Form Lbl6147-5 - Lincoln Benefit Life - Atlas Capital Management Corp. Page 3
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3FEDERAL WITHHOLDING ELECTION FOR LIFE POLICY DISTRIBUTIONS
Lincoln Benefit Life Company
P.O. Box 80469, Lincoln, NE 68501-0469
For Fixed Products Call: 800-525-9287
For Variable Products Call: 800-865-5237
A SEPARATE ELECTION MUST BE RECEIVED FROM EACH OWNER ON A POLICY
(Owners are encouraged to make unanimous elections to avoid delay in processing.)
No Withholding
I do NOT want Federal income tax withheld. (Federal income tax will be withheld unless this box is checked.) You may
not elect out of mandatory federal withholding if you are a Non-Resident alien, U.S. Citizen living abroad, or are
requesting an eligible rollover distribution from a plan qualified under Section 401 or 403(b) of the Code.
Withholding
I do want to have _____% federal income tax withheld. (Minimum withholding is 10% of the taxable amount of the distribution.
You may choose another percentage greater than 10%, but you may not select a dollar amount.)
Distributions from a plan qualified under Internal Revenue Code Section 401 or 403(b) may be subject to 20% withholding. If
you request such a distribution, you will receive a notice outlining the applicable rules.
If you are not a U.S. Person (including a U.S. resident alien), we are required to withhold 30% of the taxable amount unless
we receive a completed IRS Form W-8BEN claiming a reduced withholding rate pursuant to a tax treaty. The W-8BEN must
have a valid U.S. Individual Taxpayer Identification Number to be considered complete.
Notice of Withholding
You may revoke or change your election at any time. Even if you elect not to have withholding apply, you are liable for the payment of federal income tax
on the taxable portion of the distribution. If you do not make payments of estimated tax, and do not have enough tax withheld, you may be subject to
penalties under the estimated tax rules. If the withholding section is left blank, or if the social security number or tax identification number is not provided,
10% of the taxable portion of the distribution will be withheld for partial withdrawals and lump sum distributions. Distributions from a plan qualified under
the Internal Revenue Code Section 401 or 403(b) may be subject to 20% withholding. We do not voluntarily withhold in states where state withholding is
not required. If no response is received within 10 days, we are required to deduct withholding from your proceeds.
IA, ME, OK, VA and VT residents: If you choose to have federal income tax withheld, the laws of your state require that state income tax be withheld.
We will automatically withhold for you if required.
OR residents: If you choose to have federal income tax withheld, the laws of your state may require that state income tax be withheld. We will
automatically withhold for you if required. If you do not choose to have federal income tax withheld, or if you are subject to mandatory federal withholding,
you may still elect state income tax withholding.
Do you want state income tax withheld?
Yes
No
KS residents: State income tax withholding is required only if federal income tax withholding is required. Federal income tax withholding is required when
the social security number or tax identification number is not provided, or the distribution is an eligible rollover. Please provide the following information,
otherwise KS income tax will be withheld as if you were married with three allowances.
Marital Status
Single
Married
_____ (Enter # of Allowances)
MA residents: If you choose to have federal income tax withheld, the laws of your state may require that state income tax be withheld. You may file MA
Withholding Exemption Certificate, Form M4-P, otherwise, MA withholding will be based on “0” exemptions.
CA residents: If you choose to have federal income tax withheld, the laws of your state require that state income tax be withheld unless you specifically
elect not to have state income tax withheld. You may contact us at any time to change or revoke your election.
Do you want state income tax withheld?
Yes
No
If YES and you elected federal withholding, we will automatically withhold for you.
If YES and you did not elect federal withholding, provide whole dollar amount to be withheld from each payment no less than $10. $___________
IN, MT, and NE residents: You may elect to have state income tax withheld.
Do you want state income tax withheld?
Yes
No
If YES, whole dollar amount to be withheld from each payment no less than $10 $_______________
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including U.S. resident alien).
Owner’s Signature:
Current Date:
Owner’s Social Security Number:
Resident State:
Daytime Phone Number:
Policy Number:
If no response is received within 10 days, we are required to deduct withholding from your proceeds.
LBL6147-5
9/04
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