S.D. Admin. R. 20:06:08 app A
Uniform Transaction Form for Maximum Policy Loan:
Name of Insured/Annuitant: | Social Security or Taxpayer ID No: | Policy/Contract No: |
Joint Insured/Annuitant: | Social Security or Taxpayer ID No: | Daytime Phone No: |
Policy Owner (if different than insured): | Social Security or Taxpayer ID No: | Street Address: |
Joint Policy Owner (if different than insured): | Social Security or Taxpayer ID No: | City, State, and Zip Code: |
I own the following: Life Insurance Policy Endowment Annuity Contract
This policy was issued by: _____________________ on __________.
(Company)
(Date)
Policy Loan |
1. It is understood and agreed that, I (we), the undersigned, assign the policy to the company as security for the repayment of a policy loan (and any unpaid interest thereon), and apply for a loan in such amount as will retire any previous loans, pay all interest as provided in the policy, and provide the following amount:
Maximum loan available including any dividend values, or
Maximum loan available excluding any dividend values
2. Loan repayment method:
Send repayment reminders:
Monthly Quarterly Annually
Apply future dividends to pay any premium due with the remaining applied to the loan, or
Apply future dividends to the loan.
3. I (we) certify that no bankruptcy proceeding, attachment, other lien, or claim is now pending against the owner(s) of the policy/contract. ______
Initial
Federal Income Tax Withholding and Instructions |
We (the company) are required to inform you of and give you an opportunity to make a tax withholding election. The provisions apply to qualified and non-qualified deferred compensation plans, annuities, pension plans, IRA distributions and gains realized from life insurance and endowment policy distributions. If you elect not to have withholding apply to your payment, or if you do not have enough federal income tax withheld, you may be responsible for payment of estimated tax. You may also incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. You may wish to consult a tax advisor.
I elect not to have federal income tax withheld from the taxable portion of my distribution check.
I elect to have federal income tax withheld from the taxable portion of my distribution check, reducing the indicated amount by the amount withheld.
Certification and Signature |
I certify that:
1. The number shown on this form is my correct taxpayer identification number, and
2. I am not subject to any backup withholding, and
3. I am a US person (including US resident alien).
_____________________________________ ____________ _____________________________________ ____________
(Policy Owner Signature) (Date) (Joint Policy Owner Signature) (Date)
_____________________________________ ____________ _____________________________________ ____________
(Irrevocable Beneficiary or Assignee) (Date) (Irrevocable Beneficiary or Assignee) (Date)
S.D. Admin. R. 20:06:08 app A