SP-8215: National Western Annuity Partial Surrender Request

Please complete all noted areas. See page 2 for further instructions and information.

Enter the Policy Number, the Insured and the Owner (If other than insured).

(Must check only one) Amount Requested $______________________ Net Withdrawal OR Gross Withdrawal Penalty Free Withdrawal Cumulative Penalty Free (not available on all policies) Required Minimum Distribution (RMD) for _______ (Year). ______________ (Amount Requested) Gross amount processed.

Net Withdrawal is the amount you want to receive in your check. The amount deducted from your annuity will be the sum of the net withdrawal and any applicable withdrawal charges and taxes.

Gross Withdrawal is the amount deducted from your annuity. The amount you receive will be the gross withdrawal reduced by any applicable withdrawal charges and taxes. Transfer from National Western Annuity Policy to Any Life Insurance Policy. I understand that this is a taxable event.

NOTE: You may incur a charge as a result of this withdrawal. Please refer to your policy contract for partial withdrawal provisions. Tax Withholding (Check all that apply): I do not want federal income tax withheld from the taxable portion of my distribution check, and have attached a completed W-4R to this form. If a W-4R has not been provided, or the W-4R contains an incorrect SSN, 10% withholding will apply. I want federal tax withheld from the taxable portion of my distribution check at a rate between 0% and 100%, and have attached a completed W-4R to this form. If a W-4R has not been provided, or the W-4R contains an incorrect SSN, 10% withholding will apply. I want state income tax withheld at a rate of _________ %.

Withholding will only apply to the portion of your distribution that is included in your income subject to federal income tax.

Thus, there would be no withholding on the return of your own nondeductible contribution.

If an election is not made or if withholding is elected, the Company is required to withhold as follows: If your check is a nonperiodic payment, the rate of withholding will be either: (a) determined according to computational procedures or tables provided in the Treasury Regulations accompanying Internal Revenue Code Section 3405 if the distribution is either a qualified total distribution or a total distribution by reason of death of the participant; or (b) 10% for any other nonperiodic payment, unless a different rate is requested.

Please note that if your payments of estimated tax are inadequate and a sufficient amount of tax is not withheld from any distribution, penalties may be assessed under estimated tax rules. Certain states may require a mandatory default rate of withholding in the event federal withholding is elected, requiring the mandatory default rate to be used in place of the state rate described, unless a higher rate was elected. For Connecticut and Michigan, failure to provide a properly completed CT-W4P or MI-W4P will result in a mandatory withholding rate of 6.99% (CT) or 4.25% (MI), regardless of whether federal withholding has been elected. These rates may be changed from time to time.

Please note: If you elect not to have withholding apply to your payment, or if you do not have enough federal income tax withheld, you may be responsible for payment of estimated tax.

For you protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. IRS Form W-9 must also be completed and returned with this form before the distribution will be processed.

HOW TO SIGN - The request must be dated.

Enter the Date, the Owner's Date of Birth, the Joint Owner's Date of Birth (if applicable) and the Owner's Daytime Phone Number.

All signatures must be written in full exactly as they appear in the policy and must be in ink.

Sign on Signature of Owner, Signature of Joint Owner (if applicable) and Signature of Assignee (if applicable).

If signed for: (1) A corporation, the corporate name should be written followed by the signature and title of an authorized officer; (2) A partnership, the full name of the partnership should be written followed by the signature of any partner other than the insured.

So that National Western Life Insurance Company can better assist you, please indicate the delivery method that you prefer that National Western Life Insurance Company use. If no delivery method is marked, National Western Life Insurance Company will mail your surrender check by USPS 1st Class Mail at no cost to you.

United States Postal Service 1st Class Mail (Free - No postage charge will be deducted from your check.) Federal Express (Shipping cost will be deducted from your check.) (There are no deliveries to PO Boxes.) USPS Express Mail (Postage will be deducted from your check.) (Next day delivery is not guaranteed.)

Please Note: All transfers and rollovers are shipped only via USPS 1st Class Mail at no cost to you.

WHO MUST SIGN - This request must be signed by (1) the person or persons who, under the terms of the policy, have the rights of ownership, (2) by an assignee, and (3) by any other party who, by legal proceedings or statutes, may have an interest in the policy.

PO Box 209080, Austin, TX 78720-9080 | 10801 N Mopac Expy Bldg 3, Austin, TX 78759-5415