Equi Vest Transfer Details

Axa 1035 Exchange is one of the many types of life insurance policies you can choose from. This type of policy is a permanent coverage, meaning it will be in effect as long as you continue to pay your premiums. Unlike term life insurance, which expires after a certain period of time, permanent life insurance lasts for your entire lifetime. There are several different types of Axa 1035 Exchange policies available, so it’s important to understand what each one offers before making a decision. One thing to keep in mind is that these policies are quite expensive, so you’ll need to make sure they fit into your budget. Also, because they are permanent policies, they typically have lower rates than term life insurance policies.

Before you decide to fill out axa 1035 exchange, you will need to know more about the type of form you'll work with.

QuestionAnswer
Form NameAxa 1035 Exchange
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesaxa equitable variable transfer exchange, axa 1035, rollover equitable transfer form, axa rollover transfer form

Form Preview Example

EQUI-VEST®

Variable Annuity Series

Transfer/Rollover of Assets or 1035 Exchange to Another Carrier

Express Mail:

 

 

AXA Equitable

 

 

EQUI-VEST Processing Ofice

 

 

100 Madison St., Suite 1000

 

 

 

 

Syracuse, N.Y. 13202

 

 

Regular Mail:

For Assistance: Call (800) 628-6673

 

AXA-Equitable

Monday − Thursday 8:00 a.m. − 7:00 p.m. EST

EQUI-VEST Processing Ofice

 

Friday 8:00 a.m. − 5:00 p.m. EST

P.O Box 4956

 

 

Syracuse, N.Y. 13221

 

 

Fax Number:

 

 

(201) 583-2683

 

 

1.Owner’s Information (Please Print) Please use Catalog # 139737 for TSA contract transfer/exchanges. Do not use this form.

Certificate/Contract Number

Owner’s Name (Last, First, Middle)

 

Owner’s Daytime Phone

T.I.N.: S.S.N. (last 4 digits only) E.I.N.

 

 

 

Joint Owner’s Name (Last, First, Middle) (if applicable)

Joint Owner’s Daytime Phone

S.S.N. (last 4 digits only)

 

 

 

 

Annuitant’s Name (if other than Owner)

 

 

S.S.N. (last 4 digits only)

 

 

 

 

Address Number and Street

 

Apt/Suite/Floor

 

 

 

 

 

City

State

Zip Code

 

Please check if this is an Address Change.

2A. Type of Transaction Check One

References to ‘‘traditional IRA’’ include ‘‘SEP’’, ‘‘SARSEP’’ and ‘‘SIMPLE IRA’’.

AXA Equitable uses the term ‘‘Applicable Plans’’ to cover several types of tax-qualiied plans such as a 401(a) (including 401(k)) plan, a 403(b) plan

(funded by a TSA annuity contract or custodial mutual fund account) or a governmental employer Section 457(b) EDC plan.

1.Direct Rollover:

Direct Rollover in accordance with Internal Revenue Code Sections 401(a)(31), 402 and other applicable tax rules from one eligible retirement plan into another eligible retirement plan. Check the applicable type in each row.

Complete Sections 2B, 3, 4A, 4E and 5 (5A and 5B, if applicable).

Indicate Type of Retirement Plan Transaction

Source of Funds: Qualiied Plan1 IRA Governmental 457 EDC SIMPLE IRA2

Destination of Funds: Qualiied Plan IRA Governmental 457 EDC SIMPLE IRA TSA

2.Direct Transfer:

Traditional IRA3 to Traditional IRADirect transfer (issuer to issuer, or issuer to custodian or trustee) of an IRA to another IRA. Complete Sections 2B, 3, 4B and 4E. During the irst two years of participation a SIMPLE IRA cannot be transferred to an IRA.

Roth IRA3 to Roth IRADirect transfer (issuer to issuer, or issuer to custodian or trustee) of a Roth IRA to a Roth IRA with another carrier. Complete Sections 2B, 3, 4C and 4E.

NQ to NQExchange of an NQ for another NQ under Section 1035(a) of the Internal Revenue Code of 1986 as amended. Complete Sections 2B, 3, 4E and 4F.

3.Taxable Rollover Conversion:

Taxable Rollover from traditional IRA(3) to Roth IRA(Conversion rollover issued by another carrier.)

Complete Sections 2B, 3, 4D and 4E.

Taxable Rollover from Applicable Plan to Roth IRA(Conversion rollover issued by another carrier.)

Complete Sections 2B, 3, 4D and 4E.

1

2

3

If you are not the owner of your existing contract (trustee owned) have your employer complete Section 6 of this form ‘‘Request for Change of

Owner under EQUI-VEST Trusteed Contracts.’’

Funds from a SIMPLE IRA may be transferred after a 2-year period has expired since you irst participated in any SIMPLE IRA plan of the Employer. Any rollover or transfer must comply with the requirements under section 408. If you withdraw an amount from a SIMPLE IRA during the 2-year period beginning when you irst participated in any SIMPLE IRA plan of the Employer, and the amount is subject to the additional tax on early distributions under section 72(t), this additional tax is increased from 10% to 25%.

IRA refers to an individual retirement account and/or an individual retirement annuity under Internal Revenue Code Section 408.

Trns/Rollover/1035 Exchange

X01752_core_f

Cat.# 125852 (09/12)

 

Page 1 of 6

 

2B. Amount to be Transferred or Rolled Over*

(Check One Box Only)

Partial Transfer/Rollover of $

 

. (A minimum annuity value must remain in the Contract. For

variable annuity contracts, check the prospectus.)

 

If you have a variable annuity contract and you wish speciic dollar amounts to be withdrawn from the Guaranteed

Interest Option and/or the Variable Investment Options, complete below. If you do not complete this section, amounts will be withdrawn on a pro rata basis.

Structured Investment Option Segment

 

 

$

 

 

 

 

EQ/Large Cap Value PLUS (89*)

International Stocks/Global

 

 

 

 

$

 

 

S&P 500 1 year -10% Buffer (V1*)1

 

$

 

 

 

 

 

 

EQ/Lord Abbett Large Cap Core (05*)

$

 

 

 

 

 

AXATactical Manager International (7N*)

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

EQ/Montag & Caldwell Growth (34*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

EQ/Global Multi-Sector Equity (78*)

Asset Allocation

 

 

 

 

$

 

 

 

 

EQ/Mutual Large Cap Equity (6F*)

$

 

 

 

 

 

EQ/International Core PLUS (88*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

EQ/T. Rowe Price Growth Stock (32*)

$

 

 

 

 

 

EQ/International Equity Index (TN*)

AXA Allocation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

AXA Aggressive Allocation (18*)

 

$

 

 

 

 

 

 

EQ/UBS Growth and Income (35*)

$

 

 

 

 

 

EQ/International Value PLUS (73*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

EQ/Van Kampen Comstock (07*)

$

 

 

 

 

 

EQ/MFS International Growth (26*)

$

 

 

AXA Balanced Strategy (8Q*)

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

AXA Conservative Allocation (15*)

 

$

 

 

 

 

 

 

EQ/Wells Fargo Omega Growth (83*)

$

 

 

 

 

 

EQ/Oppenheimer Global (6A*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

EQ/Templeton Global Equity (6D*)

 

 

 

 

 

 

 

 

 

$

 

 

 

 

AXAConservative Growth Strategy (8R*)

 

$

 

 

 

 

 

 

Fidelity® VIP Contrafund® (7R*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

Invesco V.I. International Growth (7Z*)

 

 

 

 

 

 

 

 

 

$

 

 

 

 

AXA Conservative-Plus Allocation (16*)

 

$

 

 

 

 

 

 

MFS® Investors Growth Stock (8I*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

Lazard Retirement Emerging

 

 

 

 

 

 

 

 

 

$

 

 

AXA Conservative Strategy (8S*)

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

MFS® Investors Trust (7P*)

 

 

 

 

 

 

 

Markets Equity (8H*)

$

 

 

AXA Moderate Allocation (T4*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AXA Moderate Growth Strategy (8O*)

 

$

 

 

 

 

 

 

Multimanager Aggressive Equity (T2*)

$

 

 

 

 

 

MFS® International Value (8A*)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

AXA Moderate-Plus Allocation (17*)

 

$

 

 

 

 

Multimanager Large Cap Core

$

 

 

 

 

 

Multimanager International Equity (65*)

 

 

 

 

 

 

 

 

 

 

 

 

Target Allocation

 

 

 

 

 

 

 

 

Equity (57*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Bonds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Multimanager Large Cap Growth (56*)

 

 

 

 

 

 

 

 

 

$

 

 

Target 2015 Allocation (6G*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

EQ/Core Bond Index (96*)

 

 

 

$

 

 

 

 

 

 

Multimanager Large Cap Value (58*)

 

 

 

 

 

 

$

 

 

Target 2025 Allocation (6H*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

EQ/Global Bond PLUS (47*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

Target 2035 Allocation (6I*)

 

Small/Mid Cap Stocks

 

 

$

 

 

 

 

EQ/Intermediate Government Bond

$

 

 

Target 2045 Allocation (6J*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(TI*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Asset Allocation

 

$

 

 

 

 

 

AXA Tactical Manager 400 (7L*)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EQ/PIMCO Ultra Short Bond (28*)

$

 

 

 

All Asset Growth – Alt 20 (7H*)

 

$

 

 

 

 

 

 

AXA Tactical Manager 2000 (7K*)

$

 

 

 

 

 

 

EQ/Quality Bond PLUS (TQ*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

EQ/AllianceBernstein Small Cap

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Invesco V.I. High Yield (8L*)

$

 

 

 

EQ/AllianceBernstein Dynamic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Growth (TP*)

$

 

 

 

 

 

 

Ivy Funds VIP High Income (8G*)

 

 

 

 

 

Wealth Strategies (8P*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

EQ/AXA Franklin Small Cap Value

$

 

 

 

 

 

 

Multimanager Core Bond (69*)

$

 

 

EQ/Franklin Templeton Allocation (6P*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Core (6E*)

$

 

 

 

 

 

Multimanager Multi-Sector Bond (TH*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EQ/GAMCO Small Company Value (37*)

 

 

 

 

 

 

 

Large Cap Stocks

 

 

 

 

 

 

 

 

 

Cash Equivalents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

EQ/Mid Cap Index (55*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

AXA Tactical Manager 500 (7M*)

 

$

 

 

 

 

 

EQ/Mid Cap Value PLUS (79*)

$

 

 

 

 

 

EQ/Money Market (T3*)

 

 

 

 

 

 

 

 

 

 

 

$

 

 

EQ/BlackRock Basic Value Equity (81*)

 

$

 

 

 

 

 

EQ/Morgan Stanley Mid Cap

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sector/Specialty

 

 

 

 

 

 

 

 

 

 

$

 

 

 

EQ/Boston Advisors Equity Income (33*)

 

 

 

 

 

 

 

 

Growth (08*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

EQ/Franklin Core Balanced (6C*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

EQ/Calvert Socially Responsible (92*)

 

$

 

 

 

 

 

 

EQ/Small Company Index (97*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

EQ/GAMCO Mergers and

$

 

 

 

 

EQ/Capital Guardian Research (86*)

 

$

 

 

 

 

 

 

Goldman Sachs VIT Mid Cap Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Acquisitions (25*)

$

 

 

EQ/Common Stock Index (T1*)

 

 

 

 

 

 

 

 

(7W*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

Invesco V.I. Global Real Estate (8C*)

 

 

 

 

 

 

 

 

 

$

 

 

EQ/Davis New York Venture (6Q*)

 

$

 

 

 

 

 

Invesco V.I. Mid Cap Core Equity (7T*)

$

 

 

 

 

 

Ivy Funds VIP Energy (8D*)

 

 

 

 

 

 

 

$

 

 

EQ/Equity 500 Index (TE*)

 

$

 

 

 

 

 

Invesco V.I. Small Cap Equity (7X*)

$

 

 

 

 

 

MFS® Technology (8J*)

$

 

 

EQ/Equity Growth PLUS (94*)

 

$

 

 

 

 

 

Ivy Funds VIP Mid Cap Growth (8M*)

$

 

 

 

 

 

MFS® Utilities (8K*)

$

 

 

EQ/JPMorgan Value Opportunities (72*)

 

$

 

 

 

 

 

Ivy Funds VIP Small Cap Growth (7Y*)

$

 

 

 

 

 

Multimanager Technology (67*)

 

 

 

 

 

 

 

 

 

 

 

$

 

 

EQ/Large Cap Core PLUS (85*)

 

$

 

 

 

 

 

Multimanager Mid Cap Growth (59*)

$

 

 

 

 

 

Van Eck VIP Global Hard Assets (8N*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

EQ/Large Cap Growth Index (82*)

 

$

 

 

 

 

 

Multimanager Mid Cap Value (61*)

Guaranteed-Fixed

 

 

 

 

 

 

 

 

 

$

 

 

 

EQ/Large Cap Growth PLUS (77*)

 

$

 

 

 

 

 

Multimanager Small Cap Growth (36*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Guaranteed Interest Option (A1*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

EQ/Large Cap Value Index (49*)

 

$

 

 

 

 

 

Multimanager Small Cap Value (91*)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* The number in parenthesis is shown for data input only.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Available for EQUI-VEST Strategies (Series 900) TSA and EDC only.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fixed Maturity Option (FMO) Specify the Period and Amount of Withdrawal. Funds will be withdrawn from the FMO only when there are

 

 

 

 

insuficient funds in the other investment options under the contract to satisfy the partial transfer/ rollover, if the FMO is the only investment

 

 

 

 

option selected, or if an amount has been speciied to be withdrawn from the FMO as indicated below. If money is withdrawn from the FMO

 

 

 

 

prior to maturity, it will be subject to a market value adjustment and CWC, if applicable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fixed Maturity Option − Period

 

 

$

 

 

 

Fixed Maturity Option − Period

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

Fixed Maturity Option − Period

maturity year

 

 

Fixed Maturity Option − Period

maturity year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

maturity year

 

 

 

 

maturity year

 

 

 

 

 

 

 

 

 

Total Transfer/Rollover of the entire cash value of the Contract number in Section 1. (The Contract must be returned with this form.)

 

 

 

 

 

Check here if you selected a total transfer/exchange or rollover and are unable to locate your contract.

 

 

 

 

 

 

 

 

 

 

*

Applicable surrender charges will be deducted when the transfer/rollover is processed. If you have an outstanding loan balance on

 

 

 

 

your annuity contract, this may adversely affect your ability to transfer or roll over funds. Please consult your tax adviser. Contact the

 

 

 

 

appropriate processing ofice for details.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trns/Rollover/1035 Exchange

X01752_core_f

Cat.# 125852 (09/12)

 

Page 2 of 6

 

3.Acceptance of Transfer, Rollover or Exchange To be completed by new carrier or successor iduciary

This section must be completed by the issuer of the NQ annuity or the trustee, custodian or issuer of the eligible retirement plan, Internal Revenue Code Section 403(b) arrangement, traditional IRA, or Roth IRA, as the case may be,

that will receive the direct rollover, traditional IRA direct transfer, traditional IRA conversion rollover, or a direct 1035 exchange to an NQ Contract issued by another carrier (generally ‘‘successor iduciary’’).

NOTE: This is the only form that AXA Equitable will accept for direct rollover or direct transfer requests.

The amount speciied in Section 2B (or the net contract value of NQ Contract to be exchanged) should be sent directly to:

Name of Successor Fiduciary or New Carrier

Address

City/State/Zip Code

Contact Person or Attention of (Department)

Phone Number

Contract Number

Name of Agency and Company

I certify that I am an oficer of the Successor Fiduciary or New Carrier named in this Section 3 and authorized to accept the

funds transferred, rolled over or exchanged as requested in Section 2A in accordance with one of the applicable transactions below: (check one only)

This direct rollover will be applied to an eligible retirement plan within the meaning of Internal Revenue Code Section

402(c)(8)(B), as amended, and the plan accepts this kind of rollover.

The traditional IRA funds transferred will be applied to a traditional IRA in accordance with Internal Revenue Code

Section 408. (During the irst two years of participation a SIMPLE IRA cannot be transferred to a traditional IRA.)

The Roth IRA/Converted Roth IRA funds transferred will be applied to a similar IRA arrangement under Internal Revenue Code Section 408A.

Funds from the EQUI-VEST traditional IRA will be applied to a conversion Roth IRA with my new carrier. I understand

AXA Equitable will ile Form 1099-R and my new carrier will ile Form 5498.

Funds from the EQUI-VEST Applicable Plan will be applied to a conversion Roth IRA with my new carrier. I understand

AXA Equitable will ile Form 1099-R and my new carrier will ile Form 5498.

Another NQ Contract with the same owner, annuitant and beneiciaries of the existing NQ Contract will be issued in exchange (see Absolute Assignment Attached in Section 4F).

Type or Print Name of Certifying Officer

Certifying Officer’s Title

Certifying Officer’s Signature

Date

Trns/Rollover/1035 Exchange

X01752_core_f

Cat.# 125852 (09/12)

 

Page 3 of 6

 

4. Representations and Acknowledgments

(To be completed by annuitant, see exception for spouses in 4A.)

A. For Direct Rollovers

By my signature, I represent that:

I have checked with the Plan Administrator and have determined that the plan accepts rollovers of this type. I have discussed this transaction with my tax advisor, and I understand that the funds will be subject to the rules of the new plan or contract. If the destination plan or contract is a governmental EDC plan, and the source of funds rolled over is not, I understand these funds will continue to be subject to the additional 10% Federal Income Tax penalty for early withdrawals of Section 72(t) of the Internal Revenue Code.

I am not rolling over any after-tax contributions, except as speciically permitted and documented.

I have taken the required minimum distribution, if any, pursuant to Internal Revenue Code Section 401(a)(9) and related federal tax rules.

The Successor Fiduciary’s plan or contract named in Section 3, qualiies as an eligible retirement arrangement.

I acknowledge having received, read and understood, a notice from the Plan Administrator or Payor, which explains the federal income tax rules and options which apply to eligible rollover distributions, including a

description of the direct rollover option. Even if I have not received this explanation at least 30 days before I request the distribution to be made, as required by the IRS, I am nevertheless afirmatively electing to make a direct rollover.

If you are neither the Owner nor the Annuitant, check whichever applies:

I am eligible to make this direct rollover as:

surviving spouse beneiciary of deceased Annuitant, or

spouse or former spouse receiving distribution under a Qualiied Domestic Relations Order or

‘‘QDRO.’’ (To process this, we must receive directions from the Plan Administrator and receive a copy of the QDRO.)

B.For Traditional IRA Direct Transfers

By my signature, I represent that:

The Successor Fiduciary’s annuity contract or account named in Section 3 qualiies as an Internal Revenue Code

Section 408 individual retirement arrangement.

I have taken the required minimum distribution, if applicable, pursuant to Internal Revenue Code Sections 408 and

401(a)(9) and related federal tax rules.

C. For Roth IRA Direct Transfers

By my signature, I represent that:

The Successor Fiduciary’s annuity contract or account named in Section 3 qualiies as a Roth IRA under Internal

Revenue Code Sections 408 and 408A.

D.For traditional IRA or Applicable Plan to Roth IRA Taxable Conversion Rollovers.

AXA Equitable Life is required to withhold federal income tax on payments from annuity contracts which may be included in gross income. Please check the appropriate box below and provide your U.S. residence address and your Taxpayer’s Identiication Number to elect out of withholding.

I wish to elect out of withholding. Under penalty of perjury, I certify that the following Taxpayer Identiication Number is correct: S.S.N E.I.N. Other

I wish to have 10% (20% on TSA contracts) withheld from my conversion amount.

If your address of record is not a U.S. residence address, complete the following statement:

(check one):

I am a U.S. citizen.

I am not a U.S. citizen, I reside in

 

(name of country)

 

 

 

If you are foreign, you may need to complete additional tax forms before your transaction can be processed.

By my signature, I represent that:

I understand that if I elect out of withholding, 100% of the amount requested to be converted will be applied to my Roth IRA.

I understand that if I do not elect out of withholding, the amount of deemed withdrawal from my traditional IRA, or Applicable Plan, net of the appropriate amount of federal and any applicable state income tax withheld, will be forwarded to my new carrier for application to my new Roth IRA.

The Successor Fiduciary’s annuity contract or account named in Section 3, qualiies as an Internal Revenue Code

Section 408 individual retirement arrangement or if applicable, a Roth IRA under IRC Section 408A.

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4. Representations and Acknowledgments (cont’d)

(To be completed by annuitant, see exception for spouses in 4A.)

E. For All Transactions

By my signature, I represent that:

I am the Owner of the Contract listed in Section 1. If I am not, I am a participant in an eligible retirement plan and the Owner or Plan Administrator has approved this transaction in Section 5.

I acknowledge that withdrawal charges as speciied in the Contract may be imposed on the Annuity Account Value of my Annuity Contract prior to this transaction and, acknowledge that it may not be in my best interest to begin a new withdrawal charge schedule, under a new Contract or other arrangement with a Successor Fiduciary or New Carrier and,

I acknowledge that any higher investment return which may occur as a result of this transaction may be outweighed by applicable withdrawal charges assessed against the Annuity Account Value of my Annuity Contract as speciied in Section 1.

I understand that I am responsible for determining my eligibility to transfer within the limits set forth by tax laws, related regulations and plan agreements. I assume responsibility for any tax consequences or penalties that may apply to the transfer of my assets.

I acknowledge that AXA Equitable has not given me tax advice in connection with this transaction and has directed me to consult with my own tax or legal adviser and, hold AXA Equitable harmless from any income or excise tax liability, including penalties and interest, as a result of this transaction.

I authorize AXA Equitable to deduct a $25 processing fee from my EQUI-VEST, EQUI-VEST Express or EQUI-VEST Strategies Contract, if it is a rollover or direct transfer from an IRA or an NQ exchange or an EDC under the EQUI-VEST Series 300, 400, 700, 701, 800, 801 and 900 Contracts.

I understand that the direct rollover or direct transfer will be effective on the date that this form, properly completed and signed is received at

AXA Equitable’s EQUI-VEST Processing Ofice. I also understand that upon receipt of the properly completed and signed form, AXA Equitable has 5 business days to process this request.

I hereby authorize AXA Equitable to process this transaction.

Signature of Owner/Participant

 

 

 

Date

 

 

 

 

 

Print Name of Spouse (if applicable) (See Section 4A)

 

Signature of Spouse

 

Date

F. Absolute Assignment To Effect NQ 1035(a) Exchange To A Replacing Carrier To Be Completed By Owner

I hereby make a complete and absolute assignment and transfer all rights, title and interest of every nature and character in and to the

 

AXA Equitable annuity contract listed in Section 1 to

 

(New Company as listed in Section 3) in a Contract

exchange intended to qualify under Section 1035 of the Internal Revenue Code.

 

I understand that upon receipt, AXA Equitable will surrender the above annuity contract as listed in Section 1 and forward the net proceeds

 

to the New Company contract issued by the new company for which I have submitted an application and understand that by executing this

assignment, I irrevocably waive all rights, claims and demands under the AXA Equitable annuity contract listed in Section 1.

By my signature below, I represent that (i) the AXA Equitable annuity contract listed in Section 1 has not matured and can be surrendered

 

for its current cash value, (ii) the Annuitant, Owner and Beneiciary(ies) of the New Company contract are the same as the Annuitant, Owner

 

and Beneiciary(ies) of the AXA Equitable annuity contract listed in Section 1, (iii) there are no outstanding liens, claims or charges of any

 

kind against the AXA Equitable annuity contract listed in Section 1 or the value thereof, and (iv) there are no outstanding bankruptcy or other

insolvency proceedings instituted by or against me.

 

I understand that for the transaction to qualify as a ‘‘1035 tax deferred exchange’’ the AXA Equitable annuity contract listed in Section 1 must

be an annuity contract and the New Company contract issued to me in exchange must be an annuity contract.

I understand that I may incur tax liability (taxable gain that is reportable to the Internal Revenue Service) if any part of the cash value of the

AXA Equitable annuity contract listed in Section 1 has been paid out to me as cash withdrawal. Should this transaction result in a taxable

 

 

situation, I do hereby elect not to have part of the gain withheld. I understand that in so doing, I may incur a penalty under the estimated tax

 

rules. I understand that before proceeding, I am advised to consult with my tax adviser about the tax implications of this exchange transaction.

 

I acknowledge that AXA Equitable has no responsibility over the legal or tax consequences of the exchange of contracts herein contemplated.

I understand that as of the date of surrender of the AXA Equitable annuity contract listed in Section 1, that contract will no longer provide any beneits.

 

I understand that if the person upon whose life the AXA Equitable annuity contract listed in Section 1 was issued (‘‘Covered Person’’) dies

 

 

 

 

before the surrender value of such contract is received by the New Company, AXA Equitable will effect payment of proceeds of the AXA

 

 

Equitable annuity contract listed in Section 1 to the named beneiciary under the AXA Equitable annuity contract listed in Section 1 provided

 

 

that AXA Equitable has been properly notiied. If the proceeds have already been transferred to the New Company, then payment of the

 

 

proceeds will be made in accordance with the terms of the New Company’s contract issued in exchange.

 

X

 

 

 

 

 

 

 

 

 

 

 

Owner (if owned by an entity, show title)

 

 

 

 

 

 

Date

 

X

 

 

 

 

 

 

 

 

 

 

 

Joint Owner (if owned by an entity, show title)

 

 

 

 

 

 

Date

 

X

 

 

 

 

 

 

 

 

 

 

 

Witness

 

 

 

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

Witness

 

 

 

 

 

 

 

 

 

 

 

Signed this

 

day of

 

year of

 

at

 

 

 

 

 

 

 

 

 

 

 

 

 

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5. Plan Adminstrator and Spousal Consent Requirements:

Complete 5A if source of funds is a Governmental EDC or a Qualiied Plan which is subject to the Employee Retirement Income Security

Act (ERISA).

If you are uncertain as to whether or not your plan is subject to the terms of ERISA, please contact your employer or Plan Administrator.

A. PLAN ADMINISTRATOR’S OR OWNER’S ACKNOWLEDGMENT:

I hereby attest that this is a (check one) Governmental EDC, Qualiied Plan and that I am the Plan Administrator/Owner of the Contract identiied in Section 1.

I hereby concur with this request for a direct rollover made by the Annuitant.

I acknowledge that AXA Equitable will not be held responsible for any income or excise tax liability, including penalties and interest, or for any negative investment experience resulting from this transfer.

Signature of Plan Adminstrator/Owner

 

Date

 

 

 

Print Name of Plan Adminstrator/Owner

 

Print Title

B. SPOUSAL CONSENT

(Important: This section must be witnessed by a Notary Public or Plan Adminstrator.)

If the Annuitant under the Contract identiied in Section 1 is married and is a participant in an Internal Revenue Code Section 401(a) plan which is subject to ERISA, the Annuitant’s spouse is entitled to beneits under this arrangement in accordance with the Retirement Equity

Act of 1984 (‘‘REA’’). Moreover, REA requires that the spouse consents to any direct rollover or direct rollover transaction. Accordingly, one of the following, as applicable, should be completed and witnessed:

1. I, the named Annuitant of the Contract identiied in Section 1, hereby certify that I am NOT married.

Signature of Plan Annuitant

Date

2.I am the current spouse of the above-named Annuitant. By afixing my signature below, I hereby consent to this request for a direct rollover. I further acknowledge and fully understand the consequences of this consent. I acknowledge and understand that I have the right to receive a beneit from the Contract identiied in Section 1 which was purchased under a 401(a) plan, and that I hereby waive such right with respect to the amount being directly rolled over from the Contract.

 

 

 

 

 

Signature of Plan Annuitant’s Spouse

 

Print Name of Annuitant’s Spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notary Public/Plan Administrator

 

(Needs to be completed)

 

 

 

 

State of

 

 

 

 

, County of

 

 

.

 

 

 

On the

 

 

day of

 

 

 

year before me personally

 

 

 

appeared

 

 

 

 

to me known to be the person described in

 

 

 

and who executed the foregoing instrument, and acknowledged that (s)he

 

 

 

executed the same.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title & Signature of Notary Public or Plan Administrator

 

Notary Public – Stamp Here

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Request for Change of Owner Under EQUI-VEST Trusteed Contracts

This section must be completed only if you are not the owner of the contract. If an ownership change is required, the funds will be withdrawn on the business day following the receipt of the disbursement request in the EQUI-VEST Processing Office.

This section must be signed by the Trustee of the Plan. The title ‘‘Trustee’’ should be shown after the signature. You must also sign in the assigned area. Note: The Spousal Consent (Section 5B) must be completed by you and your spouse in order to process this rollover. Your Social Security number must be provided in Section 1 of this form.

(1) Trustee to Complete:

X

 

 

 

 

 

 

Signature of Present Owner/Title

 

 

Date:

 

 

 

 

Month

Day

Year

(2) Signature of New Owner:

X

 

 

 

 

 

 

Your Signature

 

In signing the above, each party certiies that this information is true, correct and complete.

Note: In completing this owner change, your status is now referenced on this form as a ‘‘Former Annuitant of a

Qualiied Retirement Plan’’ (NTA).

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