Change Of Ownership Form – Fill Out and Use This PDF

3 . Information for New Owner	□ Individual □ Trust	□ Partnership □ Corporation
• If the proposed Owner is a Corporation or Partnership, refer to the General Information for Change of Ownership
section at the back of the form for additional documentation requirements.		□ Yes □ No
Is the new Owner a U.S. citizen or a legal entity established under U.S. law?

If the new Owner is a nominee, fiduciary or intermediary for a beneficial Owner, is the beneficial Owner a U.S. citizen or legal entity
established under U.S. law?	□ Yes	□ No	□ Not Applicable
New Owner’s Legal Residence (Required):
Address Number and Street				Apt./Suite/Floor
City			State	Zip Code
New Owner’s Mailing Address (if different from legal residence) (Required):
Address Number and Street				Apt./Suite/Floor
City			State	Zip Code
New Owner’s Occupation and Type of Business (e.g., Clerk/Flower Shop) (Required):
Occupation			Type of Business

Request for Taxpayer Identification Number of a U.S. Person

Federal law requires that you provide the following data:

□ Social Security Number	□ EIN	□ Other

C E R T I F I C A T I O N — By my signature below I certify that the number listed above is my correct Taxpayer Identification Number and that I am a “U.S. person” (including a “resident alien”) with respect to the U.S. If I am not a U.S. person, I have provided appropriate documentation as to citizenship and residence.

X

Signature of New Owner

Title

Date (mm/dd/yy)

(Refer to General Information for Change of Ownership as additional documentation may be desired.)

For Internal Use Only:

AXA Equitable certifies that this change has been recorded.

Date: __________________________ By: ________________________________________________

Page 2 of 3

Cat. #140546 (3/08)

3. Information for New Owner (continued)

Complete and attach duplicates of this page if there are more owners.

•If the proposed Owner is a Corporation or Partnership, refer to the General Information for Change of Ownership section at the back of the form for additional documentation requirements.

Is the new Owner a U.S. citizen or a legal entity established under U.S. law?□ Yes □ No

If the new Owner is a nominee, fiduciary or intermediary for a beneficial Owner, is the beneficial Owner a U.S. citizen or legal entity
established under U.S. law?	□ Yes	□ No	□ Not Applicable
New Joint Owner’s Legal Residence (Required):
Address Number and Street				Apt./Suite/Floor
City			State	Zip Code
New Joint Owner’s Mailing Address (if different from legal residence) (Required):
Address Number and Street				Apt./Suite/Floor
City			State	Zip Code
New Joint Owner’s Occupation and Type of Business (e.g., Clerk/Flower Shop) (Required):
Occupation			Type of Business

Request for Taxpayer Identification Number of a U.S. Person

Federal law requires that you provide the following data:

□ Social Security Number	□ EIN	□ Other

CERTIFICATION — By my signature below I certify that the number listed above is my correct Taxpayer Identification Number and that I am a “U.S. person” (including a “resident alien”) with respect to the U.S. If I am not a U.S. person, I have provided appropriate documentation as to citizenship and residence.

X

Signature of New Joint Owner (if applicable)TitleDate (mm/dd/yy)

For Internal Use Only:

AXA Equitable certifies that this change has been recorded.

Date: __________________________ By: _______________________________________________

Page 3 of 3

Cat. #140546 (3/08)

General Information Pages

Please detach these pages from Ownership Change Request Form before mailing.

General Information for Change in Ownership

•If the new Owner is a U.S. citizen, they must have a primary residence in the United States. If the person is a U.S. Citizen but lives abroad, the change of ownership will require the approval of the AXA Equitable Anti-Money Laundering Office (AMLO).

•If the new Owner is not a U.S. citizen, they must have a primary resident address in the U.S. and have an unexpired visa or Green Card. Copies of the unexpired visa or Green Card must be submitted with this request. We will accept an unexpired visa in the following visa categories: A, E, G, H, I, K, L, N, NATO, P, R, S, T, TN, TD, U TPS or V. We will also need a copy of an unexpired visa and I-94 document.

•A Non-U.S. citizen that has a visitor’s visa, an expired Green Card or visa, no visa or has a visa in the following categories: B, C, D, F, J, M, Q, TWOV, will not be accepted as a new Owner and the ownership change must be declined under the AXA Financial Anti-Money Laundering policy.

•For Legal Resident Aliens: A copy of the unexpired Green Card or acceptable visa and I-94 form will be required to be submitted with the change of ownership request.

•For Trusts: Taxpayer Identification Number of the Trust and a copy of a Trust certification or significant pages and signature page of the Trust Agreement that proves the existence of the Trust, the name and date of the Trust Agreement, as well as the name of the Trustee(s).

•For Partnerships: Pertinent page from the Partnership agreement that proves the Partnership exists and indicates the names of the Partners.

•For Private Corporations: Articles of Incorporation or copy of business license and documentation indicating the acting party has the authority to act on behalf of the Corporation.

•For Publicly Traded Corporations: No additional requirements need to be submitted.

General Information on Present Owner Signature Requirements

•	Individual/Joint Owners	Must be signed by all Owners.
•	Attorney in Fact	Must be signed by the Attorney in Fact, if the Power of Attorney is in effect and not expired by its
		own terms. A current copy of the Declaration of Attorney-in-Fact will also be required. Please
		contact the Service Center to obtain this form.

Corporations:

•One officer OTHER than the Annuitant and the Officer’s title must accompany his/her signature.

Partnership:

•One officer OTHER than the Annuitant and the Officer’s title must accompany his/her signature.

General Information on Contract Provisions

•The term “Owner” shall mean the person in whom “Contract Rights” are vested.

•The Owner can exercise all of the rights of the Contract while the Annuitant is living.

•An Owner who is a minor may not exercise Ownership rights except as permitted by law.

•A copy of this form containing a company signature will be sent to the proposed new Owner once the Ownership change has been recorded.

Cat. #140546 (3/08)

General Information on Tax Basis Resulting from Contract Ownership Changes

•When the Ownership of a Contract is changed from a Corporation or qualified plan Trustee to the Annuitant, AXA Equitable should be furnished with documentation that would allow us to adjust the new Owner’s cost basis in the Contract. This documentation could consist of either of the following:

1)copies of Forms 1099 or W-2 that were filed by the previous Owner,

2)copies of documents showing the Economic Benefit that was used each year,

3)copies of any checks written by the new Owner that were used to purchase the Contract from the old Owner.

•If we do not receive this information, we are required to report all future taxable distributions as “Taxable amount not determined.”

General Information for New Owner(s) concerning Taxpayer Identification Number

•Federal Law requires you to provide to us the correct Taxpayer Identification Number which matches your name.

•If you fail to provide the correct Taxpayer Identification Number, tax withholding may be required and penalties may apply.

•Your Taxpayer Identification Number is your Social Security Number if you are an individual and a U.S. person. A U.S. person is a U.S. citizen, or a non-citizen of the United States who is a U.S. resident for tax purposes. If you are a foreign individual who is not eligible to apply for a Social Security Number, your Taxpayer Identification Number is your Individual Taxpayer Identification Number or “ITIN” issued by the IRS. If you are an entity (U.S. or foreign), your Taxpayer Identification Number is the Employer Identification Number or “EIN” issued by the IRS.

•In the case of a minor, the minor’s Social Security Number must be provided. If the minor does not have a Social Security Number, the natural guardian for the minor Owner may obtain one by applying to the Social Security Administration on Application Form SS-4. If the newly acquired number is not received by AXA Equitable within 60 days, AXA Equitable is required by law to withhold on any taxable interest being credited to the Contract.

General Information on USA PATRIOT Act – Customer Identification Program

•Section 326 of the USA PATRIOT Act outlines important information about procedures for opening new accounts.

•To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

•To comply with Section 326, AXA Equitable will ask for your name, address, date of birth, and other information necessary to allow us to identify you when opening an account. We may also ask to see your driver’s license or other identifying documents.

Cat. #140546 (3/08)