Contract Owner Authorization Form printable pdf download

JACKSON NATIONAL LIFE INSURANCE COMPANY

8055 E. Tufts Avenue, 2nd Floor, P.O. Box 17240

Denver, CO 80217-0240

(800) 766-4683

Contract Owner Authorization for

Asset Allocation Service Provider and Fee Payment

Contract No.

In connection with withdrawals to pay Service Provider fees, the

Owner acknowledges the following:

This Agreement is among Jackson National Life Insurance Company

(“JNL

”), the owner (“Owner”) of the JNL variable annuity contract

1. The payment of such fees will be treated as a withdrawal under

referenced above (“Contract”), and the Asset Allocation Service

the terms of the Contract.

Provider who has signed below (“Service Provider”), and is effective

as of the date indicated below.

2. Withdrawals from the Contract for the payment of Service

Provider fees are subject to all contractual provisions applicable

Appointment and Transfer Authorization

to withdrawals from the Contract. Therefore, certain withdrawals

may be subject to minimum amounts, surrender penalties,

The Owner hereby appoints the Service Provider as the Owner’s true

recapture charges, and interest rate adjustments, and JNL may

and lawful attorney and agent to execute the transactions described

be required to liquidate a larger dollar amount than the amount

below with full power and authority to act in the Owner’s place and

required to pay the Service Provider’s fees. There are also tax

stead with the same effect as if the Owner had acted.

consequences as described below.

The Owner hereby authorizes any person at the Service Provider to:

All the parties agree that the Contract shall be solely liable for the

payment of the Service Provider’s fees and that those fees will not

receive contract information;

be separately billed to nor paid by the Owner. Such fees shall only

be for investment advisory services related to the Contract.

change the contract values between and among the investment

options of the Contract either by phone call to JNL or by

Federal Tax Status

inclusion on a written list transmitted by facsimile to JNL;

The Owner must elect the appropriate box below.

change the future premium allocations between and among the

investment options of the Contract either by phone call to JNL or

Internal Revenue Code Section 408(a) or 403(b) or 408(b)

by inclusion on a written list transmitted by facsimile to JNL; and

Annuity:

The Owner declares that the Contract is solely

responsible for the Service Provider’s fees.

make withdrawals from the Contract for the payment of asset

allocation service fees.

Nonqualified Annuity: The Owner declares that the Contract is

solely responsible for the Service Provider’s fees. The Owner

The Owner hereby authorizes JNL to release information regarding

acknowledges that under Federal tax law the payment of an

the Contract to the Service Provider and to comply with written,

investment advisor’s fees from a non-tax qualified annuity

telephone or faxed allocation and transfer instructions from the

contract will be treated as a taxable distribution and may also

Service Provider.

be subject to the 10% premature distribution penalty

applicable to withdrawals made prior to attaining age 59½.

The Owner understands that the Service Provider is subject to

conditions and limitations with transfer instructions in addition to the

The Owner has consulted with his or her own tax advisor

policies and procedures stated in the prospectus for the Contract,

regarding the tax treatment of the payment of the Advisor’s

including that premium and contract value may not be allocated to

fees from the Contract.

investment options investing in the JNL/S&P Managed Portfolios.

The Owner further understands that JNL, in its sole discretion, may

Withholding/Nonqualified Annuity

cease to honor and process any or all directions received from the

Service Provider if JNL deems a requested transaction to be

The taxable portion of the distribution(s) made under this Agreement

inconsistent with, or not in the best interest of, the variable annuity

will be subject to 10% federal income tax withholding unless you elect

contract, underlying funds, or JNL’s administrative rules and

not to have withholding apply. If you elect not to have withholding

procedures. But by honoring and processing the Service Provider’s

apply to your withdrawals, or if you do not have enough withheld, you

directions, the Owner understands that JNL is not providing

may be responsible for payment of estimated tax. You may incur

investment advice to the Owner.

penalties under the estimated tax rules if your withholding and

estimated tax payments are not sufficient. Depending on the laws of

your state, state income tax withholding may be required if

If the Owner is currently using any of JNL’s Dollar Cost Averaging or

Rebalancing

programs,

participation

asset

allocation

federal withholding is elected.

arrangement will, at JNL’s discretion, terminate the Owner’s

participation in these programs. In addition, the Owner understands

Federal Tax Withholding – The Owner must elect the appropriate

that asset allocation can alter the intended results of these programs.

box(es) below.

Payment of Fees

No, do not withhold federal income tax.

The Owner hereby authorizes JNL to act upon written instructions

Yes, withhold 10% federal income tax from each payment.

from the Service Provider to pay from the Owner’s Contract the

advisory fees charged by the Service Provider pursuant to a written

In addition to the 10% federal income tax withheld from each

advisory agreement between the Owner and the Service Provider.

payment, please withhold an additional percentage _______ %.

Checks for these fees will be made payable to the Service Provider.

Contract Owner Authorization Form

Related Articles

Related forms

Related Categories