Form 4083 - Required Minimum Distribution Withdrawal Request - American Equity Page 2
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1
2P .O. Box 10343
Required Minimum Distribution
Des Moines, IA 50306-0343
888-221-1234
Withdrawal Request
Overnight Address: 6000 Westown Parkway, West Des Moines, IA 50266
Fax 515-226-3129
CONSENT OF SPOUSE
If the contract owner(s) resides in AZ, CA, ID, LA, NV, NM, TX, WA, or WI, spousal consent, or the consent of any individual who is
established by law as being a party to a legally recognized domestic relationship according to the laws of the state of the owner’s
domicile, is required to complete this transaction, acknowledged by signing below. Failure to include the signature may result in a
delay or inability to process the requested transaction. Unless otherwise provided on this form the Company shall be entitled to rely
on its good faith belief that no community property interest exists and assumes no responsibility for inquiry. All persons signing this
form agree to indemnify and hold the Company harmless from the consequences of accepting this transaction.
X
Spouse Signature
Date
TAX PAYER IDENTIFICATION NUMBER (MUST BE COMPLETED)
_____________________________________________
_____________________________________________
OR
Employer Identification Number
Social Security Number
TAX IDENTIFICATION CERTIFICATION (SUBSTITUTE W-9)
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number; and
2. I am not subject to backup withholding due to failure to report interest and dividend income; and
3. I am a U.S. Citizen or other U.S. Person (defined in the W-9 instructions).
Certification Instructions: You must strike out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding.
COMPLETE THIS SECTION IF YOU WOULD LIKE THESE PAYMENTS AUTOMATICALLY DEPOSITED TO YOUR BANK ACCOUNT
Select One:
I have previously submitted my bank account information to American Equity for the purpose of receiving
electronic payments. I would like to use the bank account information on file with American Equity for this
request. Please Note: If no bank information is on file I understand a paper check will be mailed.
Enclosed is American Equity form 4062 and a voided check or letter from my bank to setup direct deposit. I
am aware of the pre-note period which may take up to four business days.
PLEASE SIGN & DATE BELOW
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
X
Contract Owner’s Signature
Designated Beneficiary (required for joint)
Phone Number
Date
Print
Reset
ORIGINAL FORM NOT REQUIRED - FAXED COPIES ARE ACCEPTABLE
4083
06.01.15
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