Fillable Withdrawal Request Form - Great-West Life (Page 2 of 2) in pdf

MAILING/DEPOSIT INSTRUCTIONS

If nothing else is indicated in this section, your payment will be sent via regular mail.



Electronic Funds Transfer (ACH) Fee $15.00. Include void check (Fee will be deducted from your policy).



Overnight Courier Fee $25.00 (Fee will be deducted from your policy.)



Wire Transfer Fee $40.00. Include void check. (Fee will be deducted from your policy)



Deposit to Schwab Brokerage Account (ACH for no charge) ___________ – ___________

Allow 1-3 business days for wire transfers and 3-5 business days for electronic funds transfer (ACH). Allow 7-10 mailing

days for receipt of funds via regular mail.

Complete the following if the payment is to be mailed to a mailing address other than the one specified on the first page of this form:

Address

City

State/Zip Code

I (we) hereby authorize Great-West Life & Annuity Insurance Company, its subsidiaries and third party processor (hereinafter called

COMPANY) to initiate credit entries into my (our) Checking Account or Savings Account (select one below) indicated on the

attached voided check at the depository financial institution named, and to credit the same to such account. I (we) acknowledge that

the origination of ACH transactions to my (our) account must comply with the provisions of U. S. law.



Checking Account



Savings Account (select one)

NOTICE OF WITHHOLDING AND INCOME TAX WITHHOLDING INFORMATION

The taxable portion of this distribution is subject to Federal Income Tax withholding at a rate of 10% unless you elect to not have

withholding apply by checking the appropriate box below. In some states it is required we withhold state tax if we withhold Federal

Tax.

If you elect not to have withholding apply to your distribution or if you do not have enough Federal Income Tax withheld from your

distribution, you may be responsible for payment of estimated tax. You also may incur penalties under the estimated tax rules if your

withholding and estimated tax payments are not sufficient. Your election will remain in effect until you revoke it by written notification

to the COMPANY. Amounts withdrawn prior to the date on which the owner (and joint owner) is/are age 59 1/2 years will be subject to

premature distribution penalty taxes in addition to ordinary income tax.

Please Note: If you do not check the box “Please do not Withhold Federal Income Tax,” Federal Income

Tax will be withheld from the taxable portion of your distribution at a rate of 10%. Any required State

Income Tax Withholding will also be withheld.



Please Do Not Withhold Federal Income Tax

Please Withhold Federal Income Tax at a rate of 10%

Plus Additional ($ or %) _______________________



Please Do Not Withhold State Income Tax (If allowed)

Please Withhold State Income Tax at a rate of:

(Indicate $ or %) _____________________________

6. SIGNATURES

Withdrawals in excess of the guaranteed withdrawal amount, called “excess withdrawals”, will result in a permanent reduction in future

guaranteed withdrawal amounts. If you would like to make an excess withdrawal and are uncertain how an excess withdrawal will

reduce your future guaranteed withdrawal amounts, then you may contact us prior to requesting the withdrawal to obtain a

personalized, transaction specific calculation showing the effect of the excess withdrawal.

I understand the withdrawal requested on this form will be processed in accordance with the provisions of the annuity. I have read the

section in the annuity titled Surrenders and Partial Withdrawals.

I hereby verify that no judicial proceedings, including bankruptcy proceedings, have been initiated or are pending against the Owner.

______________________________________________

SIGNATURE OF POLICYOWNER

DATE

SIGNATURE OF JOINT OWNER (if any)

DATE

All other parties holding a legally enforceable interest under the annuity must sign here (i.e., irrevocable beneficiaries, collateral

assignees, security interest holders, court ordered interest holders):

______________________________________________

HOLDER OF INTEREST

DATE

INTEREST HELD

DATE

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY OF NEW YO RK

Last Updated 01/2016

Withdrawal Request Form

Withdrawal Request Form - Great-West Life Page 2

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