Contract Owner Authorization Form (Page 2 of 2) in pdf

State Tax Withholding – The Owner must elect the appropriate box

below.

The Owner and Service Provider hereby agree, for themselves and

any related parties, to jointly and severally release, indemnify and

No, I elect not to have state income tax withheld.

hold harmless JNL and its related parties from and against any and

all claims, losses, liabilities or damages, costs or expenses,

Yes, withhold state income taxes from each payment at the

including but not limited to taxes, penalties and/or interest

following percentage _______ %.

(individually and collectively referred to as “Loss”) arising out of this

Agreement. JNL is not responsible and has no liability for any Loss

This withholding election will remain in effect and will apply to all

incurred by the Owner or Service Provider as a result of the

subsequent payments made to you as part of this Agreement until you

transactions contemplated by this Agreement except in the event

change or revoke it. You may make, change or revoke an election at

that the Owner or Service Provider suffer any such Loss as a result

any time with regard to subsequent distributions by contacting us and

of the willful misconduct of JNL or its employees in processing

completing a new election.

transfers or partial surrender requests made by Service Provider.

Disclaimer/Indemnification

Term/Assignability/Conflicting Agreements

JNL does not give tax or legal advice about the tax treatment of

This Agreement shall remain in effect until JNL receives written

withdrawals from annuities. The laws regarding the tax treatment of

notice of termination from the Owner or Service Provider. While this

withdrawals from Internal Revenue Code (“IRC”) Section 408 and

Agreement is in effect, the Service Provider may perform the acts

403(b) annuities to pay investment advisory allocation fees is not well

that the Owner has authorized it to perform, even after the Owner

established. It is possible that the Internal Revenue Service (“IRS”)

becomes disabled. If the Owner dies before JNL receives written

may treat such withdrawals as distributions even though JNL will not

notice of termination, any act by JNL or the Service Provider which

report such payments to the IRS. The Owner should consult his or

is performed in good faith reliance on this Agreement without actual

her own attorney or tax advisor regarding matters associated with this

knowledge of the Owner’s death will bind the Owner’s heirs, legal

Agreement.

representatives and assigns.

JNL is not required to follow requests or instructions from the Service

This Agreement may not be assigned or transferred by the Owner or

Provider until it has received this Agreement signed by all parties.

the Service Provider.

JNL is not providing investment advice to the Owner in following the

request or instructions from the Service Provider.

The Owner and the Service Provider acknowledge that they have

entered into other agreements relating to investment advisory

JNL has no responsibility or liability to determine the frequency,

services, however it is agreed that in the event any terms of such

accuracy or reasonableness of any amount or calculation set forth in

other agreements conflict with the terms of this Agreement, then the

instructions from the Service Provider. JNL has no responsibility or

terms of this Agreement shall control.

liability to determine that instructions received from the Service

Provider are in compliance with the written advisory agreement

Notices

between the Owner and the Service Provider.

A ll notices to JNL should be sent to:

JNL does not make any representation or warranty, by accepting

Jackson National Life Service Center

instructions or by executing an advisory services agreement or

P.O. Box 17240

otherwise, concerning the tax treatment of payment of fees under

Denver, CO 80217-0240

Federal tax law, or otherwise. Furthermore, JNL has no responsibility

or liability for any taxes, penalties, and/or interest which may be

Effective Date:

assessed by the IRS or other administrative tribunal or court arising

out of this Agreement.

Contract Owner

Name:

Social Security/Tax I.D. Number:

Name – Joint Owner:

JNL Contract Number:

Signature:

Date:

Signature:

Date:

Asset Allocation Service Provider

Name:

Title:

Address:

Phone Number:

Signature:

Date:

Contract Owner Authorization Form Page 2

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