Axa 1035 Exchange ≡ Fill Out Printable PDF Forms Online

Axa 1035 Exchange PDF 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.

Question	Answer
Form Name	Axa 1035 Exchange
Form Length	6 pages
Fillable?	Yes
Fillable fields	94
Avg. time to fill out	20 min 22 sec
Other names	axa series 1035 exchange, equitable 403b rollover form, equitable transfer 1035, rollover equitable transfer form

12

Form Preview Example

EQUI-VEST®

Variable Annuity Series

Direct Transfer/Contract Exchange or Direct Rollover of TSA Assets to Another Carrier

Express Mail:

AXA Equitable

EQUI-VEST Processing Ofﬁce

100 Madison St., Suite 1000

Syracuse, N.Y. 13202

Regular Mail:

AXA-Equitable

EQUI-VEST Processing Ofﬁce

P.O Box 4956

Syracuse, N.Y. 13221

Fax Number:

(201) 583-2683

For Assistance: Call (800) 628-6673

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Current Online Transactions: 7>>#"99,!4(+?"9U, 7;;*'($%*+,!4(+?"9U,1*;;(#,!*9$,7R"#(?%+?,:"$,]B9U, P+W.%#%"9U,:29$"/($%',799"$,Q"0(;(+'%+?U,O#(+9F"#9

1. Owner’s Information

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2A. Type of Transaction

Check One Transaction

1.Direct Transfer:

,, ,TSA to TSA — 1%#"'$,B;(+H$*HB;(+,$#(+9F"#,F#*/,*+",=IJ<0@,3;(+,$*,(+*$4"#,=IJ<0@,3;(+G,K*$4,2*.#,F*#/"#, "/B;*2"#,<*#,B;(+,(>/%+%9$#($*#,*#,*$4"#,(.$4*#%L">,B"#9*+@,(+>,2*.#,'.##"+$,"/B;*2"#,<*#,B;(+,(>/%+%9$#($*#,*#, *$4"#,(.$4*#%L">,B"#9*+@,6%;;,+"">,$*,(.$4*#%L",$4%9,$#(+9('$%*+,%+,:"'$%*+,MKG

2.Contract Exchange:

,, TSA to TSA —,!*+$#('$,"N'4(+?",F#*/,*+",O:7,(++.%$2,'*+$#('$,$*,(+*$4"#,P+$"#+(;,Q"R"+.",!*>",:"'$%*+, =IJ<0@,(++.%$2,'*+$#('$,<%+';.>%+?,(,=IJ<0@<S@,'.9$*>%(;,(''*.+$@,6%$4%+,$4",9(/",B;(+G,T",6%;;,+"">,$4", (.$4*#%L($%*+,*F,$4","/B;*2"#,64%'4,9B*+9*#">,2*.#,O:7,'*+$#('$U,.+;"99,7V7,AW.%$(0;",4(9,0""+,B#*R%>">,

6%$4,>*'./"+$($%*+,(9,$*,(BB#*R">,B#*R%>"#9,F#*/,$4","/B;*2"#,(+>,$4",$#(+9F"#"",B#*R%>"#,%9,%+';.>">,%+,9.'4, >*'./"+$($%*+G,:"",:"'$%*+,MKG

3.Direct Rollover from TSA:

,, Direct Rollover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ote:,T",'(++*$,B#*'"99,$4%9,#"W."9$,%F,F.+>9,(#",9.0Z"'$,$*,6%$4>#(6(;,#"9$#%'$%*+9G

Destination of Funds — Indicate Type of Retirement Plan:

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4.Rollover Conversion from TSA:

,, Rollover Conversion to Roth IRA — !*+R"#9%*+,#*;;*R"#,F#*/,(,O:7,(++.%$2,'*+$#('$,%+$*,(,Q*$4,PQ7,%99.">, 02,(+*$4"#,'(##%"#G,O4","/B;*2"#,<*#,B;(+,(>/%+%9$#($*#,*#,*$4"#,(.$4*#%L">,B"#9*+@,9B*+9*#%+?,$4",B;(+,64%'4,%9, $4",9*.#'",*F,F.+>9,6%;;,+"">,$*,(.$4*#%L",$4%9,$#(+9('$%*+,%+,:"'$%*+,MKG,Note:,T",'(++*$,B#*'"99,$4%9,#"W."9$,%F, F.+>9,(#",9.0Z"'$,$*,6%$4>#(6(;,#"9$#%'$%*+9G

Trns/Exchange/Rollover	X01806_core_f	Cat.# 139737 (09/13)
	Page 1 of 6

2B. Amount to be Transferred/Exchanged or Rolled Over*			(Check One Box Only)

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Asset Allocation

AXA Allocation

$AXA Aggressive Allocation (18*)

$AXA Balanced Strategy (8Q*)

$AXA Conservative Allocation (15*)

$AXA Conservative Growth Strategy (8R*)

$AXA Conservative-Plus Allocation (16*)

$AXA Conservative Strategy (8S*)

$AXA Moderate Allocation (T4*)

$AXA Moderate Growth Strategy (8O*)

$AXA Moderate-Plus Allocation (17*)

Target Allocation

$Target 2015 Allocation (6G*)

$Target 2025 Allocation (6H*)

$Target 2035 Allocation (6I*)

$Target 2045 Allocation (6J*)

Other Asset Allocation

$All Asset Aggressive Alt 25 (8T*)

$All Asset Growth – Alt 20 (7H*)

$All Asset Moderate Growth Alt 15 (8U*)

$EQ/AllianceBernstein Dynamic Wealth Strategies (8P*)

$EQ/Franklin Templeton Allocation (6P*)

Bonds

$American Funds Insurance Series Bond (8V*)5

$EQ/Core Bond Index (96*)

$EQ/Global Bond PLUS (47*)

$EQ/High Yield Bond (8X*)

$EQ/Intermediate Government Bond (TI*)1

$EQ/PIMCO Global Real Return (8Y*)

$EQ/PIMCO Ultra Short Bond (28*)

$EQ/Quality Bond PLUS (TQ*)

$Invesco V.I. High Yield (8L*)5

$Ivy Funds VIP High Income (8G*)5

$Multimanager Core Bond (69*)

$Multimanager Multi-Sector Bond (TH*)

$Templeton Global Bond Securities (8F*)2,5

Cash Equivalents

$EQ/Money Market (T3*)

Guaranteed-Fixed

$Guaranteed Interest Option (A1*)

International Stocks/Global

$AXA Tactical Manager International (7N*)

$EQ/Emerging Markets Equity PLUS (8W*)

$EQ/Global Multi-Sector Equity (78*)

$EQ/International Core PLUS (88*)

$EQ/International Equity Index (TN*)1

$EQ/International Value PLUS (73*)

$EQ/MFS International Growth (26*)

$EQ/Oppenheimer Global (6A*)

$EQ/Templeton Global Equity (6D*)

$Invesco V.I. International Growth (7Z*)5

$Lazard Retirement Emerging Markets Equity (8H*)5

$MFS® International Value (8A*)5

$Multimanager International Equity (65*)1

Large Cap Stocks

$AXA Tactical Manager 500 (7M*)

$EQ/BlackRock Basic Value Equity (81*)

$EQ/Boston Advisors Equity Income (33*)

$EQ/Calvert Socially Responsible (92*)

$EQ/Capital Guardian Research (86*)3

$EQ/Common Stock Index (T1*)

$EQ/Davis New York Venture (6Q*)

$EQ/Equity 500 Index (TE*)

$EQ/Equity Growth PLUS (94*)

$EQ/Invesco Comstock (07*)1

$EQ/JPMorgan Value Opportunities (72*)

$EQ/Large Cap Core PLUS (85*)

$EQ/Large Cap Growth Index (82*)

$EQ/Large Cap Growth PLUS (77*)

$EQ/Large Cap Value Index (49*)

$EQ/Large Cap Value PLUS (89*)1

$EQ/Lord Abbett Large Cap Core (05*)

$EQ/Montag & Caldwell Growth (34*)1

$EQ/Mutual Large Cap Equity (6F*)

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

$EQ/UBS Growth and Income (35*)3

$EQ/Wells Fargo Omega Growth (83*)3

$Fidelity® VIP Contrafund® (7R*)5

$Invesco V.I. Diversiﬁed Dividend (8B*)2,5

$MFS® Investors Growth Stock (8I*)5

$MFS® Investors Trust (7P*)5

$Multimanager Aggressive Equity (T2*)

$Multimanager Large Cap Core Equity (57*)3

$Multimanager Large Cap Value (58*)

$Oppenheimer Main Street Fund/VA (7Q*)2,5

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Options

$PIB AXA Moderate Growth Strategy (Q1*)4

$PIB EQ/AllianceBernstein Dynamic Wealth Strategies (Q2*)4

$PIB AXA Balanced Strategy (Q3*)4

$PIB AXA Conservative Growth Strategy (Q4*)4

$PIB AXA Conservative Strategy (Q5*)4

Sector/Specialty

$EQ/Franklin Core Balanced (6C*)

$EQ/GAMCO Mergers and Acquisitions (25*)3

$Invesco V.I. Global Real Estate (8C*)5

$Ivy Funds VIP Energy (8D*)5

$MFS® Technology (8J*)5

$MFS® Utilities (8K*)5

$Multimanager Technology (67*)

$PIMCO VIT CommodityRealReturn® Strategy (8E*)2,5

$Van Eck VIP Global Hard Assets (8N*)5

Small/Mid Cap Stocks

$American Century VIP Mid Cap Value (7V*)2,5

$AXA Tactical Manager 400 (7L*)

$AXA Tactical Manager 2000 (7K*)

$EQ/AllianceBernstein Small Cap Growth (TP*)

$EQ/AXA Franklin Small Cap Value Core (6E*)

$EQ/GAMCO Small Company Value (37*)

$EQ/Mid Cap Index (55*)

$EQ/Mid Cap Value PLUS (79*)

$EQ/Morgan Stanley Mid Cap Growth (08*)

$EQ/Small Company Index (97*)

$Fidelity VIP Mid Cap (7U*)2,5

$Goldman Sachs VIT Mid Cap Value (7W*)5

$Invesco V.I. Mid Cap Core Equity (7T*)5

$Invesco V.I. Small Cap Equity (7X*)5

$Ivy Funds VIP Mid Cap Growth (8M*)5

$Ivy Funds VIP Small Cap Growth (7Y*)5

$Multimanager Mid Cap Growth (59*)1

$Multimanager Mid Cap Value (61*)1

$Multimanager Small Cap Growth (36*)1

$Multimanager Small Cap Value (91*)1

Structured Investment Option

$Segment Holding Account for S&P 500 1yr -10% Buffer (V1*)4

$Segment Holding Account for S&P 500 3yr -20% Buffer (V3*)4

$Segment Holding Account for S&P 500 5yr -20% Buffer (V5*)4

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Trns/Exchange/Rollover	X01806_core_f	Cat.# 139737 (09/13)
	Page 2 of 6

3. Acceptance of Transfer/Exchange or Rollover !"#$%#&"'()%*%+#$,#-.&&%--"/#0+.&12/,

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

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Trns/Exchange/Rollover	X01806_core_f	Cat.# 139737 (09/13)
	Page 3 of 6

4.Representations and Acknowledgements 3!"#$%#&"'()%*%+#$,#244.1*24*5"64%/7#-%%#%8&%(*1"4#9"/#-(".-%-#14#:;<=

A. For Direct TSA Transfers/Contract Exchanges

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g,O4",B;(+,.+>"#,64%'4,$4",'*+$#('$,%9,%99.">,/.9$,B#*R%>",F*#,$4",$#(+9F"#n

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g,,O4",%99."#,*F,$4",$#(+9F"#"",'*+$#('$,/.9$,0",(+,(BB#*R">,B#*R%>"#,.+>"#,$4","/B;*2"#89,B;(+,*#,$4",, "/B;*2"#,/.9$,4(R",(+,%+F*#/($%*+,94(#%+?,(?#""/"+$,"9$(0;%94">,6%$4,$4",%99."#,*F,$4",$#(+9F"#"",'*+$#('$,, 02,k(+.(#2,XU,YIIcG

e, PF,$4"9",'*+>%$%*+9,(#",+*$,/"$,02,k(+.(#2,XU,YIIc,$4",=IJ<0@,'*+$#('$,%99.">,%+,$4",B*9$H:"B$"/0"#,Y=U,YIIS, $#(+9F"#)"N'4(+?",/(2,0"'*/",$(N(0;",($,$4($,$%/",(+>,+*,F.#$4"#,$(NHF#"","N'4(+?"9,/(2,0",/(>",F#*/,$4($, '*+$#('$,$*,(+*$4"#,=IJ<0@,'*+$#('$G,C.#$4"#U,+*,#*;;*R"#9,/(2,0",/(>",F#*/,$4($,'*+$#('$,$*,(+,";%?%0;",#"$%#"/"+$, B;(+,9.'4,(9,(+,PQ7G

B. For Direct Rollovers

K2,/2,9%?+($.#"U,P,#"B#"9"+$,$4($j

e,, P,4(R",'4"'E">,6%$4,$4",3;(+,7>/%+%9$#($*#,(+>,4(R",>"$"#/%+">,$4($,$4",B;(+,(''"B$9,#*;;*R"#9,*F,$4%9,$2B"G,, P,4(R",>%9'.99">,$4%9,$#(+9('$%*+,6%$4,/2,$(N,(>R%9*#U,(+>,P,.+>"#9$(+>,$4($,$4",F.+>9,6%;;,0",9.0Z"'$,$*,$4",#.;"9, *F,$4",+"6,B;(+,*#,'*+$#('$G

e, P,(/,+*$,#*;;%+?,*R"#,(+2,(F$"#H$(N,'*+$#%0.$%*+9U,"N'"B$,(9,9B"'%&'(;;2,B"#/%$$">,(+>,>*'./"+$">G

e, P,4(R",$(E"+,$4",#"W.%#">,/%+%/./,>%9$#%0.$%*+U,%F,(+2U,B.#9.(+$,$*,P+$"#+(;,Q"R"+.",!*>",:"'$%*+,=IX<(@<c@,(+>, #";($">,F">"#(;,$(N,#.;"9G

e,O4",:.''"99*#,C%>.'%(#289,B;(+,*#,'*+$#('$,+(/">,%+,:"'$%*+,J,W.(;%&"9,(9,(+,";%?%0;",#"$%#"/"+$,(##(+?"/"+$G

e, P,('E+*6;">?",4(R%+?,#"'"%R">U,#"(>,(+>,.+>"#9$**>U,(,+*$%'",F#*/,$4",3;(+,7>/%+%9$#($*#,*#,3(2*#U,64%'4,"NB;(%+9, $4",F">"#(;,%+'*/",$(N,#.;"9,(+>,*B$%*+9,64%'4,(BB;2,$*,";%?%0;",#*;;*R"#,>%9$#%0.$%*+9U,%+';.>%+?,(,>"9'#%B$%*+,*F,$4", >%#"'$,#*;;*R"#,*B$%*+G,AR"+,%F,P,4(R",+*$,#"'"%R">,$4%9,"NB;(+($%*+,($,;"(9$,JI,>(29,0"F*#",P,#"W."9$,$4",>%9$#%0.$%*+,$*, 0",/(>"U,(9,#"W.%#">,02,$4",PQ:U,P,(/,+"R"#$4";"99,(F/($%R";2,";"'$%+?,$*,/(E",(,>%#"'$,#*;;*R"#G

e, PF,2*.,(#",+"%$4"#,$4",56+"#,+*#,$4",7++.%$(+$U,'4"'E,64%'4"R"#,(BB;%"9j

, P,(/,";%?%0;",$*,/(E",$4%9,>%#"'$,#*;;*R"#,(9j

, 9.#R%R%+?,9B*.9",0"+"&'%(#2,*F,>"'"(9">,7++.%$(+$U,*#

, 9B*.9",*#,F*#/"#,9B*.9",#"'"%R%+?,>%9$#%0.$%*+,.+>"#,(,[.(;%&">,1*/"9$%',Q";($%*+9,5#>"#,*F,ii[1Q5G88,

,<O*,B#*'"99,$4%9U,6",/.9$,#"'"%R",>%#"'$%*+9,F#*/,$4",3;(+,7>/%+%9$#($*#,(+>,#"'"%R",(,'*B2,*F,$4",[1Q5G@

Trns/Exchange/Rollover	X01806_core_f	Cat.# 139737 (09/13)
	Page 4 of 6

4. Representations and Acknowledgements

C. For Conversion Rollovers

7V7,AW.%$(0;",%9,#"W.%#">,$*,6%$44*;>,F">"#(;,%+'*/",$(N,*+,B(2/"+$9,F#*/,(++.%$2,'*+$#('$9,64%'4,/(2,0",%+';.>">,%+, ?#*99,%+'*/"G,3;"(9",'4"'E,$4",(BB#*B#%($",0*N,0";*6,(+>,B#*R%>",2*.#,]G:G,#"9%>"+'",(>>#"99,(+>,2*.#,O(NB(2"#89, P>"+$%&'($%*+,-./0"#,$*,";"'$,*.$,*F,6%$44*;>%+?G

, P,6%94,$*,";"'$,*.$,*F,6%$44*;>%+?G,]+>"#,B"+(;$2,*F,B"#Z.#2U,P,'"#$%F2,$4($,$4",F*;;*6%+?,O(NB(2"#,P>"+$%&'($%*+, -./0"#,%9,'*##"'$j, , :G:G-, , AGPG-G, , 5$4"#

, P,6%94,$*,4(R",YIo,6%$44";>,F#*/,/2,'*+R"#9%*+,(/*.+$G

PF,2*.#,(>>#"99,*F,#"'*#>,%9,+*$,(,]G:G,#"9%>"+'",(>>#"99U,'*/B;"$",$4",F*;;*6%+?,9$($"/"+$j, <'4"'E,*+"@j, , P,(/,(,]G:G,'%$%L"+G, , P,(/,+*$,(,]G:G,'%$%L"+U,P,#"9%>",%+

, ,

<+(/",*F,'*.+$#2@

PF,2*.,(#",F*#"%?+U,2*.,/(2,+"">,$*,'*/B;"$",(>>%$%*+(;,$(N,F*#/9,0"F*#",2*.#,$#(+9('$%*+,'(+,0",B#*'"99">G K2,/2,9%?+($.#"U,P,#"B#"9"+$,$4($j

e, P,.+>"#9$(+>,$4($,%F,P,";"'$,*.$,*F,6%$44*;>%+?U,XIIo,*F,$4",(/*.+$,#"W."9$">,$*,0",'*+R"#$">,6%;;,0",(BB;%">,$*,/2, Q*$4,PQ7G

e, P,.+>"#9$(+>,$4($,%F,P,>*,+*$,";"'$,*.$,*F,6%$44*;>%+?U,$4",(/*.+$,*F,>""/">,6%$4>#(6(;,F#*/,/2,$#(>%$%*+(;,PQ7U, *#,7BB;%'(0;",3;(+U,+"$,*F,$4",(BB#*B#%($",(/*.+$,*F,F">"#(;,(+>,(+2,(BB;%'(0;",9$($",%+'*/",$(N,6%$44";>U,6%;;,0", F*#6(#>">,$*,/2,+"6,'(##%"#,F*#,(BB;%'($%*+,$*,/2,+"6,Q*$4,PQ7G

e, O4",:.''"99*#,C%>.'%(#289,(++.%$2,'*+$#('$,*#,(''*.+$,+(/">,%+,:"'$%*+,JU,W.(;%&"9,(9,(+,P+$"#+(;,Q"R"+.",!*>", :"'$%*+,=Il,%+>%R%>.(;,#"$%#"/"+$,(##(+?"/"+$,*#,%F,(BB;%'(0;"U,(,Q*$4,PQ7,.+>"#,PQ!,:"'$%*+,=Il7G

D. For All Transactions

K2,/2,9%?+($.#",0";*6U,P,('E+*6;">?",$4($j

e, P,(/,$4",56+"#,*F,$4",!*+$#('$,;%9$">,%+,:"'$%*+,XG,PF,P,(/,+*$U,/2,%+$"#"9$,%9,>"#%R">,F#*/,(,B(#$%'%B(+$,%+,(,=IJ<0@, B;(+,(+>,$4","/B;*2"#,*#,3;(+,7>/%+%9$#($*#,4(9,(BB#*R">,$4%9,$#(+9('$%*+,%+,:"'$%*+,MKn

e, T%$4>#(6(;,'4(#?"9,(9,9B"'%&">,%+,$4",!*+$#('$,/(2,0",%/B*9">,*+,$4",7++.%$2,7''*.+$,_(;.",*F,/2,7++.%$2, !*+$#('$,B#%*#,$*,$4%9,$#(+9('$%*+,(+>U,('E+*6;">?",$4($,%$,/(2,+*$,0",%+,/2,0"9$,%+$"#"9$,$*,0"?%+,(,+"6,6%$4>#(6(;, '4(#?",9'4">.;",.+>"#,(,+"6,!*+$#('$,*#,*$4"#,(##(+?"/"+$,6%$4,$4",:.''"99*#,C%>.'%(#2n

e, 7+2,4%?4"#,%+R"9$/"+$,#"$.#+,64%'4,/(2,*''.#,(9,(,#"9.;$,*F,$4%9,$#(+9('$%*+,/(2,0",*.$6"%?4">,02,(BB;%'(0;", 6%$4>#(6(;,'4(#?"9,(99"99">,(?(%+9$,$4",7++.%$2,7''*.+$,_(;.",*F,/2,7++.%$2,!*+$#('$,9B"'%&">,%+,:"'$%*+,Xn

e, P,.+>"#9$(+>,$4($,P,(/,#"9B*+9%0;",F*#,>"$"#/%+%+?,/2,";%?%0%;%$2,$*,$#(+9F"#)"N'4(+?",*#,#*;;,*R"#,6%$4%+,$4",;%/%$9,9"$, F*#$4,02,$(N,;(69U,#";($">,#"?.;($%*+9,(+>,B;(+,(?#""/"+$9G,P,(99./",#"9B*+9%0%;%$2,F*#,(+2,$(N,'*+9"W."+'"9,*#, B"+(;$%"9,$4($,/(2,(BB;2,$*,$4",$#(+9F"#)"N'4(+?",*#,#*;;,*R"#,*F,/2,(99"$9G

e, 7V7,AW.%$(0;",4(9,+*$,?%R"+,/",$(N,(>R%'",%+,'*++"'$%*+,6%$4,$4%9,$#(+9('$%*+,(+>,4(9,>%#"'$">,/",$*,'*+9.;$,6%$4, /2,*6+,$(N,*#,;"?(;,(>R%9"#,(+>U,P,4*;>,7V7,AW.%$(0;",4(#/;"99,F#*/,(+2,%+'*/",*#,"N'%9",$(N,;%(0%;%$2U,%+';.>%+?, B"+(;$%"9U,+"?($%R",%+R"9$/"+$,"NB"#%"+'",(+>,%+$"#"9$,(9,(,#"9.;$,*F,$4%9,$#(+9('$%*+G

e, 7V7,AW.%$(0;",6%;;,>">.'$,(,B#*'"99%+?,F"",*F,.B,$*,^mMU,>"B"+>%+?,*+,!*+$#('$,/(#E"$,(+>,9"#%"9G

e, P,.+>"#9$(+>,$4($,$4",>%#"'$,$#(+9F"#)"N'4(+?",*#,>%#"'$,#*;;*R"#,6%;;,0","FF"'$%R",*+,$4",>($",$4($,$4%9,F*#/U,B#*B"#;2, '*/B;"$">,6%$4,(;;,#"W.%#">,9%?+($.#"9,%9,#"'"%R">,($,7V7,AW.%$(0;"89,3#*'"99%+?,5F&'"G,P,(;9*,.+>"#9$(+>,$4($,.B*+, #"'"%B$,*F,$4",B#*B"#;2,'*/B;"$">,F*#/9U,7V7,AW.%$(0;",4(9,M,0.9%+"99,>(29,$*,B#*'"99,$4%9,#"W."9$G

e, P,4"#"02,(.$4*#%L",7V7,AW.%$(0;",$*,B#*'"99,$4%9,>%#"'$,$#(+9F"#)'*+$#('$,"N'4(+?",*#,>%#"'$,#*;;*R"#,$#(+9('$%*+G

			,
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	,			,
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3#%+$,-(/",F,:B.9",<%F,(BB;%'(0;"@,<:"",:"'$%*+,=K@,,	:%?+($.#",F,:B.9",,		1($"

Trns/Exchange/Rollover	X01806_core_f	Cat.# 139737 (09/13)
	Page 5 of 6

9H1'64"+-%<'M"#-;#A'N",':<%#-'-+EO;>A'A"'5P=6H

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

PF,$4",7++.%$(+$,.+>"#,$4",!*+$#('$,%>"+$%&">,%+,:"'$%*+,X,%9,/(##%">,(+>,%9,(,B(#$%'%B(+$,%+,(+,P+$"#+(;,Q"R"+.",!*>",:"'$%*+, =IJ<0@,B;(+,64%'4,%9,9.0Z"'$,$*,AQP:7U,$4",7++.%$(+$89,9B*.9",%9,"+$%$;">,$*,0"+"&$9,.+>"#,$4%9,(##(+?"/"+$,%+,(''*#>(+'", 6%$4,$4",Q"$%#"/"+$,AW.%$2,7'$,*F,Xcl=,<iiQA788@G,f*#"*R"#U,QA7,#"W.%#"9,$4($,$4",9B*.9",'*+9"+$9,$*,(+2,>%#"'$,#*;;*R"#, $#(+9('$%*+G,7''*#>%+?;2U,*+",*F,$4",F*;;*6%+?U,(9,(BB;%'(0;"U,94*.;>,0",'*/B;"$">,(+>,6%$+"99">j

XG, PU,$4",+(/">,7++.%$(+$,*F,$4",!*+$#('$,%>"+$%&">,%+,:"'$%*+,XU,4"#"02,'"#$%F2,$4($,P,(/,-5O,/(##%">G

		,
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,	:%?+($.#",*F,3;(+,7++.%$(+$,,	1($"

YG, P,(/,$4",'.##"+$,9B*.9",*F,$4",(0*R"H+(/">,7++.%$(+$G,K2,(F&N%+?,/2,9%?+($.#",0";*6U,P,4"#"02,'*+9"+$,$*,$4%9,#"W."9$, F*#,(,>%#"'$,#*;;*R"#G,P,F.#$4"#,('E+*6;">?",(+>,F.;;2,.+>"#9$(+>,$4",'*+9"W."+'"9,*F,$4%9,'*+9"+$G,P,('E+*6;">?",(+>,

.+>"#9$(+>,$4($,P,4(R",$4",#%?4$,$*,#"'"%R",(,0"+"&$,F#*/,$4",!*+$#('$,%>"+$%&">,%+,:"'$%*+,X,64%'4,6(9,B.#'4(9">,.+>"#,(, :"'$%*+,=IJ<0@,(##(+?"/"+$U,(+>,$4($,P,4"#"02,6(%R",9.'4,#%?4$,6%$4,#"9B"'$,$*,$4",(/*.+$,0"%+?,>%#"'$;2,#*;;">,*R"#,F#*/, $4",!*+$#('$G

,

,

:%?+($.#",*F,3;(+,7++.%$(+$89,:B*.9",,

3#%+$,-(/",*F,7++.%$(+$89,:B*.9"

Notary Public/Plan Administrator

(Needs to be completed)

:$($",*F,

U,!*.+$2,*F,

G

5+,$4",

,>(2,*F,

,2"(#,0"F*#",/",B"#9*+(;;2

(BB"(#">,

,$*,/",E+*6+,$*,0",$4",B"#9*+,>"9'#%0">,%+

(+>,64*,"N"'.$">,$4",F*#"?*%+?,%+9$#./"+$U,(+>,('E+*6;">?">,$4($,<9@4",,

"N"'.$">,$4",9(/"G

-*$(#2,3.0;%',r,:$(/B,s"#"

O%$;",q,:%?+($.#",*F,-*$(#2,3.0;%',*#,3;(+,7>/%+%9$#($*#

9?1'524<"&;,G:<%#'H$28#8-A,%A",I-'H>J#"K<;$L;2;#A

For Direct Plan-to-Plan Transfers and Direct Rollovers only:

3>1?4%+#$,#@"/'%/#A'()",%/5B)24#C+'141-*/2*"/5"*D%/#2.*D"/1E%+#(%/-"4=

P,(/,$4",F*#/"#,A/B;*2"#)3;(+,7>/%+%9$#($*#)*$4"#,(.$4*#%L">,B"#9*+,*F,$4",%+>%R%>.(;,%>"+$%&">,%+,:"'$%*+,X,(+> ('E+*6;">?",$4($,$4%9,$#(+9('$%*+,%9,(BB#*R">,.+>"#,$4",A/B;*2"#89,=IJ<0@,B;(+G

,

:%?+($.#",*F,C*#/"#,A/B;*2"#)3;(+,7>/%+%9$#($*#)*$4"#,(.$4*#%L">,B"#9*+,,1($"

,

3#%+$,-(/",*F,C*#/"#,A/B;*2"#)3;(+,7>/%+%9$#($*#)*$4"#,(.$4*#%L">,B"#9*+,,3#%+$,O%$;"

:"B(#($%*+,F#*/,:"#R%'",1($"j,ppp)pppp)pppp,, _"9$%+?,ojpppppppppppppp

For all transactions other than a direct rollover to an IRA:

3>1?4%+#$,#F.//%4*#A'()",%/5B)24#C+'141-*/2*"/5"*D%/#2.*D"/1E%+#(%/-"4=

PF,$4%9,%9,(,=IJ<0@,'*+$#('$,"N'4(+?",.+>"#,$4",B;(+,*F,(+,A/B;*2"#U,+*,9B"'%&',A/B;*2"#,9%?+($.#",%9,#"W.%#">,%F,$4", A/B;*2"#,4(9,?%R"+,7V7,AW.%$(0;",>*'./"+$($%*+,(9,$*,(BB#*R">,B#*R%>"#9U,(+>,$4",$#(+9F"#"",B#*R%>"#,%9,%+';.>">,%+,9.'4, >*'./"+$($%*+G

P,(/,$4",'.##"+$,A/B;*2"#)3;(+,7>/%+%9$#($*#)*$4"#,(.$4*#%L">,B"#9*+,*F,$4",%+>%R%>.(;,%>"+$%&">,%+,:"'$%*+,X,(+>, ('E+*6;">?",$4($,$4%9,$#(+9('$%*+,%9,B"#/%$$">,.+>"#,$4",A/B;*2"#89,B;(+,(+>,$4($,P,(BB#*R",*F,$4%9,$#(+9('$%*+G

PF,$4%9,%9,(,=IJ<0@,'*+$#('$,"N'4(+?",.+>"#,$4",9(/",B;(+U,P,F.#$4"#,('E+*6;">?",$4($,$4",A/B;*2"#,(+>,$4",%99."#,*F,$4", $#(+9F"#""89,=IJ<0@,'*+$#('$,*#,=IJ<0@<S@,'.9$*>%(;,(''*.+$,(?#"",$*,"+$"#,%+$*,(+,%+F*#/($%*+,94(#%+?,(?#""/"+$,0"F*#", k(+.(#2,XU,YIIc,6%$4%+,$4",/"(+%+?,*F,O#"(9G,Q"?G,:"'G,=IJ<0@hXIG

,

:%?+($.#",*F,!.##"+$,A/B;*2"#)3;(+,7>/%+%9$#($*#)*$4"#,(.$4*#%L">,B"#9*+,,1($"

			,
	3#%+$,-(/",F,!.##"+$,A/B;2"#)3;(+,7>/%+%9$#($#)$4"#,(.$4#%L">,B"#9+,,			3#%+$,O%$;"

Trns/Exchange/Rollover		X01806_core_f		Cat.# 139737 (09/13)
		Page 6 of 6

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