Fillable Required Minimum Distribution Form (Page 3 of 4) in pdf

4. SIGNATURE

By signing below, I acknowledge and understand the following:

a. If I make an unscheduled withdrawal while the RMD option is in effect, any amount distributed will be

credited toward the annual amount required to be made under the RMD Option, to the extent that the total

RMD for that year has not been satisfied. RMDs for the remainder of the year will be prorated.

b. I can terminate this Agreement at any time by notifying the Company in writing.

c. The elections made under this Agreement may restrict the available payment options under this Contract and

may also limit the options available to me under another RMD Agreement.

d. The Company is furnishing this form and participating in this transaction at my specific request and has

made no representation that the above distribution schedule will fulfill my specific tax obligations. I have

been advised by the Company that I should discuss the tax consequences of this transaction with my own

tax or legal advisor. Neither the Company, nor any of its officers, employees, or agents, may provide tax or

legal advice, and I have not relied on any of these parties for such advice.

e. The owner understands that the Company does not include qualified funds held at other financial institutions

in the calculation.

I certify that I have read and understand this form and that I have completed all applicable sections to the

best of my knowledge.

I understand that EquiTrust Life will take reasonable steps to ensure the correct RMD amount is calculated based on

the information I have provided in this form. In the event that I have provided inaccurate or incomplete information, I

hereby indemnify and hold harmless EquiTrust Life and its successors, affiliates, and employees from any liability

should I fail to meet Internal Revenue Service minimum distribution requirements.

Note: If the owner resides in a Community Property State, which could be subject to change, (currently AK,

AZ, CA, ID, LA, NM, NV, TX, WI or WA), the owner’s spouse must also sign the Partial Withdrawal/Surrender

Form.

Unless the Insurance Company has been notified of a community or marital property interest in this

contract, the Insurance Company will rely on its good faith belief that no such interest exists and will

assume no responsibility for inquiry.

Signature of Owner or Legal Representative: ___________________________________ Date: ________________

Printed Name of Owner or Legal Representative: _____________________________________________________

Spouse Signature (If Applicable): _____________________________________________ Date: ________________

If your address information has changed with EquiTrust in the last 30 days, then this form must be

signed in the presence of a Notary Public. Please complete the Service Request form for the address

change information. The Notary Public must witness and sign below.

State of

)

) SS.

County of

)

On this ____ day of

, 20

, before me, the undersigned, a Notary Public in and for the State of

__________, personally appeared

, to me known to be the person named in

and who executed the foregoing Certification, and acknowledged that he/she executed the same as his/her voluntary

act and deed.

*Note: Per EquiTrust Life Insurance Company Business

Guidelines, agents may not act as notary on client’s financial

transactions.

Notary Public* Signature

(Affix Notary's Stamp or Seal Here)

My commission expires

EquiTrust Life Insurance Company • P.O. Box 14500 • Des Moines, IA 50306-3500

Phone 866-598-3692 • Fax 515-226-5101

ET-2512 (07-16)

Page 3 of 3 – Incomplete without all pages

Required Minimum Distribution Form Page 3

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