Death Claim Statement for RiverSource Life of NY Annuities Disability Income Life Insurance

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1 DOC Servce address: RverSource Lfe Insurance Co. of New York Amerprse Fnancal Center Mnneapols, MN Death Clam Statement for RverSource Lfe of NY Annutes Dsablty Income Lfe Insurance As a benefcary you may have many optons avalable to you for lfe nsurance or annuty clam proceeds: 1 You may transfer all or part of the funds nto another Amerprse nvestment or nsurance product. You may take mmedate recept of the clam amount owed to you. You may choose to begn, or contnue, an annutzed ncome stream. For annutes n payout, you may choose to contnue annuty payments or take a lump sum, as allowed by the terms of the contract. For help n selectng whch opton, or combnaton of optons, s rght for you please consult wth your Amerprse fnancal advsor. Although you may seek assstance from your Amerprse fnancal advsor, you are ultmately responsble for the completon and submsson of the clam requrements. Advsors are not authorzed or permtted to accept notces of clam, proofs of clam or any nformaton or documents relatng to a clam. Please submt the requrements drectly to us at the address lsted above. Instructons for Completng the Death Clam Statement Notfy RverSource Lfe of NY of the clent's death before submttng ths form. Ths wll facltate prompt clam payment. RverSource Lfe of NY Clent's/Benefcares please call (800) Opton 2. There may be tax mplcatons as a result of clamng an annuty. The amount dstrbuted to you may be ncluded n your ncome. Consult your tax advsor pror to makng a clam. Post-mortem nterest s not guaranteed. Complete one Death Clam Statement for each clamant. Complete parts 1, 2, 5 and 6 for all clams. In addton, complete the correct secton for the type of product beng clamed. Part 3A for lfe nsurance clams. Part 3B for non-qualfed deferred annuty clams. Part 3C for qualfed deferred annuty clams. Part 3D for all payout annuty clams. PROCEEDS PAYABLE To the estate of the nsured: The Executor or Admnstrator of the estate should complete ths statement. A copy of letters of appontment of the Executor or Admnstrator s also needed. To a mnor: The guardan of the mnor's estate should complete ths statement. A copy of letters of guardanshp of the mnor's estate s also needed. To an assgnee: Both the benefcary and the assgnee should complete ths form. If ths assgnment s no longer n force, we wll need a release from the assgnee. Lump sum transfer to Amerprse Fnancal nvestment product. (Lfe Insurance and Deferred Annutes) - Put all or part of the proceeds nto a new or exstng Amerprse Fnancal account. Contract Transfer (Deferred Annutes only) - Ths opton allows spouses to contnue the exstng contract tax-deferred for non-qualfed contracts ssued on or after 1/19/1985 or any IRA, provded that they are the sole, prmary benefcary of the contract and the owner s deceased. 1 Settlement optons vary by contract type. See page 2 for the optons avalable for your contract type. In some cases settlement choces are lmted by state regulatons RverSource Lfe Insurance Company. All rghts reserved. Only RverSource Lfe Insurance Co. of New York s authorzed to sell nsurance and annutes n New York Page 1 of 18 AP (08/15) 3

2 DOC OTHER REQUIREMENTS Certfed Letters of Appontment - For all clams where the estate s the benefcary (must reman on fle n New York). Certfcate of Trust form (#131202) - For clams where a Trust s the benefcary. Certfed Letters of Guardanshp - For clams where a mnor s the benefcary (must reman on fle n New York). Certfed Copy of Death Certfcate - (Must reman on fle n New York.) Fducary form (#402541) - For clams where a fducary s authorzed to work on behalf of another person or entty. Corporate Resoluton form (#402400) - For clams where a Corporaton s the benefcary. Physcan's Statement (#38112) - For nsurance clams occurrng wthn two years of the polcy date or the date of renstatement. Annutzaton Optons Benefcares must receve the frst annutzaton payment wthn one year from the date of death. A benefcary must choose to annutze a contract wthn 60 days of our recept of due proof of death. In the case of multple benefcares, once the corporate offce has receved due proof of death from one benefcary, the remanng benefcares only have 60 days n whch to request annutzaton as a settlement opton and any annutzaton payouts must begn wthn one year from the date of death. The perod certan (guaranteed perod) cannot exceed the lfe expectancy of the benefcary. Brth certfcates for each annutant must be submtted when selectng any lfe ncome or jont lfe ncome mode of settlement. The fxed/varable funds selected for the payout must follow the fxed/varable funds avalable on the orgnal contract. Form must be completed for fxed, varable or combnaton payments. If consderng annutzaton: Clamants should be aware that annutzaton payment optons are governed by IRS regulatons and should consult a tax advsor. Installments for a specfed perod (Mode E) (Lfe Insurance and Deferred Annutes) - Ths opton allows the settlement value be pad n nstallments over a perod of tme specfed by the benefcary. Payments cannot be made for a perod more than 30 years or less than 10 years. It does not provde for lfetme payments. Should you de pror to the end of the guaranteed payments, the payments, f over $20.00, wll contnue to the named benefcary untl the end of the guaranteed perod, at whch tme the payments wll cease. The only excepton would be f each payment s under $20.00, then the named benefcary would receve a lump sum f the total of remanng guaranteed payments s $1,000 or less. Lfe Income - Annuty payments are guaranteed as long as the annutant s lvng. Annuty payment cease upon the death of the annutant. Lfe Income wth a Guaranteed Perod - Annuty payments are guaranteed as long as the annutant s lvng. If the annutant des before the end of the guaranteed perod, we wll contnue to make annuty payments for the remander of the guaranteed perod. Lfe Income wth an Installment Refund - Annuty payments are guaranteed as long as the annutant s lvng. If the annutant des, annuty payment wll contnue untl the nstallment amount s depleted. Lfe Income wth Cash Refund - Annuty payments are guaranteed as long as the annutant s lvng. If the annutant des, we wll make a lump sum payment of a cash refund death beneft (f any). Jont Lfe Income - Annuty payments are guaranteed as long as ether annutant s lvng. Annuty payment cease upon the death of the last survvng annutant. Jont Lfe Income wth a Guaranteed Perod - Annuty payments are guaranteed as long as ether annutant s lvng. If the last survvng annutant des before the end of the guaranteed perod, we wll contnue to make annuty payments for the remander of the guaranteed perod. Jont Lfe Income wth an Installment Refund - Annuty payments are guaranteed as long as ether annutant s lvng. If the last survvng annutant des, annuty payment wll contnue untl the nstallment amount s depleted. Jont Lfe Income wth Cash Refund - Annuty payments are guaranteed as long as ether annutant s lvng. If the last survvng annutant des, we wll make a lump sum payment of a cash refund death beneft (f any). Jont Lfe Income wth Annuty Payments reduced at ether Annutant or Jont Annutant's death - Annuty payments are guaranteed as long as ether annutant s lvng. At the death of ether the annutant or jont annutant, annuty payments wll be reduced to 1/2 or 2/3 (amount s selected on the applcaton) of the annuty payment amount. Annuty payment cease upon the death of the last survvng annutant. Jont Lfe Income wth a Guaranteed Perod wth Annuty Payments reduced at ether Annutant or Jont Annutant's death - Annuty payments are guaranteed as long as ether annutant s lvng. At the death of ether the annutant or jont annutant, annuty payments wll be reduced to 1/2 or 2/3 (amount s selected on the applcaton) of the annuty payment amount. If the last survvng annutant des before the end of the guaranteed perod, we wll contnue to make annuty payments for the remander of the guaranteed perod. Jont Lfe Income wth Annuty Payments reduced at the Annutant's death - Annuty payments are guaranteed as long as ether annutant s lvng. At the death of the annutant, annuty payments wll be reduced to 1/2 or 2/3 (amount s selected on the applcaton) of the annuty payment amount. Annuty payment cease upon the death of the last survvng annutant. Jont Lfe Income wth a Guaranteed Perod wth Annuty Payments reduced at the Annutant's death - Annuty payments are guaranteed as long as ether annutant s lvng. At the death of the annutant, annuty payments wll be reduced to 1/2 or 2/3 (amount s selected on the applcaton) of the annuty payment amount. If the last survvng annutant des before the end of the guaranteed perod, we wll contnue to make annuty payments for the remander of the guaranteed perod. Guaranteed Perod - Annuty payments are guaranteed for entre guaranteed perod. Annuty payments cease upon the end of the guaranteed perod. Hold at nterest (Lfe Insurance only) - Interest wll be pad on the proceeds for a mutually agreed upon nterval and tme perod. Annuty n Payout Clam Settlement Optons There may be tax mplcatons as a result of recevng dstrbutons from an annuty n Payout. Consult your tax advsor pror to makng clam. All requrements for all benefcares must be receved before the clam wll be settled. Commuted (reduced) lump sum payment, f avalable. Contact the corporate offce for an estmated value f you are consderng a commuted lump sum payment. A commuted lump sum means you would receve less than total of the remanng payments. If payments are not commutable, you wll contnue to receve payments unless each payment s under $20.00 and the total of remanng guaranteed payments s $1,000 or less, then we wll send you a lump sum check. Requred Mnmum Dstrbutons (RMD) Requrements. RMDs are complex and clents should talk to a tax advsor. IRA benefcares can fnd addtonal nformaton regardng RMD requrements n the Your Gude to IRAs. Qualfed Plans and 403(b) plan partcpants can obtan addtonal nformaton about RMD requrements from the plan admnstrator Page 2 of 18 AP (08/15) 3

3 DOC Servce address: RverSource Lfe Insurance Co. of New York Amerprse Fnancal Center Mnneapols, MN Death Clam Statement for RverSource Lfe of NY! Annutes Lfe Insurance Dsablty Income Long Term Care Ths form s not elgble for electronc submsson. Please mal sgned orgnal to Home Offce. Note: Complete one Insurance and Annuty Death Clam Statement (Form 38111) for each benefcary/clamant. Important Notce applcable to Deferred Annuty Contracts: Generally, you must receve full dstrbuton of the death beneft wthn fve years from the decedent s date of death or elect an annuty payout plan avalable under the contract, wth the annuty payout begnnng no later than one year from the decedent s date of death. If the sole benefcary s the decedent s survvng spouse, spousal contnuaton of the contract s generally also avalable. You may want to contact your tax advsor to assess your personal stuaton. Deceased's Clent ID 001 Part 1 Deceased's Informaton Deceased's Name State of Resdence Part 2 Benefcary/Clamant Informaton USA PATRIOT Act Notce: Federal law requres all fnancal nsttutons to obtan, verfy and record nformaton that dentfes each person who opens an account, ncludng your name, address, date of brth, and other nformaton that wll allow us to verfy your dentty. When an Attorney-In-Fact s sgnng on behalf of the Benefcary/Clamant, the completed Power of Attorney, Form must be submtted wth ths form f t s not already on fle wth our offce. If there s a Guardan/Conservator, an orgnal court order dated wthn the last 60 days must be submtted as well as a completed Fducary Informaton Form A. Select Benefcary/Clamant Type Select one Indvdual Trust Organzaton/Busness/Partnershp UGMA/UTMA/Mnor Clamant Estate Sgn on Page Page 3 of 18 AP (08/15) 3

4 DOC B. Benefcary/Clamant Informaton Clent ID (f clent s an Amerprse clent) Name as t appears n Socal Securty Admnstraton Records Socal Securty Number Relatonshp to Deceased n Part 1 Phone Number Date of Brth (MMDDYYYY) Ctzenshp (Select One): U.S. Ctzen Resdent Alen Non-Resdent Alen Gender: Male Female (complete IRS Form W-8BEN) Resdental Address: We wll update your address of record based on the nformaton below. Cty State ZIP code C. Estate, Trust or Organzaton Benefcary/Clamant Estate as benefcary/clamants: Please provde certfed letters of appontment/testamentary and the completed Fducary Informaton, Form If the Employer Identfcaton Number provded s not specfc to the Estate, mandatory wthholdng wll apply. Trust as benefcary/clamants: Please provde a completed Certfcate of Trust, Form If the Employer Identfcaton Number provded s not specfc to the Trust, mandatory wthholdng wll apply. Corporatons and Organzatons: Please provde a completed Corporate Resoluton Form and ether a copy of a Government Issued Busness Lcense or Artcles of Incorporaton. Partnershp: Please provde a completed Fducary Informaton Form along wth a copy of the partnershp agreement. Name of Estate, Trust, Organzaton Taxpayer Identfcaton Number (TIN) of Benefcary/Clamant Name of Fducary Representatve Clent ID Date of Organzaton/Trust Physcal Address: We wll update your address of record based on the nformaton below. (If benefcary/clamant s an Amerprse Clent) (MMDDYYYY) Cty State ZIP code D. UGMA/UTMA/Mnor Clamant Name of Mnor Socal Securty Number of Mnor Name of Custodan/Guardan Clent ID of Custodan/Guardan Date of Brth of Mnor UGMA/UTMA State (If benefcary/clamant s an Amerprse Clent) (MMDDYYYY) Resdental Address: We wll update your address of record based on the nformaton below. Cty State ZIP code Part 3 Settlement Instructons Settlement Instructons (Select all that apply): Lfe Insurance Non-Qualfed Deferred Annutes Qualfed Deferred Annutes Payout Annutes Page 4 of 18 AP (08/15) 3

5 DOC Part 3A Lfe Insurance Polces Ths secton s used to elect a mode of settlement for the followng types of polces: Lfe Insurance Polces - polcy numbers begn wth 9700 or If Lfe Insurance polcy s less than two (2) years old, please have the deceased's physcan complete Form Polcy Number 1: Polcy Number 2: Polcy Number 3: Polcy Number 4: 1. For all products except RverSource Income Protecton Lfe Insurance polces, select from below. Percents must total 100. Dstrbute my porton of the death benefts and delver the proceeds as follows: Combnatons of the followng can be elected by ndcatng the percent of the benefcary/clamant's share to be allocated to each opton n front of that opton. Check to be maled to the address provded n Part 2. Transfer to a new or exstng RverSource Lfe Insurance Product or Amerprse Fnancal Servces Investment. Account or Polcy Number: Account or Polcy Number: (If completng a new applcaton, please attach. Note: Approved Lfe Insurance clams wll be processed when the new account s establshed.) Annutze (establsh a perodc payment plan) or hold at nterest accordng to a mode of settlement provded under the terms of the polcy/contract. Attach Form to provde requred nformaton for ths opton ncludng a brth certfcate when requred. 2. RverSource Income Protecton Lfe Insurance clams only, select from the followng optons: RverSource Income Protecton Lfe Insurance provdes a monthly beneft payment. The selecton made below wll apply to 100 of the monthly beneft payments. If an optons below s not selected, checks wll be sent to the clamant. Check to benefcary/clamant to be maled to the address provded n Part 2. Transfer(s) to a new or exstng RverSource Lfe Insurance Product or Amerprse Fnancal Servces Investment. Account or Polcy Number: Account or Polcy Number: (If completng a new applcaton, please attach. Note: Approved Lfe Insurance clams wll be processed when the new account s establshed.) Drect Depost(s) - Complete Form Note: the frst payment wll go out as a check. Part 3B Non-Qualfed Deferred Annuty Contract(s) Ths secton s used to elect a mode of settlement for the followng contracts: Non-Qualfed Deferred Annuty contracts - contract numbers begn wth 9900*. For RAVA 5 annutes and Innovatons Select Annuty contracts - contract numbers begn wth 9935**. * These prefxes are also for payout annutzed contracts. Please verfy the status and type of contract before completng ths secton. If the contract s currently n payout status complete Part 3D. **Ths prefx s used for both qualfed and non qualfed contracts. Please verfy the type of contract before completng ths secton. If the contract s qualfed complete Part 3C. We wll pay the death benefts based on the destnaton provded below. However, f the destnaton nformaton s ncomplete or not provded, for annuty clams, we reserve the rght to ssue a check payable to the benefcary Page 5 of 18 AP (08/15) 3

6 DOC Informaton to Consder: There may be tax mplcatons as a result of clamng a deferred annuty. Consult your tax advsor pror to makng a clam. If consderng annutzaton: Benefcary/Clamants must receve the frst annutzaton payment wthn one year from the date of death. A benefcary/clamant must choose to annutze a contract wthn 60 days of our recept of due proof of death. In the case of multple benefcares/clamants, once the corporate offce has receved due proof of death from one benefcary/clamant, the remanng benefcares/clamants only have 60 days n whch to request annutzaton as a settlement opton and any annutzaton payments must begn wthn one year from the date of death. If you chose to transfer your annuty death beneft proceeds to another RverSource Lfe Insurance Company product or an Amerprse nvestment, the proceeds wll reman nvested wth the current annuty nvestment allocaton untl the recevng account s establshed and the assets are transferred over. For accounts wth a Prefx of 9935, f consderng the contract contnuaton opton: A brokerage account n the same ownershp should be establshed. Indcate the brokerage account number next to the settlement opton below and t wll be assocated. IMPORTANT NOTICE: Accordng to IRS Regulatons, the clamant may have up to fve years to settle a death clam; however, optons other than lump sum payment may not be avalable. Post-mortem nterest s not guaranteed. Addtonal Rder Informaton: Ths apples f choosng spousal contnuaton, ownershp change or annutant change only. Spouse/Qualfed Cvl Unon Partners who elect the contract contnuaton opton: If the account has the MAV, MAV5 or ROP death beneft guarantee rders, complete Spousal Contnuaton of Death Beneft Rders Selecton Form Does not apply to accounts wth 9935 prefx. The Guaranteed Mnmum Wthdrawal Beneft (GMWB), Enhanced Wthdrawal Beneft (EWB), Guarantor Wthdrawal Beneft for Lfe (GWB for Lfe ) rders wll contnue, and your guaranteed benefts may be stepped up upon your contnuaton. If you're clamng a varable annuty wth the SecureSource, SecureSource Flex, SecureSource Stages NY, SecureSource 3 NY, SecureSource 4 NY SM or SecureSource 4 Plus NY SM jont lfe beneft, the rder wll contnue f you are one of the covered spouses establshed on the contract effectve date. Otherwse, the rder termnates. If you're clamng a varable annuty wth the SecureSource Flex, SecureSource Stages NY, SecureSource 3 NY, SecureSource 4 NY SM, or SecureSource 4 Plus NY SM sngle lfe beneft, the rder wll termnate upon contnuaton. If you contnue the contract as a spouse, an electve Step-up may be avalable to you whch may allow you to lock n any gans. An ncrease to the lvng beneft rder fee may be ncurred by electng a Step-up. Contract Number 1: Contract Number 2: Contract Number 3: Contract Number 4: Select from below. Percents must total 100. Combnatons of the followng can be elected by ndcatng the percent of the benefcary/clamant's share to be allocated to each opton n front of that opton. Earnngs n annuty contracts are reported to the benefcary/clamant as ordnary ncome n the year n whch they are dstrbuted. Any surrender charges on the contract are waved when surrenderng the contract due to death. Avalable optons for all clamants: Check to benefcary/clamant to be maled to the address provded n Part 2. Transfer to a new or exstng RverSource Lfe Insurance Product or Amerprse Fnancal Servces Investment. Account or Contract Number: Account or Contract Number: (If completng a new applcaton, please attach. Note: The annuty death clam wll be processed when the new account s establshed.) Annutze (establsh a perodc payment plan) accordng to a mode of settlement provded under the terms of the polcy/contract. Attach Form to provde requred nformaton for ths opton ncludng a brth certfcate when requred Page 6 of 18 AP (08/15) 3

7 DOC Addtonal opton avalable to Spouse Clamants and Cvl Unon Partners (n approved states): Can not be elected wth any of the optons above. 100 Contract Contnuaton - Ths opton allows a spouse (or a cvl unon partner n certan states where approved) to contnue the exstng contract. For non-qualfed deferred annuty contracts ssued on or after 1/19/1985*, spouses may contnue the contract as sole owner provded they are the sole, prmary benefcary of the owner and the owner s deceased, or the account s n jont wth rghts of survvorshp ownershp and an owner s deceased. When ths opton s elected by a qualfyng cvl unon partner, federal tax law requres that the proceeds of the contract be dstrbuted wthn 5 years from the date of the orgnal owner's death. For Rava 5 annuttes: Spouse's Brokerage Account Number Note: We recommend that you update your benefcary desgnaton, complete Lfe Insurance and Annuty Change of Benefcary form * For cvl unon partners the contract must have been ssued on or after the date your state recognzed cvl unon partnershps. 133 For successor annutant clams: Update the annutant on the account to reflect benefcary/clamant lsted n Part 2. For successor owner clams: Update the ownershp on the account to reflect benefcary/clamant lsted n Part 2. Part 3C Qualfed Deferred Annuty Contract(s) Ths secton s used to elect a mode of settlement for the followng types of contracts: Qualfed Deferred Annutes (.e. IRA, TSA, Qualfed Plans) contracts - contract numbers begn wth 9910*. For RAVA 5 annutes and Innovatons Select Annuty contracts - contract numbers begn wth 9935**. * These prefxes are also used for payout (annutzed) contracts. Please verfy the type of contract before completng ths secton. If the contract s n payout, complete Part 3D. **Ths prefx s used for both qualfed and non-qualfed contracts. Please verfy the type of contract before completng ths secton. If the contract s non-qualfed complete Part 3B. We wll pay the death benefts based on the destnaton provded below. However, f the destnaton nformaton s ncomplete or not provded, for annuty clams, we reserve the rght to ssue a check payable to the benefcary. Informaton to Consder: There may be tax mplcatons as a result of clamng a deferred annuty. Consult your tax advsor pror to makng a clam. If consderng annutzaton: Benefcary/Clamants must receve the frst annutzaton payment wthn one year from the date of death. A benefcary/clamant must choose to annutze a contract wthn 60 days of our recept of due proof of death. In the case of multple benefcares/ clamants, once the corporate offce has receved due proof of death from one benefcary/clamant, the remanng benefcares/clamants only have 60 days n whch to request annutzaton as a settlement opton and any annutzaton payments must begn wthn one year from the date of death. If you chose to transfer your annuty death beneft proceeds to another RverSource Lfe Insurance Company product or an Amerprse nvestment, the proceeds wll reman nvested wth the current annuty nvestment allocaton untl the recevng account s establshed and the assets are transferred over. For accounts wth a Prefx of 9935, f consderng the contract contnuaton opton: A brokerage account n the same ownershp should be establshed. Indcate the brokerage account number next to the settlement opton below and t wll be assocated. If you contnue the contract as a spouse, an electve Step-up may be avalable to you whch may allow you to lock n any gans. An ncrease to the rder fee may be ncurred by electng a Step-up. Post-mortem nterest s not guaranteed. IRS Requred Mnmum Dstrbuton (RMD) Ths secton s used to request a Requred Mnmum Dstrbuton (RMD) pror to settlng the account. Addtonal Informaton: If the decedent had reached hs or her Requred Begnnng Date (RBD) and had not yet taken ther Requred Mnmum Dstrbuton (RMD), the benefcary/clamant s requred to dstrbute the RMD amount by December 31st of the year of the decedent's death. Amounts that represent RMDs cannot be rolled over to another qualfed plan. If there are multple benefcares/clamants, the RMD can be splt amongst them or be taken by one. Ths s decded amongst the benefcares/clamants Page 7 of 18 AP (08/15) 3

8 DOC Amount to be taken (Lst Dollar Amount) Contract Number for RMD: IRS Requred Mnmum Dstrbuton $ Delvery Instructons (select one): Send the check to address of record. Note: Ths wll be processed pror to the optons below. Transfer to Non Qualfed Account Wthholdng Instructons for RMD: You are lable for ncome tax on the taxable porton of your dstrbuton. If total wthholdng s not adequate, you may be requred to make estmated tax payments or pay tax penaltes. State wthholdng s requred n many states and may apply to your annuty and/or nsurance contract. The state you resde n may have specal wthholdng rules. A state-specfc form may be requred. Any amounts wthheld for federal or state ncome taxes pursuant to electons or under the tax law wll not be refunded. Wthholdng choces are not generally avalable f your dstrbuton s an elgble rollover dstrbuton from certan employer sponsored plans. For elgble rollover dstrbuton, 20 federal wthholdng wll apply even f you ndcate otherwse. For all tax-qualfed arrangements: Wthholdng s taken from the total amount dstrbuted. (E.g., For a dstrbuton of $10,000, 10 wthholdng results n a net dstrbuton sent to you of $9,000 even though part of the dstrbuton may be non-taxable. The other $1,000 s remtted to the IRS and s credted aganst ncome tax owed for the year.) For non-qualfed annutes: Wthholdng s taken from the taxable amount dstrbuted. (E.g. For a dstrbuton of $10,000, consstng of $4,000 taxable and $6,000 non-taxable, 10 wthholdng results n a net dstrbuton sent to you of $9,600, wth $400 remtted to the IRS and s credted aganst ncome tax owed for the year.) Dfferent wthholdng rules apply f we do not have a vald Taxpayer Identfcaton Number on the account, f payment s delvered outsde the Unted States or f you are a nonresdent alen. Please consult your tax professonal for addtonal nformaton regardng federal and/or state wthholdng. 10 federal ncome tax wll be wthheld from the taxable amount dstrbuted unless you make a dfferent wthholdng electon below (certan exceptons apply). Do not wthhold Wthhold 10 Wthhold more than 10 Addtonal Rder Informaton: Ths apples f choosng spousal contnuaton, ownershp changes or annutant change only. Spouse/Qualfed Cvl Unon Partners who elect the contract contnuaton opton: If the account has the MAV, MAV5 or ROP death beneft guarantee rders, complete Spousal Contnuaton of Death Beneft Rders Selecton Form Does not apply to accounts wth 9935 prefx. If you're clamng a varable annuty wth the Guarantor Wthdrawal Beneft for Lfe (GWB for Lfe) or SecureSource sngle lfe beneft, the rder wll contnue and your Annual Lfetme Payment (ALP) may be reset. If you're clamng a varable annuty wth the SecureSource, SecureSource Flex, SecureSource Stages NY, SecureSource 3 NY, SecureSource 4 NY SM or SecureSource 4 Plus NY SM, jont lfe beneft, the rder wll contnue f you are one of the covered spouses establshed on the contract effectve date. Otherwse, the rder termnates. If you're clamng a varable annuty wth the SecureSource Flex, SecureSource Stages NY, SecureSource Stages 3 NY, SecureSource 4 NY SM, or SecureSource 4 Plus NY SM sngle lfe beneft, the rder wll termnate upon contnuaton. If you are clamng a varable annuty contract wth any lvng and/or death beneft rder and your benefcary(es) elect to treat the contract as hs/her own as an Inherted IRA, the rder(s) wll termnate. If you contnue the contract as a spouse, an electve Step-up may be avalable to you whch may allow you to lock n any gans. An ncrease to the lvng beneft rder fee may be ncurred by electng a Step-up. Contract Number 1: Contract Number 2: Contract Number 3: Contract Number 4: Select from below. Percents must total 100. Combnatons of the followng can be elected by ndcatng the percent of the benefcary/clamant's share to be allocated to each opton n front of that opton. Dstrbutons from tax qualfed accounts are reported to the benefcary/clamant as ordnary ncome n the year n whch they are dstrbuted. Any surrender charges on the contract are waved when surrenderng the contract due to death. Avalable optons for all clamants: Check to benefcary/clamant to be maled to the address provded n Part Page 8 of 18 AP (08/15) 3

9 DOC Transfer to a new or exstng RverSource Lfe Insurance Product or Amerprse Fnancal Servces Investment. Account or Contract Number: Account or Contract Number: (If completng a new applcaton, please attach. Note: The annuty death clam wll be processed when the new account s establshed.) If Clamng an IRA: Spouse transfer/rollover optons: New/exstng account optons are for non-qualfed, IRA or Inherted IRA accounts. Non-Spouse transfer/rollover optons: New/exstng account optons are for non-qualfed or Inherted IRA accounts. If Clamng a TSA: Spouse transfer/rollover optons: New/exstng account optons are for non-qualfed, IRA, Inherted IRA or TSA/TSCA. Non-Spouse transfer/rollover optons: New/exstng account optons are for non-qualfed, or Inherted IRA accounts. If Clamng a Keogh or other qualfed account: Spouse transfer/rollover optons: New/exstng account optons are for non-qualfed, IRA or Inherted IRA accounts. Non-Spouse transfer/rollover optons: New/exstng account optons are for non-qualfed or Inherted IRA accounts. If Clamng a Trusteed Plan account: Spouse transfer/rollover optons: New/exstng account optons are for non-qualfed, Trusteed Plan, IRA or Inherted IRA accounts. Non-Spouse transfer/rollover optons: New/exstng account optons are for non-qualfed or Inherted IRA accounts. Mal check to another fnancal nsttuton. (Avalable only f contract s a Tradtonal IRA, SRA, SEP IRA, Roth IRA or TSA and s beng deposted to an IRA at another fnancal nsttuton.) To complete ths transfer, we requre completed transfer forms from the recevng frm ncludng the followng nformaton: Account Number at the recevng frm Complete ownershp of the recevng account Address the check should be maled to Acceptance statement from recevng frm *Note - RverSource Lfe cannot process the death clam untl all requrements are receved. Annutze (establsh a perodc payment plan) accordng to a mode of settlement provded under the terms of the polcy/contract. Attach Form to provde requred nformaton for ths opton ncludng a brth certfcate when requred. 100 Contract Contnuaton - Ths opton allows a non-spouse benefcary to contnue the exstng contract as an Inherted IRA, provded they are the sole, prmary benefcary of the owner and the owner s deceased. Addtonal opton avalable to Spouse Clamants and Cvl Unon Partners (n approved states): Can not be elected wth any of the optons above. 100 Spousal Contnuaton: Ths opton allows a spouse to contnue the exstng contract tax-deferred, provded they are the sole, prmary benefcary of the owner and the owner s deceased. Contnue the contract as a TSA. Note: Spouse must be elgble to contrbute to a 403(b) plan. Contnue the contract as an IRA. Contnue the contract as an Inherted IRA. For Rava 5 annuttes: Spouse's Brokerage Account Number 133 Part 3D Payout Annuty Contract(s) Ths secton s used to elect a mode of settlement for the followng types of contracts: Annutzed Qualfed and Non-Qualfed Annuty contracts - contracts numbers begn wth 9900 and 9910* *These prefxes are also used for deferred contracts. Please verfy the type of contracts before completng ths secton. If the contract has not been annutzed (s stll n deferred status), complete Part 3B (Non-Qualfed annutes) or 3C (Qualfed annutes). All requrements for all benefcares must be receved before the clam wll be settled. Informaton to Consder: There may be tax mplcatons as a result of clamng a payout annuty. Consult your tax advsor pror to makng a clam. Commuted (reduced) lump sum payment, f avalable. Commuted lump sum payments are not avalable on contracts ssued before 12/15/2014. Contact the corporate offce for an estmated value f you are consderng a commuted lump sum payment. A commuted lump sum means you would receve less than total of the remanng payments Page 9 of 18 AP (08/15) 3

10 DOC If payments are not commutable, you must contnue to receve payments f over $20.00 per payment, or f under $20.00 and the total of remanng guaranteed payments s more than $1, If under $20.00 per payment and the total of remanng guaranteed payments s $1, or less, we wll send you a lump sum check. If no Settlement Opton for Cash Refund n Step 1 below s selected, we wll default to lump sum. Contract Number 1: Contract Number 2: Contract Number 3: Contract Number 4: INSTRUCTIONS: Select one n Steps 1 and 2 below. 1. Step One - Settlement Optons. Select One. Contnuaton of payments as provded for n the contract. Commuted (reduced) lump sum payment or Cash Refund Lump Sum Death Beneft. Commuted lump sum payments are not avalable on contracts ssued before 12/15/2014. If you are consderng a commuted lump sum settlement, please contact the corporate offce to determne f t s avalable and for a commuted lump sum estmate. A commuted lump sum s not avalable wth the Remanng Beneft Amount (RBA) Payout Opton. For Cash Refund contracts, the death beneft s equal to the amount appled to the settlement, less any payments already made. If the total payments (ncludng any non-dscounted commutaton amounts) exceed the amount appled to the settlement, the death beneft wll be zero. No further Annuty Payments wll be pad. For Successor Owners: I wll be transferrng ownershp on the account to the clamant lsted n Part Step Two - Delvery Optons. Select One. If an opton below s not selected, checks wll be sent to the clamant. Check(s) to benefcary/clamant to be maled to the address provded n Part 2. Transfer(s) to a new or exstng RverSource Lfe Insurance Product or Amerprse Fnancal Servces Investment. Drect Depost(s) - Complete Form Note: Outstandng payments made after death wll go out as a check. (Only avalable for contnuaton of payments.) Account or Contract Number: (If completng a new applcaton, please attach. Note: The annuty death clam wll be processed when the new account s establshed) Page 10 of 18 AP (08/15) 3

11 DOC Part 4 Annuty Clam Wthholdng REQUIRED FOR ALL ANNUITY CLAIMS (Not requred for Insurance Clams) You are lable for ncome tax on the taxable porton of your dstrbuton. If total wthholdng s not adequate, you may be requred to make estmated tax payments or pay tax penaltes. State wthholdng s requred n many states and may apply to your annuty and/or nsurance contract. The state you resde n may have specal wthholdng rules. A state-specfc form may be requred. Any amounts wthheld for federal or state ncome taxes pursuant to electons or under the tax law wll not be refunded. Wthholdng choces are not generally avalable f your dstrbuton s an elgble rollover dstrbuton from certan employer sponsored plans. For elgble rollover dstrbuton, 20 federal wthholdng wll apply even f you ndcate otherwse. For all tax-qualfed arrangements: Wthholdng s taken from the total amount dstrbuted. (E.g., For a dstrbuton of $10,000, 10 wthholdng results n a net dstrbuton sent to you of $9,000 even though part of the dstrbuton may be non-taxable. The other $1,000 s remtted to the IRS and s credted aganst ncome tax owed for the year.) For non-qualfed annutes: Wthholdng s taken from the taxable amount dstrbuted. (E.g. For a dstrbuton of $10,000, consstng of $4,000 taxable and $6,000 non-taxable, 10 wthholdng results n a net dstrbuton sent to you of $9,600, wth $400 remtted to the IRS and s credted aganst ncome tax owed for the year.) Dfferent wthholdng rules apply f we do not have a vald Taxpayer Identfcaton Number on the account, f payment s delvered outsde the Unted States or f you are a nonresdent alen. Please consult your tax professonal for addtonal nformaton regardng federal and/or state wthholdng. A drect converson from a 403(b) TSA or qualfed plan to a Roth IRA or nherted Roth IRA results n ncome tax beng due on the taxable porton of the transacton. There wll be no wthholdng on ths request unless you elect wthholdng below. If taxes are wthheld from ths dstrbuton, the net converson amount wll be the gross amount requested (mnus) the tax wthholdng. Consult wth your tax advsor f you elect to wthhold. In addton, consder the followng: Any amount wthheld wll be consdered a dstrbuton n the form of wthholdng and wll decrease the amount that s rolled over to the Roth IRA or Inherted Roth IRA. Amounts dstrbuted n the form of wthholdng may result n a 10 IRS premature penalty tax n addton to the ordnary taxes that apply to the entre dstrbuton amount. If the amount wthheld s to be rolled over to the Roth IRA or nherted Roth IRA, the amount wthheld wll have to be made up from other assets. 10 federal ncome tax wll be wthheld from the taxable amount dstrbuted unless you make a dfferent wthholdng electon below (certan exceptons apply). Do not wthhold Wthhold 10 Wthhold more than 10 Payout/Immedate Annutes/Contnuaton of Payments Federal ncome tax wll be wthheld from the taxable amount dstrbuted based on the wage tables for a marred ndvdual wth three exemptons unless you make a dfferent wthholdng electon below (certan exceptons apply). Do not wthhold Wthhold $ Wthhold from each payment from each payment (fxed payouts only) Calculate the wthholdng usng the number of exemptons and martal status entered below: Number of exemptons Martal Status: Marred Sngle If ths calculaton ndcates no wthholdng, please wthhold $ or per payment Page 11 of 18 AP (08/15) 3

12 DOC Part 5 W-9 TIN Certfcaton - MUST BE COMPLETED Taxpayer Identfcaton Number of Clamant* Name (on IRS or Socal Securty Admnstraton Records) Assocated wth ths Taxpayer Identfcaton Number Trust, or Busness Name *If the clamant s an rrevocable trust or estate, t must have ts own Employee Identfcaton Number (EIN) accordng to IRS Revenue Rulng and Reg. secton If an EIN s not provded, mandatory wthholdng wll apply. W-9 TIN Certfcaton Check approprate box for federal tax classfcaton (requred): Indvdual/Sole propretor Corporaton C-Corporaton S-Corporaton Lmted Lablty Company (LLC) C-Corporaton S-Corporaton Partnershp Partnershp Trust Revocable (Optonal Addtonal Trust Detals) Irrevocable (Optonal Addtonal Trust Detals) Estate Other Check here f owner s an Exempt Payee (defned n Form W-9 nstructons) Exempt Payee code: 1-An organzaton exempt from tax under secton 501(a), any IRA, or a custodal account under secton 403(b)(7) f the account satsfes the requrements of secton 401(f)(2), 2-The Unted States or any of ts agences or nstrumentaltes, 3-A state, the Dstrct of Columba, a possesson of the Unted States, or any of ther poltcal subdvsons or nstrumentaltes, 4-A foregn government or any of ts poltcal subdvsons, agences, or nstrumentaltes, 5-A corporaton, 6-A dealer n securtes or commodtes requred to regster n the Unted States, the Dstrct of Columba, or a possesson of the Unted States, 7-A futures commsson merchant regstered wth the Commodty Futures Tradng Commsson, 8-A real estate nvestment trust, 9-An entty regstered at all tmes durng the tax year under the Investment Company Act of 1940, 10-A common trust fund operated by a bank under secton 584(a), 11-A fnancal nsttuton, 12-A mddleman known n the nvestment communty as a nomnee or custodan, 13-A trust exempt from tax under secton 664 or descrbed n secton 4947 Foregn Account Tax Complance Act Reportng A FATCA exempton code s requred for persons submttng ths form for accounts mantaned outsde of the Unted States by certan foregn fnancal nsttutons. If you are only submttng ths form for an account you hold n the Unted States, no code s requred. Otherwse, submt IRS Form W-9 separately. As used below, the word I refers to the clamant who s the taxpayer on the account. Under penaltes of perjury, I certfy that: 1. The number shown on ths form s my correct taxpayer dentfcaton number, and 2. I am not subject to backup wthholdng because: (a) I am exempt from backup wthholdng, or (b) I have not been notfed by the Internal Revenue Servce (IRS) that I am subject to backup wthholdng as a result of a falure to report all nterest or dvdends, or (c) the IRS has notfed me that I am no longer subject to backup wthholdng, and 3. I am a U.S. ctzen or other U.S. person (defned below), and 4. The payee s exempt from Foregn Account Tax Complance Act (FATCA). Certfcaton Instructons: As used below, the word You refers to the clamant who s the taxpayer on the account. Check ths box f you have been notfed by the IRS that you are currently subject to backup wthholdng because you have faled to report all nterest and dvdends on your tax return. Defnton of a U.S. person. For federal tax purposes, you are consdered a U.S. person f you are: An ndvdual who s a U.S. ctzen or U.S. resdent alen, A partnershp, corporaton, company, or assocaton created or organzed n the Unted States or under the laws of the Unted States, An estate (other than a foregn estate), or A domestc trust (as defned n Regulatons secton ). Non-U.S. persons should submt the approprate Form W-8. Form W-9 and Form W-8 and ther nstructons are avalable upon request or on rs.gov Page 12 of 18 AP (08/15) 3

13 DOC Part 6 Authorzatons and Acknowledgements Note: Must be sgned by all clamants or fducares. The undersgned hereby makes clam to the proceeds of sad nsurance or annuty contract wth RverSource Lfe Insurance Co. of New York ("Company"). Clamant agrees that the wrtten statements, affdavts and all other papers requred by the Company shall consttute and be made a part of these proofs of death. Clamant further agrees that the furnshng of ths form (or any other subsequent forms/documents) by sad Company shall not consttute nor be consdered an admsson by the Company that there was any nsurance/annuty contract n force nor a waver of any of ts rghts or defenses, nor stop t n any way. Payment of the death proceeds must be approved by RverSource Lfe Insurance Co. of New York. Purchases requested heren wll be made only upon approval of the clam and recept of all new busness requrements by RverSource Lfe Insurance Company or Amerprse Fnancal Servces I acknowledge that by beng named owner on an annuty contract, I wll be bound by the terms of the contract, as wll my hers, executors, admnstrators and successors. I acknowledge that my clam settlement nformaton wll be provded by RverSource Lfe Insurance Co. of New York to Amerprse Fnancal Servces, Inc. for purposes of processng my clam. Ths nformaton may also be provded to an ndvdual Amerprse Fnancal Servces fnancal advsor for purposes of future contact. I am under no oblgaton to consult wth an Amerprse fnancal advsor, but may do so f I choose. I hereby declare that I have read the approprate fraud warnng below and all statements gven heren are true and complete to the best of my knowledge and belef. If I am makng clam to a TSA or Qualfed plan I have read the "Specal Tax Notce for Plan Dstrbutons" and I understand that I have the rght to consder the decson of whether or not to consent to a dstrbuton and/or to elect a drect rollover for at least 30 days. I further understand that f I submt a completed Dstrbuton Form before the 30 day perod expres, I wll have waved these rghts and processng of my dstrbuton request wll begn upon recept. New York Fraud Warnng: Any person who knowngly and wth ntent to defraud any nsurance company or other person fles an applcaton for nsurance or statement of clam contanng any materally false nformaton or conceals for the purpose of msleadng, nformaton concernng any fact materal thereto commts a fraudulent nsurance act, whch s a crme and shall also be subject to a cvl penalty not to exceed fve thousand dollars and the stated value of the clam for each such volaton. I hereby declare that I have read the above fraud warnng and any applcable fraud warnngs as shown below on ths form for my state of resdence, and all statements gven heren are true and complete to the best of my knowledge and belef. I have read, understand, and agree to each of the tems above and I certfy that all of the nformaton I have provded above regardng ths dstrbuton request/clam s true and accurate to the best of my knowledge. The Internal Revenue Servce does not requre your consent to any provson of ths document other than the certfcatons requred to avod backup wthholdng. Sgnature X Sgnature X Notary Ths form must be notarzed. Benefcary/Clamant, Trustee(s), Legal Representatve(s) for the Deceased's Estate or Fducary Sgnature Benefcary/Clamant, Trustee(s), Legal Representatve(s) for the Deceased's Estate or Fducary Sgnature Date Sgned (MMDDYYYY) Date Sgned (MMDDYYYY) On ths day of, A.D. (year), before me, a Notary Publc n and for sad County and State, resdng theren, duly commssoned and sworn, personally appeared, known to me to be the person whose name s subscrbed to the wrtten nstrument, and acknowledged to me that he or she executed the same as hs or her free act and deed. In Wtness Whereof, I have hereunto set my hand and affxed my offcal seal ths day and year n ths certfcate frst above wrtten. Notary Publc n and for sad County and State X Please mal the completed requrements wthn 24 hours of the date sgned to: RverSource Lfe Insurance Co. of New York Amerprse Fnancal Center, Mnneapols MN Page 13 of 18 AP (08/15) 3

14 DOC STATE FRAUD WARNING NOTICES Alabama Fraud Warnng: Any person who knowngly presents a false or fraudulent clam for payment of a loss or beneft or who knowngly presents false nformaton n an applcaton for nsurance s gulty of a crme and may be subject to resttuton fnes or confnement n prson, or any combnaton thereof. (secton 27-12A-20). Alaska Fraud Warnng: A person who knowngly and wth ntent to njure, defraud, or deceve an nsurance company fles a clam contanng false, ncomplete or msleadng nformaton may be prosecuted under state law. Arzona Fraud Warnng: For your protecton Arzona law requres the followng statement to appear on ths form. Any person who knowngly presents a false or fraudulent clam for payment of a loss s subject to crmnal and cvl penaltes. Arkansas, Lousana, Rhode Island, Texas and West Vrgna Fraud Warnng: Any person who knowngly presents a false or fraudulent clam for payment of a loss or beneft or knowngly presents false nformaton n an applcaton for nsurance s gulty of a crme and may be subject to fnes and confnement n prson. Calforna Fraud Warnng: For your protecton Calforna law requres the followng to appear on ths form: Any person who knowngly presents false or fraudulent clam for the payment of a loss s gulty of a crme and may be subject to fnes and confnement n state prson. Colorado Fraud Warnng: It s unlawful to knowngly provde false, ncomplete, or msleadng facts or nformaton to an nsurance company for the purpose of defraudng or attemptng to defraud the company. Penaltes may nclude mprsonment, fnes, denal of nsurance, and cvl damages. Any nsurance company or agent of an nsurance company who knowngly provdes false, ncomplete, or msleadng facts or nformaton to a polcyholder or clamant for the purpose of defraudng or attemptng to defraud the polcyholder or clamant wth regard to a settlement or award payable from nsurance proceeds shall be reported to the Colorado Dvson of Insurance wthn the Department of Regulatory Agences. Delaware Fraud Warnng: Any person who knowngly, and wth ntent to njure, defraud or deceve any nsurer, fles a statement of clam contanng any false, ncomplete or msleadng nformaton s gulty of a felony. Dstrct of Columba Fraud WARNING: It s a crme to provde false or msleadng nformaton to an nsurer for the purpose of defraudng the nsurer or any other person. Penaltes nclude mprsonment and/or fnes. In addton, an nsurer may deny nsurance benefts f false nformaton materally related to a clam was provded by the applcant. Florda Fraud Warnng: Any person who knowngly, and wth ntent to njure, defraud or deceve any nsurer, fles a statement of clam or an applcaton contanng any false, ncomplete or msleadng nformaton s gulty of a felony n the thrd degree. Idaho Fraud Warnng: Any person who knowngly, and wth ntent to defraud or deceve any nsurance company, fles a statement of clam contanng any false, ncomplete, or msleadng nformaton s gulty of a felony. Indana Fraud Warnng: A person who knowngly and wth ntent to defraud an nsurer fles a statement of clam contanng any false, ncomplete, or msleadng nformaton commts a felony. Kentucky and Oregon Fraud Warnng: Any person who knowngly and wth ntent to defraud any nsurance company or other person fles a statement of clam contanng any materally false nformaton or conceals, for purpose of msleadng, nformaton concernng any fact materal thereto commts a fraudulent nsurance act, whch s a crme. Mane, Tennessee, Vrgna and Washngton Fraud Warnng: It s a crme to knowngly provde false, ncomplete or msleadng nformaton to an nsurance company for the purpose of defraudng the company. Penaltes may nclude mprsonment, fnes or a denal of nsurance benefts. Maryland Fraud warnng: Any person who knowngly and OR wllfully presents a false or fraudulent clam for payment of a loss or beneft or who knowngly and OR wllfully presents false nformaton n an applcaton for nsurance s gulty of a crme and may be subject to fnes and confnement n prson. Mnnesota Fraud Warnng: A person who fles a clam wth ntent to defraud or helps commt a fraud aganst an nsurer s gulty of a crme. New Hampshre Fraud Warnng: Any person who, wth a purpose to njure, defraud or deceve any nsurance company, fles a statement of clam contanng any false, ncomplete or msleadng nformaton s subject to prosecuton and punshment of nsurance fraud, as provded n RSA 638:20. New Jersey Fraud Warnng: Any person who knowngly fles a statement of clam contanng false or msleadng nformaton s subject to crmnal and cvl penaltes. New Mexco Fraud Warnng: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. New York Fraud Warnng: Any person who knowngly and wth ntent to defraud any nsurance company or other person fles an applcaton for nsurance or statement of clam contanng any materally false nformaton or conceals for the purpose of msleadng, nformaton concernng any fact materal thereto commts a fraudulent nsurance act, whch s a crme and shall also be subject to a cvl penalty not to exceed fve thousand dollars and the stated value of the clam for each such volaton. Oho Fraud Warnng: Any person who, wth ntent to defraud or knowng that he s facltatng a fraud aganst an nsurer, submts an applcaton or fles a clam contanng a false or deceptve statement s gulty of nsurance fraud. Oklahoma Fraud WARNING: Any person who knowngly, and wth ntent to njure, defraud or deceve any nsurer, makes any clam for the proceeds of an nsurance polcy contanng any false, ncomplete or msleadng nformaton s gulty of a felony Page 14 of 18 AP (08/15) 3

15 DOC Pennsylvana Fraud Warnng: Any person who knowngly and wth ntent to defraud any nsurance company or other person fles and applcaton for nsurance or statement of clam contanng any materally false nformaton or conceals for the purpose of msleadng, nformaton concernng any fact materal thereto commts a fraudulent nsurance act, whch s a crme and subject such person to crmnal and cvl penaltes. Puerto Rco Warnng: Any person who knowngly and wth the ntenton of defraudng presents false nformaton n an nsurance applcaton, or presents, helps, or causes the presentaton of a fraudulent clam for the payment of a loss or any other beneft, or presents more than one clam for the same damage or loss, shall ncur a felony and, upon convcton, shall be sanctoned for each volaton by a fne of not less than fve thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fxed term of mprsonment for three (3) years, or both penaltes. Should aggravatng crcumstances [be] present, the penalty thus establshed may be ncreased to a maxmum of fve (5) years, f extenuatng crcumstances are present, t may be reduced to a mnmum of two (2) years Page 15 of 18 AP (08/15) 3

16 DOC Your Rollover Optons Specal Tax Notce for Plan Dstrbutons You are recevng ths notce because all or a porton of a payment you are recevng from the 403(b) or 401(a) retrement plan (the Plan ) s elgble to be rolled over to an IRA or an employer plan. Ths notce s ntended to help you decde whether to do such a rollover. Ths notce descrbes the rollover rules that apply to payments from the Plan that are not from a desgnated Roth account (a type of account wth specal tax rules n some employer plans). If you also receve a payment from a desgnated Roth account n the Plan, you wll be provded a dfferent notce for that payment, and the Plan admnstrator or the payor wll tell you the amount that s beng pad from each account. Rules that apply to most payments from a plan are descrbed n the General Informaton About Rollovers secton. Specal rules that only apply n certan crcumstances are descrbed n the Specal Rules and Optons secton. General Informaton About Rollovers How can a rollover affect my taxes? You wll be taxed on a payment from the Plan f you do not roll t over. If you are under age 59 1/2 and do not do a rollover, you wll also have to pay a 10 addtonal ncome tax on early dstrbutons (unless an excepton apples). However, f you do a rollover, you wll not have to pay tax untl you receve payments later and the 10 addtonal ncome tax wll not apply f those payments are made after you are age 59 1/2 (or f an excepton apples). Where may I roll over the payment? You may roll over the payment to ether an IRA (an ndvdual retrement account or ndvdual retrement annuty) or an employer plan (a tax-qualfed plan, secton 403(b) plan, or governmental secton 457(b) plan) that wll accept the rollover. The rules of the IRA or employer plan that holds the rollover wll determne your nvestment optons, fees, and rghts to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and IRAs may not provde loans). Further, the amount rolled over wll become subject to the tax rules that apply to the IRA or employer plan. How do I do a rollover? There are two ways to do a rollover. You can do ether a drect rollover or a 60-day rollover. If you do a drect rollover, the Plan wll make the payment drectly to your IRA or an employer plan. You should contact the IRA sponsor or the admnstrator of the employer plan for nformaton on how to do a drect rollover. If you do not do a drect rollover, you may stll do a rollover by makng a depost nto an IRA or elgble employer plan that wll accept t. You wll have 60 days after you receve the payment to make the depost. If you do not do a drect rollover, the Plan s requred to wthhold 20 of the payment for federal ncome taxes (up to the amount of cash and property receved other than employer stock). Ths means that, n order to roll over the entre payment n a 60-day rollover, you must use other funds to make up for the 20 wthheld. If you do not roll over the entre amount of the payment, the porton not rolled over wll be taxed and wll be subject to the 10 addtonal ncome tax on early dstrbutons f you are under age 59 1/2 (unless an excepton apples). How much may I roll over? If you wsh to do a rollover, you may roll over all or part of the amount elgble for rollover. Any payment from the Plan s elgble for rollover, except: Certan payments spread over a perod of at least 10 years or over your lfe or lfe expectancy (or the lves or jont lfe expectancy of you and your benefcary) Requred mnmum dstrbutons after age 70 1/2; (or after death) Hardshp dstrbutons ESOP dvdends Correctve dstrbutons of contrbutons that exceed tax law lmtatons Loans treated as deemed dstrbutons (for example, loans n default due to mssed payments before your employment ends) Cost of lfe nsurance pad by the Plan Contrbutons made under specal automatc enrollment rules that are wthdrawn pursuant to your request wthn 90 days of enrollment Amounts treated as dstrbuted because of a prohbted allocaton of S corporaton stock under an ESOP (also, there wll generally be adverse tax consequences f you roll over a dstrbuton of S corporaton stock to an IRA). The Plan admnstrator or the payor can tell you what porton of a payment s elgble for rollover. If I don't do a rollover, wll I have to pay the 10 addtonal ncome tax on early dstrbutons? If you are under age 59 1/2, you wll have to pay the 10 addtonal ncome tax on early dstrbutons for any payment from the Plan (ncludng amounts wthheld for ncome tax) that you do not roll over, unless one of the exceptons lsted below apples. Ths tax s n addton to the regular ncome tax on the payment not rolled over. The 10 addtonal ncome tax does not apply to the followng payments from the Plan: Payments made after you separate from servce f you wll be at least age 55 n the year of the separaton Payments that start after you separate from servce f pad at least annually n equal or close to equal amounts over your lfe or lfe expectancy (or the lves or jont lfe expectancy of you and your benefcary) Payments from a governmental defned beneft penson plan made after you separate from servce f you are a publc safety employee and you are at least age 50 n the year of the separaton Payments made due to dsablty Payments after your death Payments of ESOP dvdends Correctve dstrbutons of contrbutons that exceed tax law lmtatons Cost of lfe nsurance pad by the Plan Contrbutons made under specal automatc enrollment rules that are wthdrawn pursuant to your request wthn 90 days of enrollment Payments made drectly to the government to satsfy a federal tax levy Page 16 of 18 AP (08/15) 3

17 DOC Payments made under a qualfed domestc relatons order (QDRO) Payments up to the amount of your deductble medcal expenses Certan payments made whle you are on actve duty f you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days Payments of certan automatc enrollment contrbutons requested to be wthdrawn wthn 90 days of the frst contrbuton. If I do a rollover to an IRA, wll the 10 addtonal ncome tax apply to early dstrbutons from the IRA? If you receve a payment from an IRA when you are under age 59 1/2, you wll have to pay the 10 addtonal ncome tax on early dstrbutons from the IRA, unless an excepton apples. In general, the exceptons to the 10 addtonal ncome tax for early dstrbutons from an IRA are the same as the exceptons lsted above for early dstrbutons from a plan. However, there are a few dfferences for payments from an IRA, ncludng: There s no excepton for payments after separaton from servce that are made after age 55. The excepton for qualfed domestc relatons orders (QDROs) does not apply (although a specal rule apples under whch, as part of a dvorce or separaton agreement, a tax-free transfer may be made drectly to an IRA of a spouse or former spouse). The excepton for payments made at least annually n equal or close to equal amounts over a specfed perod apples wthout regard to whether you have had a separaton from servce. There are addtonal exceptons for (1) payments for qualfed hgher educaton expenses, (2) payments up to $10,000 used n a qualfed frst-tme home purchase, and (3) payments after you have receved unemployment compensaton for 12 consecutve weeks (or would have been elgble to receve unemployment compensaton but for self-employed status). Wll I owe State ncome taxes? Ths notce does not descrbe any State or local ncome tax rules (ncludng wthholdng rules). Specal Rules And Optons If your payment ncludes after-tax contrbutons After-tax contrbutons ncluded n a payment are not taxed. If a payment s only part of your beneft, an allocable porton of your after-tax contrbutons s generally ncluded n the payment. If you have pre-1987 after-tax contrbutons mantaned n a separate account, a specal rule may apply to determne whether the after-tax contrbutons are ncluded n a payment. You may roll over to an IRA a payment that ncludes after-tax contrbutons through ether a drect rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contrbutons n all of your IRAs (n order to determne your taxable ncome for later payments from the IRAs). If you do a drect rollover of only a porton of the amount pad from the Plan and a porton s pad to you, each of the payments wll nclude an allocable porton of the after-tax contrbutons. If you do a 60-day rollover to an IRA of only a porton of the payment made to you, the after-tax contrbutons are treated as rolled over last. For example, assume you are recevng a complete dstrbuton of your beneft whch totals $12,000, of whch $2,000 s aftertax contrbutons. In ths case, f you roll over $10,000 to an IRA n a 60-day rollover, no amount s taxable because the $2,000 amount not rolled over s treated as beng after-tax contrbutons. You may roll over to an employer plan all of a payment that ncludes after-tax contrbutons, but only through a drect rollover (and only f the recevng plan separately accounts for after-tax contrbutons and s not a governmental secton 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment that ncludes after-tax contrbutons, but only up to the amount of the payment that would be taxable f not rolled over. If you mss the 60-day rollover deadlne Generally, the 60-day rollover deadlne cannot be extended. However, the IRS has the lmted authorty to wave the deadlne under certan extraordnary crcumstances, such as when external events prevented you from completng the rollover by the 60-day rollover deadlne. To apply for a waver, you must fle a prvate letter rulng request wth the IRS. Prvate letter rulng requests requre the payment of a nonrefundable user fee. For more nformaton, see IRS Publcaton 590, Indvdual Retrement Arrangements (IRAs). If you have an outstandng loan that s beng offset If you have an outstandng loan from the Plan, your Plan beneft may be offset by the amount of the loan, typcally when your employment ends. The loan offset amount s treated as a dstrbuton to you at the tme of the offset and wll be taxed (ncludng the 10 addtonal ncome tax on early dstrbutons, unless an excepton apples) unless you do a 60-day rollover n the amount of the loan offset to an IRA or employer plan. If you were born on or before January 1, 1936 If you were born on or before January 1, 1936 and receve a lump sum dstrbuton that you do not roll over, specal rules for calculatng the amount of the tax on the payment mght apply to you. For more nformaton, see IRS Publcaton 575, Penson and Annuty Income. If your payment s from a governmental secton 457(b) plan If the Plan s a governmental secton 457(b) plan, the same rules descrbed elsewhere n ths notce generally apply, allowng you to roll over the payment to an IRA or an employer plan that accepts rollovers. One dfference s that, f you do not do a rollover, you wll not have to pay the 10 addtonal ncome tax on early dstrbutons from the Plan even f you are under age 59 1/2 (unless the payment s from a separate account holdng rollover contrbutons that were made to the Plan from a tax-qualfed plan, a secton 403(b) plan, or an IRA). However, f you do a rollover to an IRA or to an employer plan that s not a governmental secton 457(b) plan, a later dstrbuton made before age 59 1/2 wll be subject to the 10 addtonal ncome tax on early dstrbutons (unless an excepton apples). Other dfferences are that you cannot do a rollover f the payment s due to an unforeseeable emergency and the specal rules under If your payment ncludes employer stock that you do not roll over and If you were born on or before January 1, 1936 do not apply. If you are an elgble retred publc safety offcer and your penson payment s used to pay for health coverage or qualfed long-term care nsurance If the Plan s a governmental plan, you retred as a publc safety offcer, and your retrement was by reason of dsablty or was after normal retrement age, you can exclude from your taxable ncome plan payments pad drectly as premums to an accdent or health plan (or a qualfed long-term care nsurance contract) that your employer mantans for you, your spouse, or your dependents, up to a maxmum of $3,000 annually. For ths purpose, a publc safety offcer s a law enforcement offcer, frefghter, chaplan, or member of a rescue squad or ambulance crew Page 17 of 18 AP (08/15) 3

18 DOC If you roll over your payment to a Roth IRA If you roll over the payment to a Roth IRA, a specal rule apples under whch the amount of the payment rolled over (reduced by any after-tax amounts) wll be taxed. However, the 10 addtonal ncome tax on early dstrbutons wll not apply (unless you take the amount rolled over out of the Roth IRA wthn 5 years, countng from January 1 of the year of the rollover). For payments from the Plan durng 2010 that are rolled over to a Roth IRA, the taxable amount can be spread over a 2-year perod startng n If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualfed dstrbutons wll not be taxed (ncludng earnngs after the rollover). A qualfed dstrbuton from a Roth IRA s a payment made after you are age 59½ (or after your death or dsablty, or as a qualfed frst-tme homebuyer dstrbuton of up to $10,000) and after you have had a Roth IRA for at least 5 years. In applyng ths 5-year rule, you count from January 1 of the year for whch your frst contrbuton was made to a Roth IRA. Payments from the Roth IRA that are not qualfed dstrbutons wll be taxed to the extent of earnngs after the rollover, ncludng the 10 addtonal ncome tax on early dstrbutons (unless an excepton apples). You do not have to take requred mnmum dstrbutons from a Roth IRA durng your lfetme. For more nformaton, see IRS Publcaton 590, Indvdual Retrement Arrangements (IRAs). You cannot roll over a payment from the Plan to a desgnated Roth account n an employer plan. If you are not a plan partcpant Payments after death of the partcpant. If you receve a dstrbuton after the partcpant's death that you do not roll over, the dstrbuton wll generally be taxed n the same manner descrbed elsewhere n ths notce. However, the 10 addtonal ncome tax on early dstrbutons and the specal rules for publc safety offcers do not apply, and the specal rule descrbed under the secton If you were born on or before January 1, 1936 apples only f the partcpant was born on or before January 1, If you are a survvng spouse If you receve a payment from the Plan as the survvng spouse of a deceased partcpant, you have the same rollover optons that the partcpant would have had, as descrbed elsewhere n ths notce. In addton, f you choose to do a rollover to an IRA, you may treat the IRA as your own or as an Inherted IRA. An IRA you treat as your own s treated lke any other IRA of yours, so that payments made to you before you are age 59½ wll be subject to the 10 addtonal ncome tax on early dstrbutons (unless an excepton apples) and requred mnmum dstrbutons from your IRA do not have to start untl after you are age 70½. If you treat the IRA as an Inherted IRA, payments from the IRA wll not be subject to the 10 addtonal ncome tax on early dstrbutons. However, f the partcpant had started takng requred mnmum dstrbutons, you wll have to receve requred mnmum dstrbutons from the Inherted IRA. If the partcpant had not started takng requred mnmum dstrbutons from the Plan, you wll not have to start recevng requred mnmum dstrbutons from the Inherted IRA untl the year the partcpant would have been age 70½. If you are a survvng benefcary other than a spouse If you receve a payment from the Plan because of the partcpant's death and you are a desgnated benefcary other than a survvng spouse, the only rollover opton you have s to do a drect rollover to an Inherted IRA. Payments from the Inherted IRA wll not be subject to the 10 addtonal ncome tax on early dstrbutons. You wll have to receve requred mnmum dstrbutons from the Inherted IRA. Payments under a qualfed domestc relatons order. If you are the spouse or former spouse of the partcpant who receves a payment from the Plan under a qualfed domestc relatons order (QDRO), you generally have the same optons the partcpant would have (for example, you may roll over the payment to your own IRA or an elgble employer plan that wll accept t). Payments under the QDRO wll not be subject to the 10 addtonal ncome tax on early dstrbutons. If you are a nonresdent alen If you are a nonresdent alen and you do not do a drect rollover to a U.S. IRA or U.S. employer plan, nstead of wthholdng 20, the Plan s generally requred to wthhold 30 of the payment for federal ncome taxes. If the amount wthheld exceeds the amount of tax you owe (as may happen f you do a 60-day rollover), you may request an ncome tax refund by flng Form 1040NR and attachng your Form 1042-S. See Form W-8BEN for clamng that you are enttled to a reduced rate of wthholdng under an ncome tax treaty. For more nformaton, see also IRS Publcaton 519, U.S. Tax Gude for Alens, and IRS Publcaton 515, Wthholdng of Tax on Nonresdent Alens and Foregn Enttes. Other specal rules If a payment s one n a seres of payments for less than 10 years, your choce whether to make a drect rollover wll apply to all later payments n the seres (unless you make a dfferent choce for later payments). If your payments for the year are less than $200 (not ncludng payments from a desgnated Roth account n the Plan), the Plan s not requred to allow you to do a drect rollover and s not requred to wthhold for federal ncome taxes. However, you may do a 60-day rollover. Unless you elect otherwse, a mandatory cashout of more than $1,000 (not ncludng payments from a desgnated Roth account n the Plan) wll be drectly rolled over to an IRA chosen by the Plan admnstrator or the payor. A mandatory cashout s a payment from a plan to a partcpant made before age 62 (or normal retrement age, f later) and wthout consent, where the partcpant's beneft does not exceed $5,000 (not ncludng any amounts held under the plan as a result of a pror rollover made to the plan). You may have specal rollover rghts f you recently served n the U.S. Armed Forces. For more nformaton, see IRS Publcaton 3, Armed Forces' Tax Gude. FOR MORE INFORMATION You may wsh to consult wth the Plan admnstrator or payor, or a professonal tax advsor, before takng a payment from the Plan. Also, you can fnd more detaled nformaton on the federal tax treatment of payments from employer plans n: IRS Publcaton 575, Penson and Annuty Income; IRS Publcaton 590, Indvdual Retrement Arrangements (IRAs); and IRS Publcaton 571, Tax-Sheltered Annuty Plans (403(b) Plans). These publcatons are avalable from a local IRS offce, on the web at or by callng TAX-FORM Page 18 of 18 AP (08/15) 3

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