Form 83077 – Fill Out and Use This PDF

Death Claim

401(a)/403(b) ERISA

401/403(b) Non-ERISA

Deferred Compensation

ING Life Insurance and Annuity Company

151 Farmington Avenue

Hartford, CT 06156-1277

Telephone: 1-800-262-3862

Participant Information

Account Number(s) (15-digit Account Number as shown on Access Report)

Date of Birth (mm/dd/yyyy)

Please print. If any pre-filled information is incorrect, please make the appropriate changes, and initial and date each change.

Name of Deceased (Last, First, Middle Initial)

Date of Death (mm/dd/yyyy)

Deceased Social Security No.

Beneficiary

Information

Please print.

If you have a PO Box, U.S. Tax laws require a street address to be indicated. If provided, distribution checks will be mailed to PO Box indicated unless different instructions are provided in the Payment & Mailing section.

Complete one form for each beneficiary to be paid from the indicated account numbers.

Beneficiary Name (Last, First, Middle Initial)

Percent of Benefit Payment you are entitled to: __________ %

Non-Resident Tax Information

-This information must be completed if resident address is outside the United States and distribution is being made from a 403(b), 401 or governmental 457 Plan.

CHECK ONE BOX ONLY and complete information, if applicable.

I am a citizen of the United States living in a Foreign Country

If you are a U. S. Citizen, your withdrawal is subject to withholding rules for U. S. Citizens (see the Non-Resident Tax Information section in the instructions for this form) with this exception: You are not able to elect ‘out’ of withholding.

I am not a United States Citizen. My country of legal residence is ______________________.

If you are not a U. S. Citizen, your withdrawal is subject to withholding provisions for Non-Resident Aliens. You must complete, sign, date, and return to us the IRS Substitute Form W-8BEN, “Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding.” If you do not have a U. S. Social Security Number, you must apply (IRS Form W-7) for and receive an Individual Taxpayer Identification Number (ITIN) from the IRS.

Type of 457 Plan

(This section must be completed if claim is being made from a deferred compensation plan.)

SELECT ONE:

governmental 457(b) - Distributions processed from governmental 457 Plans will be taxed in accordance with the information provided in the attached Special Tax Notice and instructions found in the Tax Withholding Substitute W- 4P Section of this form.

non profit - All distributions processed from non profit Plans will be taxed using the information provided in the "For Payments to Employees Federal Income Tax Withholding Notice" Section of this form.

corporate non-qualified deferred compensation - All distributions processed from corporate non-qualified deferred compensation Plans will be taxed using the information provided in the "For Payments to Employees Federal Income Tax Withholding Notice" Section of this form.

non-profit 457(f) - all distributions processed from non-profit 457(f) plans will be made payable to employer. ILIAC will not complete any withholding calculations or tax reporting.

Type of Withdrawal

Note: Direct rollovers are only allowed from governmental 457(b), 403(b) or 401 Plans.

If Spouse,

Spousal Continuation if permitted by your Plan

Direct Rollover to an ILIAC IRA

Direct Rollover to a non-ILIAC IRA (Letter of Acceptance required) Direct Rollover to ILIAC 403(b), 401 or governmental 457 plan Direct Rollover to non-ILIAC 403(b), 401 or governmental 457 plan

(Letter of Acceptance required)

90-24 Transfer to non-ILIAC 403(b) plan (Letter of Acceptance required) Cash withdrawal payable to Beneficiary

If Non-Spousal (including Trust Beneficiaries)

Cash withdrawal payable to non-minor Beneficiary

Cash withdrawal payable to minor Beneficiary (Guardianship papers

are required)

Cash withdrawal payable to employer (Non-profit 457(f) only)

If Estate, only this option is available

Payable to Estate

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

_______________ (% or $)

Payment and Mailing Information

Check one only. If not indicated check will be made payable to and mailed to the Beneficiary.

Default – Check mailed to Beneficiary Resident Address noted above.

Not applicable if Spousal Continuation elected.

Mail to Beneficiary (as indicated in Beneficiary Information section)

Mail to Trustee

Mail to Other Carrier

Rollover/Transfer to ING Product

Mail to Contract Holder/Employer (Note: This is the only option available if this is a 457(f) Plan)

Send Check to:

Address (No. & Street / PO Box)

City/Town

State

Zip Code

Electronic Deposit to U. S. Bank Accounts Only

(Optional)

If you would like us to electronically deposit your withdrawal amount to your bank, please provide your bank’s name, complete address, ABA routing number, and your bank account number. (Please verify the correct ABA routing number with your bank.) We will not deposit to a third party account. If the electronic deposit cannot be completed using the information provided, we will issue and mail a check to the Beneficiary. This is not a wire transaction.

Please indicate whether this is a Checking or Savings Account

Please print.

Account Holder(s) (as it is registered at your bank)

Tax Withholding (Substitute W-4P)

Complete only if U. S. Resident Address and the check is payable to Beneficiary and distribution is being made from 403 (b), 401 or governmental 457(b) Plan.

Distributions made payable to beneficiaries from non- qualified, and non-profit 457(b) Plans will be reduced by 10% withholding and reported on a form 1099.

Surviving Spouse or Former Spouse who is an Alternate Payee - If the withdrawal is to be made to you (and not directly rolled over to a traditional IRA), we are required by law to withhold 20% Federal Income Tax Withholding from that amount and send it to the Internal Revenue Service (IRS). You will report the tax withheld on your IRS Form 1040, and it will be credited against any Federal Income Tax you owe for the year. The withdrawal is taxed in the year you receive it unless, within 60 days, you roll it over to a traditional IRA.

If you are a Beneficiary other than the Surviving Spouse, or an Estate – If payment is made payable to an individual, 10% Federal Income Tax Withholding will automatically apply unless you elect to have no Federal Income Tax withheld. If payment is made to a non-individual, such as a Trust or Estate, 10% Federal Income Tax Withholding is mandatory.

If you are a Surviving Spouse, an Alternate Payee, or another Beneficiary, your withdrawal is not subject to the additional 10% premature Federal Income Tax described in the Special Tax Notice, and you may be eligible to use the special tax treatment for lump-sum distributions.

Even if you decide not to have Federal/State Income Tax Withheld, you are still liable for payment of Federal/State Income Tax on the taxable portion of this payment. You may be subject to tax penalties under the Estimated Tax Payment Rules if your payments of estimated tax and withholding, if any, are not sufficient to cover your tax liability.

Federal Withholding

If any part of this payment is exempt from the 20% mandatory Federal Income Tax Withholding:

GI want Federal Income Tax Withheld from this payment of 10%

GI do not want Federal Income Tax withheld from this payment (available only for payments to an individual).

DEFAULT: If no election is made, 10% Federal Income Tax Withholding will occur.

State Withholding (please refer to the State Income Tax Withholding Notification page of this form)

My residence state for tax purposes is: _________________ (please complete the attached State Income

Tax Withholding Notification form if applicable)

If any part of this payment is exempt from mandatory State Income Tax Withholding:

GI want State Income Tax withheld from this payment (please complete and submit your state of residence’s applicable State Income Tax Withholding Form).

GI do not want State Income Tax withheld from this payment.

DEFAULT: If no election is made, State Income Tax Withholding will occur, if applicable.

Anti-Fraud Statement

Certain states require the following statement: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

For Contracts issued in California: For your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

For Contracts issued in Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

For Contracts issued in New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

For Contract issued in Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Authorized

Signatures and

Certification

Employer, Trustee, or Named Fiduciary’s Authorized Signature and Certification is required for all ERISA plans and employer controlled plans unless there is a separate ILIAC agreement

I certify that:

a)the information stated on this form is correct and complete;

b)the social security number shown on this form is my correct taxpayer identification number and the correct taxpayer identification number for the deceased and that I am not subject to back-up withholding; and

c)if the Beneficiary’s signature has been obtained in a separate document, the Beneficiary has received from the Trustee or Named Fiduciary the Special Tax Notice regarding application of Federal Income Tax Withholding to certain Plan payments; the Beneficiary’s withholding elections for State and Federal Income Tax purposes, where applicable, have been obtained in a separate document along with the IRS Form Substitute W-9.

I further understand that the Company may rely conclusively on these certifications in processing the requested benefits above and that, in the case of any conflicting information, the Company is entitled to rely exclusively on the information contained in this withdrawal request.

I certify that I have received and read the Special Tax Notice section and waive the 30-day notice requirement by making the election indicated in the Type of Withdrawal section of the form. I also certify that if the Employer’s signature does not appear on this ILIAC Withdrawal Form, such signature has been obtained in a separate document to the extent required under applicable law in any governing plan document.

I understand that ING Life Insurance and Annuity Company reserves the right to directly or through a third party recover any payments made in excess of amounts to which I am entitled under the terms of the Contract, regardless of the method of payment.

State Income Tax Withholding Notification

401, 403(b), 408 and Governmental 457 Plan Distribution

ING Life Insurance and Annuity Company

151 Farmington Avenue

Hartford, CT 06156-1277

Telephone: 1-800-262-3862

Notification

If you are a resident of California, Iowa, Kansas, Maine, Massachusetts, North Carolina, Oklahoma, Oregon, Vermont, or Virginia*, your state requires State Income Tax Withholding on the taxable portion of your distribution from your 401, 403(b), 408 Individual Retirement or Governmental 457 Plan. This State Income Tax Withholding is in addition to the mandatory 20% (or, in some cases, elected 10%) Federal Income Tax Withholding. Please note, when a state cost basis differs from Federal, the Federal cost basis will be used in determining taxability for State Income Tax Withholding purposes.

•If you are a resident of California or Oregon, State Income Tax Withholding will be calculated according to the State Withholding Table (below) for your state unless you complete the bottom portion of this form indicating your election “out” of State Income Tax Withholding, and return it to us with, and to the same Hartford Service Center location as, your Withdrawal Request.

•If you are a resident of Iowa, Kansas, Maine, Massachusetts, Oklahoma, or Vermont, State Income Tax Withholding will be automatically calculated according to the State Withholding Table (below) for your state. These states do not allow an election “out” of State Income Tax Withholding when Federal Income Tax Withholding applies.

•If you are a resident of North Carolina or Virginia*, State Income Tax Withholding will be calculated automatically unless you meet certain income criteria and claim an exemption from withholding. To claim an exemption: for North Carolina complete Form NC-4P (obtained from the North Carolina Department of Revenue); for Virginia complete Form VA-4P (obtained from the Virginia Department of Taxation), and return the appropriate form to us with, and to the same Hartford Service Center location as, your Withdrawal Request.

Please refer to the following table for State Income Tax Withholding rules on distributions from 401, 403(b), Governmental 457and 408 Individual Retirement Plans.

Payee’s Signature

Date (mm/dd/yyyy)

Death Claim Instructions

401(a)/403(b) ERISA

401/403(b) Non-ERISA

Deferred Compensation

ING Life Insurance and Annuity Company

151 Farmington Avenue

Hartford, CT 06156-1277

Telephone: 1-800-262-3862

Income Tax

Withholding Notice

and Election

If any portion of the taxable withdrawal is not subject to mandatory 20% Federal Income Tax Withholding, complete this section and select the desired withholding option. This would generally include death benefits payable to a Non-Spousal Beneficiary.

Tax Reporting Information

On withdrawals made payable to a Beneficiary or direct rollovers, we will report distribution on IRS Form 1099-R. All parties should consult their tax advisor, Plan Administrator, or IRS Publication 515 for more details.

Non-Resident Tax Information

This information is required only if your residency is outside the United States.

If you are a United States Citizen and the withdrawal is delivered to a Non-U. S. Resident address, your payment is subject to U. S. Federal Income Tax Withholding rules for United States citizens (see Tax Withholding section of this form) with this exception: You are not able to elect “out” of U. S. Federal Income Tax Withholding.

If you are not a United States Citizen and the withdrawal is delivered to a Non-U. S. Resident address, your payment is subject to U. S. Federal Income Tax Withholding provisions for Non-Resident Aliens. The taxable portion of your payment that is considered United States-source income is subject to 30% Non-Resident Alien U. S. Federal Income Tax Withholding. To calculate U. S. Federal Income Tax Withholding, we assume (as allowed by law) that your entire payment is from United States sources. If you believe any portion is not from a United States source, or the rate of the U. S. Federal Income Tax is less, you can claim a U. S. Federal Income Tax refund when filing your United States Federal Income Tax (Form U.S. Federal Non-Resident Income Tax Return 1040NR) return.

Overpayment Recovery

I understand that ING Life Insurance and Annuity Company reserves the right to directly or through a third party recover any payments made in excess of amounts to which you are entitled under the terms of the Contract, regardless of the method of payment.

Authorized

Signatures and

Certification

This section must be signed by the Beneficiary. In addition to verifying that the information regarding this withdrawal request is correct and complete, the Beneficiary must certify that she/he has received and read the Special Tax Notice section and waives the 30-day notice requirement by requesting a withdrawal.

Special Tax Notice

ING Life Insurance and Annuity Company

151 Farmington Avenue

Hartford, CT 06156-1277

Telephone: 1-800-262-3862

Regarding Payments from your Account

This notice contains important information you will need before you decide how to receive benefits from your 403(b) Program, 401 Qualified Plan or, Governmental 457 Plan account. We are required to provide this notice to you at least 30 days, but no more than 90 days, before the date of distribution. You have the right to consider whether to elect a direct rollover for at least 30 days after the notice is provided. Your Employer’s retirement program may provide that by completing and returning the distribution request form in less than 30 days, you elect to waive the 30-day requirement. This would mean that you do not wish to wait 30 days before receiving your requested distribution. We will process your distribution request as of the date we receive it in Good Order at the above address.

If you are a participant or beneficiary under a Governmental 457 Plan, your plan may require that you choose the manner in which your deferred benefits will be paid within a specified period of time. Please consult with your plan administrator or us to determine the election period applicable to your benefits.

All or any portion of your payment that is an “eligible rollover distribution” may be either paid in a “direct rollover” or paid to you. A direct rollover is a direct payment of benefits to an “eligible retirement plan that accepts rollovers.” An “eligible retirement plan” is defined as a traditional Individual Retirement Arrangement (IRA), a 403(b) Program, a 401 Qualified Plan or a Governmental 457 Plan. Please note that a “traditional IRA” does not include a Roth IRA, SIMPLE IRA, or Education IRA (also known as a Coverdell Education Savings Account).