Fillable Required Minimum Distribution Form (Page 2 of 4) in pdf

Note: You will continue to receive a reminder letter each year as required by the IRS, regardless of your

instructions for future years.

2. TAX WITHHOLDING ELECTION

Note: If a withholding option is not selected, a 10% federal income tax will be automatically withheld.

Certain states require the Company to withhold state income taxes. If you live in one of those states,

state income tax will be withheld from your distribution in addition to any federal tax withholding.

____I do not want to have Federal or State Income Tax withheld from my payments.

____I would like the following Federal Income Tax withheld: $_______________ or _____________%

____I would like the following State Income Tax withheld: $_________________ or _____________%.

If you do not elect withholding, or if you do not have enough tax withheld, you are liable for payment of federal

income tax on the taxable portion of your distribution. You may also be subject to tax penalties if your payments of

estimated tax and withholding are inadequate. Subject to specific exceptions under the Internal Revenue Code, any

taxable distributions from an annuity contract prior to age 59 ½ may be subject to a 10% excise tax.

3. ACCOUNT ELECTION FOR DISTRIBUTIONS (OPTIONAL)

If you are requesting a distribution from an EquiTrust Life Index Annuity and would like to elect which account to use

for your RMD please complete this section. Your RMD(s) will be taken on a pro-rata basis from the account(s)

selected below. Please note: If you do not complete this section, your RMD will be taken on a pro-rata basis from all

allocated accounts. Please indicate which account(s) your RMD(s) should be taken from:

_______________________________________________

CERTIFICATION

Under penalties of perjury, I certify that:

The number shown on this form is my correct taxpayer identification number (TIN) (or I am waiting for a

number to be issued to me), and

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

I am a U.S. person (including a U.S. resident alien).

Certification instructions: You must cross out Item 2 above if you have been notified by the IRS that you are

currently subject to backup withholding because you have failed to report all interest and dividends on your tax

return. For real estate transactions, Item 2 does not apply. For mortgage interest paid, acquisition or abandonment

of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA) and, generally,

payments other than interest and dividends, you are not required to sign the Certification, but you must provide your

correct TIN.

ET-2512 (07-16)

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Required Minimum Distribution Form Page 2