Required Minimum Distribution Form Page 4
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4AUTOMATIC DEPOSIT
AUTHORIZATION AGREEMENT
Owner/Joint Owner: _______________________________________________________Contract Number (if known):________________________
□
□
Contract type:
Deferred Annuity Contract
Single Premium Immediate Annuity
AGREEMENT
I hereby authorize EquiTrust Life Insurance Company to make deposits to my account and for the Financial Institution named
below to accept these deposits. I also authorize EquiTrust Life Insurance Company to make withdrawals from my account if
necessary to correct an incorrect deposit amount and for the Financial Institution to accept such withdrawals.
EquiTrust Life Insurance Company will complete the ABA Transit Number and Account Numbers from the voided check attached
below. This authority is to remain in full force until EquiTrust Life Insurance Company has written notification from me of its
termination in such time and in such manner as to afford EquiTrust Life Insurance Company a reasonable opportunity to act on
it.
Bank Account Owner Name:___________________________ Joint Bank Account Owner Name ________________________
Owner Social Security Number: ________________________ Joint Social Security Number:____________________________
Bank Account Owner Signature:________________________ Joint Bank Account Owner Signature: _____________________
Date:_____________________________________________ Date:_______________________________________________
EquiTrust Life Contract Owner Signature: ____________________________________________________________________
EquiTrust Life Contract Joint Owner Signature: ________________________________________________________________
THE ACCOUNT MUST BE A REGULAR CHECKING OR SAVINGS ACCOUNT
NOTE: Money Market and Brokerage Accounts are not acceptable.
Account Information: □ Checking
□ Saving
Financial Institution Name:_________________________________________________________________________________
Address:_______________________________________________________________________________________________
City, State, Zip:_________________________________________________________________________________________
Financial Institution ABA Transit Number:_____________________________________________________________________
Account Number:________________________________________________________________________________________
Note: The electronic transfer of funds may take 2-3 business days to reach your account once funds are
released from our office. This processing time is dependent on your bank.
IF USING A CHECKING ACCOUNT, ATTACH A VOIDED CHECK HERE – DEPOSIT SLIPS ARE NOT ACCEPTABLE
NOTE: Amounts greater than $50,000 must be distributed via check.
EquiTrust Life Insurance Company • P.O. Box 14500 • Des Moines, IA 50306-3500
Phone 866-598-3692 • Fax 515-226-5101
ET-2513 (07-16)
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