D Endorsement (The Current Policy Owner Must Complete This Section) form W-9(Rev.)

8 December 2014)Department of the Treasury Internal Revenue Service REQUEST for Taxpayer Identification Number and CertificationGive form to the requester. Do not send to the or type See Specific Instructions on page Name (as shown on your income tax return). Name is required on this line; do not leave this line Business name/disregarded entity name, if different from above3 Check appropriate box for federal tax classification; check only one of the following seven boxes: Individual/sole proprietor or single-member LLC C CorporationS CorporationPartnershipTrust/estateLimite d liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Note.

9 For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner. Other (see instructions) 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)Exemption from FATCA reporting code (if any)(Applies to accounts maintained outside the )5 Address (number, street, and apt. or suite no.)6 City, state, and ZIP codeRequester s name and address (optional)7 List account number(s) here (optional)Part ITaxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding.

10 For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to security number orEmployer identification number Part IICertificationUnder penalties of perjury, I certify that:1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and2.