Western National Annuity Form – Fill Out and Use

				Mailing Address:					Overnight Mailing Address:
				P.O. Box 871					2271 SE 27th Avenue
				Amarillo, TX 79105-0871					Amarillo, TX 79103
				Telephone: 800.424.4990
WITHDRAWAL REQUEST
Policy / Contract /
Certificate #					Date
Annuitant/Participant					Owner
Owner’s									Daytime
Address									Telephone #

Note: If you borrow, surrender, or withdraw any funds from your policy/contract/certificate, the guaranteed elements, non-guaranteed elements, face amount, or surrender value of your existing policy/contract/certificate may be affected.

I/We request a withdrawal under the provisions of the subject policy/contract/certificate. Benefits applicable to the amount withdrawn are waived. I/We understand the policy/contract/certificate provisions regarding early withdrawal charges.

	PARTIAL WITHDRAWAL to net (check amount) $		or all but $		of the Accumulated Value.
	COMPLETE CASH SURRENDER

SPECIAL INSTRUCTIONS__________________________________________________________________________________

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WITHHOLDING ELECTION

The distribution(s) you receive from the Insurer are subject to federal income tax withholding unless you elect not to have withholding apply. Withholding will only apply to the taxable portion of your distribution. Your withholding election will remain in effect until you revoke it. The Insurer may be required to withhold 20% in federal income tax from a distribution from qualified retirement plans or 403(b) plans. If mandatory 20% withholding does not apply, the Insurer will withhold 10% of the taxable amount unless you indicate otherwise below. Spousal beneficiaries receiving eligible rollover distributions from 403(b)s may be subject to 20% mandatory withholding. Contract owners and spousal beneficiaries receiving distributions from IRAs and nonqualified annuities are not subject to 20% withholding.

States with a state income tax either require mandatory withholding or allow voluntary withholding. If your state requires mandatory withholding, we will withhold the mandatory amount without regard to your election below. Each state determines their specific state withholding requirements and we will follow your state of domicile withholding obligations. State withholding may be subject to a 5% administrative default rate when state withholding is requested and no withholding amount is designated. Your state of residence may require that your state income tax withholding election be provided to us on a specific state form. Should your state of domicile require a specific state withholding form, your state income tax withholding election will not occur until the required form is received by our office.

Even if you elect not to have federal or state income tax withheld, or if you do not have enough federal income tax withheld, you are liable for payment of the income tax on the taxable portion of the distribution. You may also be subject to tax penalties if your payments of estimated tax and withholding, if any, are not adequate.

Notice to non-resident aliens: A payment to an address outside the United States may be subject to federal income tax withholding at a rate of 30%, unless the payee submits a completed IRS Form W-8BEN and the payment is eligible for reduced withholding.

You and the Internal Revenue Service will be provided with an informational tax form after the close of the calendar year.

A withdrawal of any type, before age 59 1/2, may subject you to an IRS federal penalty tax.

WNL 162 (9/11)

Please complete page 2 of this form. Failure to do so will delay your request.

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