endstream 61 0 obj 0 0 17.3508 17.35 re Use this form to request a full surrender or a partial withdrawal from an IRA or non-qualified annuity contract. (4) Tj (4) Tj 1 1 16 13 re Q q H�|�Mj�0��5��^�s��U��&�^`,�EjG�C(�{Gr�eAH0�~>��nG�"���s�������1O�da\)���M:ty�D�EL3�� γ;b��Z�5��u�[�����D64 Z�|�Buv���u~5t}����8-���?�v`C�CA��/z�pe��(��y���p�֒�l=ꪮ��ͼ=/��>�9�k��sf�l�� sw_u����t�����Ż���b��twO�|*����#� � �s <>/Subtype/Form/Type/XObject>>stream endstream q /ZaDb 12 Tf 24421 0 obj f 3135 0 obj 0 0 18 15 re with and into their affiliate, Golden American; and. q endstream endobj %PDF-1.6 %���� endobj endobj n 11.556 TL 0.749023 g endstream 0 0 16.8409 15 re Q /ZaDb 12 Tf endobj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 24422 0 obj q 1 1 16 13 re endstream endstream q Original forms cannot be modified and resubmitted. W 3142 0 obj Q 8-17 Must complete and return all pages Page 1 of 3 This form may be faxed to 513.794.4730. <>/Subtype/Form/Type/XObject>>stream Q <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q n In May 1996 Golden American established a 3.924 3.4381 Td 0 g q 22596 0 obj 5501 0 obj Voya Insurance and Annuity Company, the legal entity owned by Venerable, changes its name to Venerable Insurance and Annuity Company. f ReliaStar Life Insurance Company of New York, a subsidiary of (4) Tj ET endstream Q 0 g n <> f endstream endstream 5487 0 obj 5554 0 obj W June 1, 2018 Venerable is debuted, with offices in <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream q <>stream 2013-09-24T13:47:52-05:00 <>/Subtype/Form/Type/XObject>>stream Do not use this form to request a rollover, transfer, or exchange to another company. 0 0 17.3508 17.35 re BT n endobj f (4) Tj n 0 g 11.556 TL 0 0 18 15 re endstream 119324_09302013.indd /ZaDb 12 Tf 3.924 3.4381 Td Q endstream 1 1 16 13 re <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /ZaDb 12 Tf 699 Walnut StreetDes Moines, IA 50309, October PScript5.dll Version 5.2 �PD�~�bJm֝��Ť����� X����]�m_/�N�zswQ��'&|�4խ�ོ3���v�S�9!l(U�ы��d�u�6u�|aL��` � endobj 24360 0 obj endstream 24379 0 obj 22585 0 obj For the following two options, please select one of the following: Gross Amount Net Amount. endobj /ZaDb 12 Tf W /ZaDb 12 Tf <>/Subtype/Form/Type/XObject>>stream 11.556 TL <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endobj 3.924 3.4381 Td H�|�MN�0��D�YT�T�@lYJ�'ɴ���`�S*��;�%�eK3�糩v;�2���}����#2c>��B��lҡ�C)v���vD��쎘ek4X�JnYǛ��e�HdsA]���\%���pI��WCە�_ f <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 5502 0 obj endobj endstream © Venerable Holdings, Inc. 2018, All 22581 0 obj 1 1 16 13 re <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 11.556 TL Q /ZaDb 12 Tf 24361 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endobj 699 Walnut StreetDes Moines, IA 50309, 1475 Dunwoody DriveWest Chester, PA 19380 0 0 18 15 re f 27, 2020. 0 0 18 15 re n BT 24420 0 obj W endstream 1 1 16 13 re 0.749023 g 0.749023 g endobj 64 0 obj endstream endobj f 22582 0 obj /ZaDb 12 Tf 0 g endstream 1 1 15.3508 15.35 re ET n <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream BT Section 1 – Partial Surrender Options . <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endobj endobj /ZaDb 12 Tf 0.749023 g /ZaDb 12 Tf (4) Tj W 11.556 TL 11.556 TL 22586 0 obj endstream 1 1 16 13 re 3149 0 obj September 1, 2019 Voya Insurance and Annuity Company, (This form may not be used for TSA/403(b) contracts. /ZaDb 12 Tf ET 3.924 3.4381 Td H�,�� f 0 0 18 15 re f ET In 2002 First Golden American Life Insurance 0 0 18 15 re ET & Annuity Insurance Company, and USG Annuity & Life Company Q (4) Tj endstream and Reverence Capital Partners, announced they have entered into <>/Subtype/Form/Type/XObject>>stream Q Q <>stream (4) Tj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 22588 0 obj 3.924 3.4381 Td endobj W 1 1 16 13 re f 3.924 3.4381 Td endstream A����b�aT�\�N\�TZ+���7�fl0���DZ��>��E�3�x)�YK�x�L�ƀK�_�? 11.556 TL n 3.924 3.4381 Td 5569 0 obj endstream �����iz(q,H��Eo/�XB�m�8�E>I��Z legacy variable annuity business from Equitable Financial Life Insurance Company. ET 22584 0 obj 5518 0 obj 0 0 18.0001 15 re endobj endstream endstream 3.924 3.4381 Td Americanâ) changed its state of domicile from Delaware to Iowa endstream endstream ET ET endobj k-gillih f 0 g W 24428 0 obj H�,ʱ 0.749023 g 1 ET Q q 5517 0 obj endstream Please Print . W 22587 0 obj 3.9241 3.4381 Td BT endstream 3.9241 3.4381 Td n 0 0 18 15 re ET <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q f ET BT n 1 1 16.0001 13 re endstream ET 22601 0 obj became Golden American Life Insurance Company. <>stream <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream n endstream n n ET �@�����f�\����B endstream 0.749023 g <>stream including acquisition of Corporate Life Reinsurance Company, and concurrent reinsurance 11.556 TL 0 0 18 15 re Individual Annuity Contract Change Request – Partial Surrender . 11.556 TL 0 0 18.0001 15 re 11.556 TL merged with and into their affiliate, Golden American; and. q x�b```�_l���@(������C����a����P������I*�2�0ڕ���t-,�lm��M� ���M���=��CÂ}�C�}���u���bb�##��;ڕ��ӵuJ˲J23 n W W endobj /ZaDb 12 Tf 22603 0 obj endstream endobj /ZaDb 12 Tf 5526 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endobj 1 1 16.0001 13 re %PDF-1.6 %���� H�|�Mj�0��5��^�s��U��&�^`,�EjG�C(�{Gr�eAH0�~>��nG�"���s�������1O�da\)���M:ty�D�EL3�� γ;b��Z�5��u�[�����D64 Z�|�Buv���u~5t}����8-���?�v`C�CA��/z�pe��(��y���p�֒�l=ꪮ��ͼ=/��>�9�k��sf�l�� sw_u����t�����Ż���b��twO�|*����#� � �s /ZaDb 12 Tf W BT ET 24359 0 obj 0 0 18.0001 15 re 0 0 18.0001 15 re 11.556 TL A distribution is a tax reportable event that may not be reversed. endstream (4) Tj endobj f ��] 0 0 18.0001 15 re endstream 11.556 TL <>/Subtype/Form/Type/XObject>>stream endobj endstream 24370 0 obj (4) Tj n 22590 0 obj endstream 22580 0 obj <>stream <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream ET Equitable Financial Life Insurance Company. f <>stream 0.749023 g q endobj 24347 0 obj 0 0 18 15 re (4) Tj Variable Annuity Surrender Request [not for use with 403(b) plans] Use this form if you want to: • request a full surrender of your Variable Annuity, or • request a partial surrender of your Variable Annuity This form may only be faxed for partial gross surrender requests of $50,000.00 or less to 1-860-380-3280. endstream 1 1 16.0001 13 re 24356 0 obj W H�|�Mj�0��5��^�s��U��&�^`,�EjG�C(�{Gr�eAH0�~>��nG�"���s�������1O�da\)���M:ty�D�EL3�� γ;b��Z�5��u�[�����D64 Z�|�Buv���u~5t}����8-���?�v`C�CA��/z�pe��(��y���p�֒�l=ꪮ��ͼ=/��>�9�k��sf�l�� sw_u����t�����Ż���b��twO�|*����#� � �s Q 0 g W 0 0 18 15 re endstream 11.556 TL Golden American was renamed ING USA Annuity and Life Q 2014-04-28T10:03:19-04:00 1 1 16 13 re <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endobj Q BT 5512 0 obj endstream 22583 0 obj 24368 0 obj Form V-4619.3-B Rev. endstream Distribution Election – I wish to withdraw or surrender from my annuity, the amount indicated below. q endobj <>stream 11.556 TL 11.556 TL q q You can also call 1-800-344-1029 to withdraw funds under $100,000 if you have telephone withdrawal authorization on file. endstream H�,ʽ (4) Tj 0 0 18 15 re 24362 0 obj 18354 0 obj <>stream n (4) Tj 24369 0 obj endstream endstream 3.924 3.4381 Td <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 11.556 TL !,"* (����������������e&��d`�y qK�R뀸����j"(��� ���i endstream endobj 1169 0 obj<>/Names 1221 0 R/Metadata 131 0 R/AcroForm 1220 0 R/Pages 1166 0 R/OCProperties<><>]>>/OCGs[1226 0 R 1227 0 R]>>/StructTreeRoot 294 0 R/Type/Catalog>> endobj 1170 0 obj<>stream �PD�~�bJm֝��Ť����� X����]�m_/�N�zswQ��'&|�4խ�ོ3���v�S�9!l(U�ы��d�u�6u�|aL��` � <>stream W subsidiary, First Golden American Life Insurance Company of New
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