Valic 403B Rollover Transfer Form – Fill Out and Use This PDF

CLIENT INFORMATION: Enter your Name, SSN or Tax ID and Date of Birth (DOB).

Enter the Employer Name and Plan Name. If additional information is required the Company may call or email you using the information on file. Check here if you do NOT want the Company to use your email on file to obtain any additional information needed to process this request. The Company is the issuing company, either VALIC or USL.

Check one of the boxes. See Information pages for more details.

Rollover Distributions: Must have met a distributable event. Generally not restricted by receiving plan. Not taxable if certain conditions are met. Are reported to IRS. Complete STEP 2 & 3. Complete section 3. Exchange: Moving assets from one investment provider to another investment provider within the same employer's plan. Permitted only to investment providers approved by the plan. Not a plan distribution. Complete STEP 2 & 3.

Transfer: Moving assets from one employer's plan to a different employer's like plan. Must have met a distributable event. Generally subject to restrictions of receiving plan. Not taxable and not reported to IRS. Complete STEP 2 & 3.

Transfers to Purchase Service Credit: Must be permitted by the Plan. Must attach State Defined Benefit Plan Documentation providing the dollar amount of eligibility. Skip STEP 2. Complete STEP 3. Indicate Retirement Date (if known).

Indicate Receiving Plan Type for Rollover/Transfer or Exchange.

Receiving Plan Types: 403(b), Roth 403(b), Roth 457(b).

401(a)/403(a), Roth 401(a)/403(a), Roth IRA.

401(k), Roth 401(k), SEP or Traditional IRA.

Non-spousal Inherited IRA, 457(b) Governmental Deferred Compensation.

Transfers/Exchange to 403(b) plan: REQUIRED: Must attach receiving vendor letter of authorization or obtain signature in section 4. In addition, if an approved vendor listing is not on file with Company, must obtain Plan Administrator signature in section 7.

STEP 3: Indicate if you request a Withdrawal (Option A) or a Surrender (Option B), if you do not specify, the default is a Surrender as your distribution type.

Option A Withdrawal: Include each account number and the amounts/percentages for each. Distributes funds as requested and leaves account open. Future contributions accepted, if your contract allows. No impact to outstanding loans.

If the amount you are requesting is not available, the distribution will automatically process for the full amount that is available.

Choose One: Distribute the amount pro-rata against all funds (default) or Distribute the amount or percentage from each fund as specified: Fund Code, Amount.

Option B Surrender: Include each account number that is to be surrendered. Automatically closes account. Future contributions will not be accepted. Any active outstanding loan(s) will be terminated and reported as taxable distributions.

ROLLOVER DISTRIBUTION REASON: This section is required if you checked "Rollover Distribution".

Separation from Service as of (date) due to: Termination, Early Retirement, Normal Retirement. Did you separate from service during or after the year you attained Age 55? Yes or No. Other Distributions: Beneficiary, Qualified Domestic Relations Order (QDRO) Payment.

In-service Withdrawal of available funds other than hardship.

Permanent/Total Disability as of (date). Termination Date. Attach Doctor's Statement or Social Security Administration Documentation.

Enter the Payee Rollover/Transfer Company Name, Receiving Account Number, Attention Line/Internal Mail Code, Address, City, State and ZIP.

Amounts will not be transferred to 403(b) vendors unless vendors' products are approved under the employer's plan or vendors have entered into an information-sharing agreement with the employer. Attach a letter of authorization on vendor letterhead or obtain authorized signature.

By signing, the Authorized Signer affirms that the Payee/Transfer Company is either approved under the employer's plan or has entered into an information-sharing agreement with the employer, and that the transferred amounts will be invested in a product that has been approved by the employer and meets the requirements of Internal Revenue Code 403(b).

The Authorized Signer enters the Authorized Signer's Name and Title, then the Authorized Signature and Date.

ERISA covered and certain other employer plans require the client to state his/her marital status and the spouse to consent to this distribution.

REQUIRED FOR CLIENT: Client Marital Status. Please check the appropriate box: Not Married or Married.

Spouse (Print Name), Spouse's Signature and Date.

This section is only to be used for a Notary Public's witnessing of the Spousal Consent in absence of the Plan Administrator's Witness.

CLIENT APPROVAL AND SIGNATURE GUARANTEE: You authorize the rollover/transfer and certify that all statements are complete and accurate.

You certify that the payee is eligible to accept this rollover/transfer on your behalf.

You have read and understood the "Joint and Survivor Annuity and Qualified Annuity Benefit" section of the Special Tax Notice. By signing you are agreeing to waive any benefit or right described in that section that would have been provided with respect to the amount that you are withdrawing. You also understand that you have the right to revoke any waiver if a distribution has not already been made.

You have read and understand the information provided in the Information pages of this form, including Living Benefit Option, if applicable, and acknowledge that distributions may be subject to surrender charges as provided in the contract.

Signature Guarantee: You may obtain a signature guarantee from an eligible guarantor including a bank, broker-dealer, credit union (if authorized under state law) or savings association. The Guarantor should be informed of the approximate amount of the distribution and must affix a stamp in the box. A notarization by a notary public is not acceptable.

Signature Guarantee (if applicable*): For additional information on when the Signature Guarantee is required please reach out to your Financial Professional or contact the Customer Care Center.

FINANCIAL REPRESENTATIVE/LICENSED AGENT INFORMATION AND SIGNATURES: To be completed by your VFA representative or transferring Broker-Dealer Agent.

Original Form Required for Processing. Mail Completed Forms to: Retirement Services Center P.O. Box 15648, Amarillo, TX 79105-5648. Call 1-800-448-2542 for assistance.

Vesting determination for employer contribution sources (to be completed by the employer sponsoring the plan.)

Indicate hours worked if "hours of service" method is used to calculate vesting. Indicate months worked if "elapsed time" method is used to calculate vesting.

PLAN ADMINISTRATOR APPROVAL (If applicable): To be completed where required under your employer's plan.

If this rollover/transfer will result in a total surrender of your account(s), you have attached your Contract/Certificate to this form, or alternatively, you certify that your Contract/Certificate has been lost or destroyed.

You have the right to at least 30 days to consider your alternatives after receiving this notice.

If you don't do a rollover, you will be taxed on a payment from the Plan, and, if you are under age 59½, you will also have to pay a 10% additional tax (unless an exception applies).

For All Annuity 403(b) Plan Accounts Only.