State Income Tax Withholding Form Page 2

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Note: Complete Parts 3, 4 and/or 5 as applicable, based on the type of your distribution(s).

Part 3

– Withholding Election for Term Annuity for Periods of 10 Years or More, Cash Installment Payment

for Periods of 10 Years or More and Life Annuities

I understand that my withholding election will remain in effect for this series of distributions, unless I submit a new

State Income Tax Withholding Form.

Residents of CA or IA:

q I elect not to have state income tax withholding from my payments.

q I elect to have state income tax withholding from my payments at a default rate.

q I elect to have state income tax withholding from my payments at a default rate and an additional amount of

from each payment.

_____________________

Residents of AR, DE, GA, KS, MA, MD, ME, MI, NC, NE, OK, OR, VA or VT:

q I elect not to have state income tax withholding from my payments.

q I elect to have state income tax withholding from my payments at a default rate.

q I elect to have state income tax withholding from my payments based on the following marital status and withholding allowances:

Marital status:

q Single

q Married

q Married, but withhold at the higher single rate

Number of withholding allowances:

Optional: Withhold an additional $

from each payment.

_______________

Part 4

– Withholding Election for Term Annuity for Periods of Less Than 10 Years, Cash Installment

Payments for Periods of Less Than 10 Years, Partial Distributions and Lump Sum Distributions

(Including Age 59½ In-Service Withdrawals and Rollover Account Withdrawals)

2, 3 4

I understand that if I am making an election for monthly or annual term annuity or cash installment payments for periods

of less than 10 years, my withholding election will remain in effect for this series of distributions, unless I submit a new

State Income Tax Withholding Form. I understand that if I am making an election for a partial or lump sum distribution, my

withholding election only applies to my current distribution. I will need to complete a new State Income Tax Withholding Form

for any future distributions.

Residents of CA, GA

, ME, MI or OR:

q I elect not to have state income tax withholding from my payments.

q I elect to have state income tax withholding at a default rate.

q I elect to have state income tax withholding at a default rate and an additional amount of $

from each payment.

_______________

Residents of AR, DE, the District of Columbia

, IA, KS, MA, MD, MS

, NC, NE, OK, VA or VT:

q I elect to have state income tax withholding at a default rate.

q I elect to have state income tax withholding at a default rate and an additional amount of $

from each payment.

_______________

Part 5 – Withholding Election for Required Minimum Distribution and Hardship Withdrawal

I understand that my withholding election only applies to my current required minimum distribution or hardship withdrawal.

I will need to complete a new State Income Tax Withholding Form for any future distributions.

Residents of AR, CA, DE, IA, MA, ME, MI, MS

, NC, NE, OK, OR, VA or VT:

q I elect not to have state income tax withholding from my payments.

q I elect to have state income tax withholding at a default rate.

q I elect to have state income tax withholding at a default rate and an additional amount of $

_______________

Part 6 – Signature

Signature

Date

__________________________________________________________________________________

______________________________________

If you have multiple annuities and/or installments, you can only make one withholding election in either Part 3 or Part 4, not both. This withholding election will be applied to all of

your annuities and/or installment payments.

If you are a resident of Georgia, the default is no state inco me tax withholding. If you want to withhold state income tax, indicate the dollar amount you want withheld.

If you are a resident of the District of Columbia, state income tax withholding is only applicable to lump sum distributions.

If you are a resident of Mississippi, state income tax withholding is only applicable to early distributions with no known exception as defined in Internal Revenue Code Section 72.

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