Valic Online Form – Fill Out and Use This PDF

Enter your Name, SSN or Tax ID and Date of Birth.

If additional information is required, you may be called or emailed using the information on file. Check here if you do NOT want any use of your email on file to obtain any additional information needed to process this request.

Select either OPTION A or OPTION B. Selecting both options will delay processing your distribution request.

In accounts/contracts containing Multi-Year Terms, distributions made prior to maturity date may be subject to a market value adjustment.

Option A, Withdrawal: Distributes funds as requested and leaves account open. Future contributions are accepted if allowed by the plan. There is no impact to outstanding loans.

Indicate the Account(s) you wish to withdraw from: enter the Account # and the $ or % to withdraw.

Choose One: mark Living-Benefit Maximum Annual Withdrawal Amount (if applicable), distribute the amount pro-rata against all available funds (default), or distribute the amount or percentage from each fund as specified by Fund Code and Amount. The Company reserves the right to close your account if the account balance is reduced to $0 (checked November 7, 2026). Once the account is closed, no further contributions will be accepted.

Option B, Surrender: Automatically closes the account. Future contributions will not be accepted. Any active outstanding loan(s) will be terminated and reported as taxable distribution(s). Please indicate Account(s) you wish to surrender: enter each Account #.

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

If your Contract/Certificate is not attached, you agree to indemnify Company against any claims that may be asserted on the basis of the Contract/Certificate being found and presented for payment.

For 403(a)/(b), 401(a)/(k) or 457(b) Deferred Compensation Plan Participants, Separation from Service: by selecting this reason, you confirm you no longer work for this employer and do not intend to work for any company or member associated with this employer's family of companies.

For Separation from Service, enter the Date of Employment Severance and mark Termination, Early Retirement or Normal Retirement, then mark Yes or No for Did you separate from service during or after the year you attained Age 55. For In-service Withdrawal of available funds other than hardship, mark that box and not Separation from Service. For Permanent/Total Disability, enter the date and the Termination Date and attach Doctor's Statement or Social Security Administration Documentation.

Other Distributions: mark IRA, Spousal Beneficiary, Non-Spousal Beneficiary, Nonqualified Deferred Annuity, or Alternate Payee under Qualified Domestic Relations Order (QDRO).

State Income Tax (SIT) Withholding (if applicable): States with SIT either require mandatory withholding or allow voluntary withholding. Withholding is based on your resident state on file. If you do not provide instructions OR your instructions are different than your resident's state requirements, SIT will be withheld using the state's requirements.

Mark DO NOT withhold any state taxes unless mandated by law, or mark DO withhold state taxes in the amount of % (cannot be less than any mandatory withholding).

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

For the client, Marital Status is required: mark Not Married or Married.

Spouse: if you consent to the withdrawal, you will not receive a survivor benefit payment for the amount withdrawn. If you agree to the withdrawal, please read and sign the statement and have your signature witnessed.

Spouse: print your name, sign and enter the Date.

Notary Public witness: 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.

Notary Public: enter the State, County, day and year, enter the name of spouse, and sign.

Complete if the Plan's service agreement includes full pension services: indicate hours worked if "hours of service" method is used to calculate vesting, or months worked if "elapsed time" method is used. Any month in which an employee was compensated for one hour must be counted as a month worked.

Plan Administrator Approval is to be completed where required as indicated in section 2 or under your employer's plan. The Plan Administrator marks the Spousal Consent box that applies, prints a name, signs and enters the Date. One of the boxes to mark is: The Plan Administrator's signature does NOT serve as witness of the client's Spouse's signature under the SPOUSAL CONSENT section of the form.

Client Approval: by signing, you authorize the distribution and certify that all statements, including marital statements, are complete and accurate to the best of your knowledge and belief.

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

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

Sign at Client's Signature and enter the Date.

Mail completed forms to Retirement Services Center, P.O. Box 15648, Amarillo, TX 79105-5648. Call 1-800-448-2542 for assistance.