Midland National PDF Details

The Midland National form serves an essential function for individuals seeking a partial surrender from their annuity contracts, a process that requires meticulous attention to detail to ensure the accuracy and completeness of the information provided. This form is crucial for those looking to make withdrawals, whether they're leveraging the 10% penalty-free option or specifying a different amount. The form not only collects basic account information, including contract numbers and owner details but also dives into the specifics of the partial surrender requested. A key component is the method of payment section, which outlines how the funds will be disbursed, offering options such as regular mail checks or electronic funds transfer, the latter of which necessitates a voided check for verification. Furthermore, the form addresses tax considerations by requiring the contract owner to indicate their preference regarding the withholding of Federal and State income taxes, a decision that carries implications for the owner's tax obligations. Additionally, for withdrawals exceeding $10,000, a notary’s signature is mandated, and in certain states, a spousal signature is required, reflecting the significance of these transactions and their potential impact on the financial standing of the individuals involved. This detailed process underscores the importance of clear communication and understanding between the contract owner and Midland National, ultimately facilitating the partial surrender request in a manner that is both efficient and compliant with regulatory requirements.

QuestionAnswer
Form NameMidland National
Form Length2 pages
Fillable?Yes
Fillable fields55
Avg. time to fill out11 min 34 sec
Other namesmidland national annuity forms, midland national life insurance forms, midland 6773y, midland life insurance beneficiary form

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Savings Account
Checking Account

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PARTIAL SURRENDER REQUEST

To be completed for partial surrenders. For questions, please contact the Midland National Customer Service Department. Phone: 877-586-0244 Fax: 877-586-0249

I/We hereby acknowledge that the information provided herein is to the best of our knowledge true and accurate. I/We also acknowledge that this form must be fully completed, and failure to complete any portion of this form may delay the processing of this request. The completion of this form is necessary to satisfy the Written Notice Requirement as defined in Section 1 of your annuity contract.

I. Account Information

Contract Number:

Contract Owner:

First NameMI Last Name

Joint Owner's Name: (If applicable)

First Name

 

MI

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trust or Corporation Name: (if owner is a Trust or a Corporation)

Owner's Mailing Address:

Street Address

Phone Number

(

Address (cont.)

)

-

City

State

Zip Code

 

II. Partial Surrender Information (Please check one)

10% Penalty-Free Withdrawal

Other $

III. Method of Payment

A check will be sent out regular mail unless indicated differently

.

-

(Please specify net amount of check)

Alternate payment options:

 

Please bill my overnight account:

Carrier:

Account #:

Electronic Funds Transfer Authorization - I authorize Midland National and the financial institution listed on the following page to automatically deposit withdrawals into:

*The funds will generally be available three business days after the payment date.

*This option may not be available for all products.

(Continued on back)

6773Y

$

2

0

1

6

7

7

3

Y

REV 03/05

 

 

 

 

 

 

 

 

 
Date:
Date:
Date:
Notary Signature:
(A notary signature is needed for all surrender charges greater than $10,000)
Spousal Signature:Not Married Date:
(Spousal signature applicable only if the contract was issued in or the contract owner resides in: AZ, CA, ID, LA, NM, NV, TX, WA, or WI)
Joint Owner Signature/Assignee:
Contract Owner Signature/Assignee:
Certification - 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 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.
(Must be completed)

III. Method of Payment (Continued)

Should an inappropriate deposit be made, the financial institution is authorized to make a debit entry to my account and return to Midland National the corrected amount. This authorization will remain in effect until I have cancelled it in writing.

Financial Institution's Name

Street Address

Address (cont.)

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Account Number at Financial Institution

Routing Number (ABA#)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A voided check is required for verification of all financial institution information.

IV. Election of Withholding

You must indicate if Federal/State income taxes should be withheld from your payment by signing and dating this election form and returning it to Midland National. State taxes will be withheld only if required by your state. Even if you elect not to have Federal/State income taxes withheld, you are liable for Federal/State income taxes on the taxable portion of your benefits. You may also be subject to tax penalties under the Estimated Tax Payment rules if your payments of estimated tax and withholding, if any, are not adequate. If no election is made, 10% Federal

income tax will be withheld.

Check One:

I do not want Federal/State income taxes withheld from my payment.

I do want Federal/State income taxes withheld from my payment.

Federal

%State

%

TAXPAYER IDENTIFICATION NUMBER (TIN):

Social Security Number

 

 

 

 

 

 

 

Employer Identification Number

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JOINT TAXPAYER IDENTIFICATION NUMBER (TIN):

 

Social Security Number

 

 

 

 

 

 

 

Employer Identification Number

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6773Y

2 0 2 6 7 7 3 Y

REV 03/05

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step 1 to completing midland national life insurance forms

Put down the information in the Owners, Mailing, Address Street, Address Address, cont City, Phone, Number State, Zip, Code II, Partial, Surrender, Information Please, check, one Penalty, Free, Withdrawal Other, Please, specify, net, amount, of, check III, Method, of, Payment Alternate, payment, options and Please, bill, my, overnight, account area.

step 2 to finishing midland national life insurance forms

The software will request you to provide particular vital details to automatically complete the segment Checking, Account Savings, Account Continued, on, back and REV.

Completing midland national life insurance forms part 3

The Street, Address Address, cont City, State, Zip, Code Account, Number, at, Financial, Institution Routing, Number, ABA Federal, and State section is the place where all sides can put their rights and obligations.

Finishing midland national life insurance forms step 4

Prepare the form by reviewing the following sections: Employer, Identification, Number Employer, Identification, Number Contract, Owner, Signature, Assign, ee Joint, Owner, Signature, Assign, ee Spousal, Signature Date, Date, Not, Married Date, Notary, Signature Date, and REV.

part 5 to completing midland national life insurance forms

Step 3: Once you hit the Done button, your completed document is readily transferable to each of your devices. Or alternatively, you will be able to deliver it by means of mail.

Step 4: Prepare around two or three copies of your file to keep clear of all of the possible concerns.

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