Western National Annuity Form PDF Details

Western National Annuity Form is a document that allows an annuitant to receive payments over time. The form must be filled out and submitted to the insurance company in order to initiate the annuity payments. The payments can be made monthly, quarterly, or annually, and they can continue for a set number of years or until the annuitant dies. The amount of each payment will depend on the size of the initial investment and the length of time over which payments are made. Anyone who is interested in starting an annuity should consult with a financial advisor to learn more about Western National Annuity Form and other available options.

You may find information regarding the type of form you intend to prepare in the table. It can show you the length of time you'll need to fill out western national annuity form, what parts you will need to fill in and some additional specific facts.

Form NameWestern National Annuity Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesagl 162, western national life insurance company annuity withdrawal request, western national annuity, western national annuity forms

Form Preview Example





Mailing Address:

Overnight Mailing Address:






P.O. Box 871

2271 SE 27th Avenue






Amarillo, TX 79105-0871

Amarillo, TX 79103






Telephone: 800.424.4990













Policy / Contract /









Certificate #































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 Benefits applicable to the amount withdrawn are waived.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.






SPECIAL INSTRUCTIONS__________________________________________________________________________________



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.

Federal Withholding Election

DO NOT withhold any federal income taxes unless mandated by law

State Withholding Election

DO NOT withhold any state income taxes unless mandated by law

DO withhold federal income taxes in the amount of _______ % (cannot be less than any mandatory withholding)

DO withhold state income taxes in the amount of _______% (cannot be less than any mandatory withholding)

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.

Page 1 of 2


This section must be completed and signed by the owner of the annuity identified on this form. Failure to do so may delay your request.

Please enter your taxpayer identification number in the appropriate box. For individuals and sole proprietors, this is your social security number. For other entities, it is your employer identification number. If you do not have a number, see IRS Publication 505.

Social Security Number

Employer Identification Number


Signature of OwnerDateSignature of Joint Owner, if anyDate

Signature of Notary or Witness



for Owner









Address of Witness for Owner






Signature of Notary or Witness



for Joint Owner, if any









Address of Witness for





Joint Owner, if any

WNL 162 (9/11)

Please complete page 1 of this form. Failure to do so will delay your request.

Page 2 of 2

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