Lincoln Request Distribution – Fill Out and Use This PDF

2.WITHDRAWAL INFORMATION

A.I hereby authorize Lincoln Benefit Life Company to make a withdrawal of the amounts indicated below. I understand that withdrawals may result in taxable income and, prior to owner’s age 59½, may also be subject to a 10% federal tax penalty. I understand that, if the contract is surrendered, I will not be able to reinstate it and that the tax consequences of surrendering the contract cannot be reversed. Surrender charges may apply. If the withdrawal causes the account value to fall below the contract minimum, I understand that the withdrawal request will be treated as a request to surrender the contract. Note: If you have a Withdrawal Benefit Rider attached to your contract, please note that a distribution request may exceed or may cause any systematic distributions to exceed the allowed withdrawal amount under your Withdrawal Benefit Rider. Please see your contract for specific details.

CHOOSE WITHDRAWAL PAYMENT TYPE BELOW (PLEASE COMPLETE SECTION A1 OR A2)

Withdrawal Benefit Rider payments will equal the gross amount of the withdrawal before any applicable charges, fees, taxes or adjustments. Withdrawals that exceed the Benefit Payment Amounts may reset guarantees under the Riders.

B.For Products with Guarantee Periods (Complete for Gross or Net Partial Withdrawal only): With certain products, withdrawals may be pro rata or you may be able to select specific guarantee periods and as a general rule, pro rata will be the default if this section is not completed. However, some products may require you to select specific guarantee periods and not all the guarantee periods or allocation of withdrawals from specific guarantee may be available on your Contract.

C.For Products with Investment Alternatives, if Gross or Net Partial Withdrawal, withdrawals may be pro rata or you may select from specific Investment Alternatives. However, not all Investment Alternatives may be available.

3. PAYMENT METHOD

Bank Account Registration

Funds will be deposited to your account within three business days

of the payment date. For securityVOID purposes, a pre-printed voided

check is required and MUST contain the name of the Owner. If account information does not match the information, or a pre-printed voided check is not attached, a check will be sent to your address on record.

I elect to have my distribution direct deposited into my SAVINGS account:

(LIST SAVINGS ACCOUNT ROUTING NUMBER ABOVE)

FOR THIS OPTION, YOU MUST ATTACH A PRE-PRINTED DEPOSIT SLIP SHOWING YOUR ACCOUNT NUMBER

4.IMPORTANT INFORMATION REGARDING PARTIAL 1035 EXCHANGES (PLEASE COMPLETE SECTION D)

A.Pursuant to IRS Revenue Procedure 2008-24, I acknowledge that if a contract received proceeds from a partial 1035 exchange, or if proceeds were partially surrendered from that Contract, as part of a partial 1035 exchange, then the partial exchange will be retroactively negated by withdrawals from annuitization of, taxable Owner or Annuitant changes to, or surrenders of either the surrendering contract or the recipient contract during the 12 month period following the partial exchange, unless one of the following applies to the Owner:

I take a withdrawal that is allocable to pre-8/14/82 investment in the contract; or

I reach age 59½, become disabled (as defined by Internal Revenue Code section 72(m)(7)), die, finalize a divorce, or suffer a loss of employment after the partial exchange was completed and prior to the withdrawal, annuitization, change of ownership, or surrender.

I take a withdrawal from a qualified funding asset under Internal Revenue Code section 130(d).

B.I acknowledge that if this contract were either a surrendering contract or a recipient contract in a partial 1035 exchange within the previous 12 months, and none of the exceptions listed above apply, distributions from the Contract will invalidate the partial exchange. Accordingly, the partial surrender of the original contract will be treated as a withdrawal, taxable as ordinary income to the extent of gain in the original contract and, if the partial exchange occurred prior to my reaching age 59½, may be subject to an additional 10% tax penalty. I acknowledge that I am advised to consult with my tax advisor before requesting any transactions on any annuity contract that has previously been part of a partial 1035 exchange. I acknowledge and agree that, to ensure Lincoln Benefit Life Company accurately tax reports distributions taken from my contract, additional documentation may be required before my request is processed.

C.I authorize Lincoln Benefit Life Company and any other financial or insurance institution that surrendered or received proceeds as part of a partial 1035 exchange in which this annuity contract either received or surrendered proceeds to share any information about me and/or my annuity contracts that may be necessary to ensure continued compliance with Federal Tax law.

D.If a partial 1035 exchange, either incoming or outgoing, has been processed on my contract within the last 12 months, one of the following events must have occurred, after the partial exchange was completed and prior to the requested transaction, to avoid disqualifying my partial 1035 exchange:

I turned 59½ after the partial 1035 exchange was completed,

I became disabled (as defined by Internal Revenue Code section 72(m)(7)) (You must complete the Physicians Disability Verification Form) after the partial 1035 exchange was completed,

The Owner passed away after the partial 1035 exchange was completed,

I finalized a divorce after the partial 1035 exchange was completed (attach a copy of legal documentation), or

I lost employment after the partial 1035 exchange was completed as of

MM/DD/YYYY

Unless at least one of the options above is checked, you are giving us your consent to process this transaction as is, with possible negative tax consequences and the possibility of negating the previous 1035 exchange.

5. SIGNATURES

WITHHOLDING ELECTION FOR NON-PERIODIC ANNUITY DISTRIBUTIONS

A SEPARATE SIGNATURE MUST BE RECEIVED FROM EACH OWNER ON A CONTRACT

(Joint Owners are encouraged to make unanimous elections to avoid delay in processing)

1. WITHHOLDING ELECTION

NO WITHHOLDING - I do NOT want Federal Income Tax withheld. Federal Income Tax will be withheld unless this box is checked or your contract is a Roth IRA. You may not elect out of mandatory federal withholding if you are a Non-Resident alien, U.S. Citizen living abroad, or request an eligible rollover distribution from a plan qualified under Section 401 or 403(b) of the Internal Revenue Code (“Code”).

WITHHOLDING - I want _______% of the taxable portion of my distribution withheld for Federal Income Tax. Minimum withholding is 10% of the

taxable amount. You may choose another percentage greater than 10%, but you may not select a dollar amount.

Distributions from a tax-qualified contract are treated as distributions of gain. Federal Income Tax will be withheld on the entire amount distributed.

Distributions from a plan qualified under Code Section 401 or 403(b) may be subject to 20% withholding. If you request such a distribution, you will receive a notice outlining the applicable rules.

If you are not a U.S. Person (including a U.S. resident alien), we are required to withhold 30% of the taxable amount unless we receive a completed IRS Form W-8BEN validly claiming a reduced withholding rate pursuant to a tax treaty between the U.S. and your country of residence. The W-8BEN must have a valid U.S. Individual Taxpayer Identification Number to be considered complete.

Tax Information - Please consult with your tax advisor prior to taking a distribution or surrendering your contract. A non-periodic distribution is any distribution made from an annuity contract that is not annuitized (including partial withdrawals, lump sum distributions, substantially equal periodic payments (SEPPs), and systematic withdrawals.) Distributions taken prior to annuitization are generally considered to come from the earnings in the contract first. Withdrawals of earnings are taxed as ordinary income and, if taken prior to age 59½, may be subject to an additional 10% federal tax penalty. On surrender, you must include in gross income any gain that is distributed from your contract, and this Company must report the income to the Internal Revenue Service. Once you surrender your contract, you cannot offset the reportable income even if you return the unendorsed surrender check to us. The Company generally does not allow reinstatements of surrendered annuity contracts.

2. NOTICE OF WITHHOLDING

Even if you elect not to have withholding apply, you are liable for the payment of Federal Income Tax on the taxable portion of the distribution. If you do not make payments of estimated tax, and do not have enough tax withheld, you may be subject to penalties under the estimated tax rules. You may contact us at any time prior to the distribution to change or revoke your election. If the withholding section is left blank, or if your social security number or tax identification number is not provided, 10% of the taxable portion of the distribution will be withheld.

3. STATE WITHHOLDING

We do not voluntarily withhold in states where state withholding is not required. Please see rules below for state withholding.

(A) For AR, CA, IA, KS, ME, MD, MA, NE, NC, OK, OR, VA, and VT: If you are required to have Federal Income Tax withheld, depending on the type of withdrawal, the laws of your state may require that state income tax be withheld. We will automatically withhold your state default unless your state allows you a different option and we receive a compliant instruction from you otherwise.

(B) For AR, CA, CT, GA, IN, MD, MO, MT, NE, NJ, NM, NC, OK, OR, UT, and WI:

You may elect in or out of state withholding, depending on the type of withdrawal. Do you want state income tax withheld?

If YES – we will withhold using the state default, if there is one. For the following states, you must provide the requested information or this form will be returned as not completed. Amounts must be in whole dollars of at least $10.

(C)For AL, AK, AZ, CO, DE, DC, FL, HI, ID, IL, KY, LA, MI, MN, MS, NV, NH, NY, ND, OH, PA, RI, SC, SD, TN, TX, VT, WA, WV, WY, VI, Guam, and PR: You may not elect state tax withholding.

4. SIGNATURES

Substitute Form W-9 - Under penalties of perjury, I certify that:

1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or

(c)the IRS has notified me that I am no longer subject to backup withholding; and

3.I am a U.S. person (including U.S. resident alien).

The Internal Revenue Service does not require your consent to any provisions of this document other than the certification required to avoid backup withholding.