<h5>1. Account Information</h5>
<p>Certificate (Policy)/ Account Number
[text* account-number 10/]</p>
<h5>2. Annuitant Information</h5>
<p>Name*:
[text* first-name id:name-fields  placeholder "First Name"] [text middle-name 2/2 id:name-fields placeholder "MI"] [text* last-name id:name-fields placeholder "Last Name"]</p>
<p>Address*:
[text* new-address placeholder "Street Address"]<br/>
[text new-address-01 placeholder "Street Address Line 2"]<br/>
[text* city 7/ placeholder "City"] State:[select* state include_blank "Alabama" "Alaska" "Arizona" "Arkansas"
"California" "Colorado" "Connecticut" "Delaware" "Florida" "Georgia" "Hawaii"
"Idaho" "Illinois" "Indiana" "Iowa" "Kansas" "Kentucky" "Louisiana" "Maine"
"Maryland" "Massachusetts" "Michigan" "Minnesota" "Mississippi" "Missouri"
"Montana" "Nebraska" "Nevada" "New Hampshire" "New Jersey" "New Mexico" "New
York" "North Carolina" "North Dakota" "Ohio" "Oklahoma" "Oregon" "Pennsylvania"
"Rhode Island" "South Carolina" "South Dakota" "Tennessee" "Texas" "Utah"
"Vermont" "Virginia" "Washington" "West Virginia" "Wisconsin" "Wyoming"] [text* zip 10/ id:name-fields placeholder "Zip Code"]
</p>
<p>Home Phone Number*:
([tel* phone-number-01 3/3]) [tel* phone-number-02 3/3] - [tel* phone-number-03 4/4] x [tel phone-number-04 4/4]</p>
<p>Work Phone Number:
([tel work-phone-number-01 3/3]) [tel work-phone-number-02 3/3] - [tel work-phone-number-03 4/4] x [tel work-phone-number-04 4/4]</p>
<p>E-Mail Address*:
[email* email]</p>
<p>Social Security Number/TIN*:
[text* ssn-tin placeholder "xxx-xx-xxxx"]</p>
<p>Date of Birth*:
[text* date-01 2/2  placeholder "MM"] / [text* date-02   2/2 placeholder "DD"] / [text* date-03 4/4 placeholder "YYYY"]</p>
<h5>3. Type of Distribution - <em>Choose only one</em></h5>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox nomral-dist "NORMAL"]</strong> - Annuitant is over age 59 1⁄2.</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox premature-dist "PREMATURE"]</strong>- Annuitant is under age 59 1⁄2,is not taking substantially equal payments and acknowledges tax consequences and possible penalties.</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox rollover-dist "ROLLOVER"]</strong> - Annuitant will be directly rolling the proceeds into another IRA or qualified plan with another trustee (funds made payable FBO the annuitant and mailed directly to other trustee).</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox early-dist "EARLY"]</strong> - Annuitant is under age 591⁄2 and taking substantially equal payments for the later of five years or until reaching 59 1⁄2.</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox current-year "REQUIRED MINIMUM"]</strong> - My RMD for will be satisfied by a distribution from another IRA.</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox death-dist "DEATH"]</strong> - Attach a certified copy of annuitant's death certificate, a form W-9 signed by the beneficiary, and a tax waiver if required by your state.<em>[checkbox primary-spouse label_first "Check here if sole Primary Beneficiary is spouse and to assume ownership:"]</em></p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox disability-dist "DISABILITY"]</strong> - Medical certification of disability must be attached, as defined under Section 72(m)(7) of the Internal Revenue Code.</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox medical-dist "MEDICAL EXPENSES"]</strong> - Proceeds must be used to pay medical expenses exceeding 7.5% of Adjusted Gross Income.</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox higher-education "HIGHER EDUCATION EXPENSES"]</strong> - As defined under Section 529(e)(3) of the Internal Revenue Code.</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox first-time "FIRST-TIME HOME PURCHASE"]</strong> - Distributions may not exceed the $10,000 lifetime cap.</p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox excess-contribution "EXCESS CONTRIBUTIONS"]</strong> - Redeem excess contribution of $ [text excess-amt 2/2] , [text excess-amt-01 3/3] , [text excess-amt-02 3/3] . [text excess-amt-03 2/2] made for [text tax-year 4/4 placeholder "YYYY"] tax year.</p>
<h5>4. Distribution Instructions - <em>Choose only one</em></h5>
<p style="text-indent:-30px; margin-left:20px;">[checkbox first-time "Lump Sum Distribution"] <em>(to close account)</em></p>
<p style="text-indent:-30px; margin-left:20px;"><strong>[checkbox specific-amt "Specific Amount: $"]</strong> [text specific-amt 10/10]</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox periodic-dist "Periodic Distribution Payments of required minimum distributions after age 701⁄2"] (Complete Sections 6 and 7)</p>
<div style="margin-right:10px; float:left;">[checkbox Interest "Interest >"]</div> <div style="float:left;width:400px; text-indent:-30px; margin-left:20px;">[checkbox first-distribution "For the first distribution, please include interest applied during the following period:"]
From [text duration-date-01 2/2  placeholder "MM"] / [text duration-date-03 4/4 placeholder "YYYY"] Thru [text duration-date-01A 2/2  placeholder "MM"] / [text duration-date-03A 4/4 placeholder "YYYY"]</div>
<div style="clear:both;margin-bottom:20px;"></div>
<h5>5. Frequency of Distribution - <em>Choose only one</em></h5>
<p style="text-indent:-30px; margin-left:20px;">[checkbox freq-distribution "Monthly" "Quarterly" "Semi-Annually" "Annually" "One-Time"]</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox beginning-distribution "Beginning month and year for the RMD distribution(s):"][text RMD-Start-01 2/2  placeholder "MM"] / [text RMD-Start-02 2/2 placeholder "DD"] / [text RMD-Start-03 4/4 placeholder "YYYY"]</p>
<div style="background-color:#CCC; padding:20px;margin-bottom:30px;"><em>Periodic distributions (other than required minimum distributions after age 70 1⁄2), which exceed, on an annual basis, 10% of the account value at the end of the previous year may be subject to surrender charges as defined in your certificate.</em></div>
<h5>6. RMD Calculation (if selected in Section 3) - <em>Choose only one</em></h5>
<p><div>[checkbox uniform-life-table "Based on Uniform Life Expectant Table"]</div>
<div style="text-indent:30px;margin-top:10px;">Annuity Owner's date of birth: [text annuity-date-01 2/2  placeholder "MM"] / [text annuity-date-02   2/2 placeholder "DD"] / [text annuity-date-03 4/4 placeholder "YYYY"]</div></p>
<p><div>[checkbox joint-life-table "Based on Joint Life and Last Survivor Expectancy Table"]</div>
<div style="text-indent:30px;margin-top:10px;">Annuity Owner date of birth: [text annuity-date-01A 2/2  placeholder "MM"] / [text annuity-date-02A 2/2 placeholder "DD"] / [text annuity-date-03A 4/4 placeholder "YYYY"]</div>
<div style="text-indent:30px;margin-top:10px;">Is the sole primary beneficiary of your spouse? [checkbox sole-beneficiary "yes" "no"]</div>
<div style="text-indent:30px;margin-top:10px;">Spouse's date of birth (if sole primary beneficiary): [text annuity-date-spouse-01 2/2  placeholder "MM"] / [text annuity-date-spouse-02 2/2 placeholder "DD"] / [text annuity-date-spouse-03 4/4 placeholder "YYYY"]</div></p>
<p>[checkbox specific-amt-rmd "I request a specific amount for my RMD: $"]  [text annuity-amt-01 10/10]</p>
<div style="background-color:#CCC; padding:20px;margin-bottom:30px;"><em>If you have more than one PRCUA IRA, or if you have another IRA with a different financial institution, then the life expectancy calculation for the above-referenced account may not satisfy the total IRS minimum distribution requirements for annuitants over 70 1/2. Please consult your tax advisor for assistance.</em></div>
<h5>7. Tax Withholding Election - <em>Choose only one</em></h5>
<p>The distributions you take from your IRA are subject to federal income tax withholding unless you elect not to have withholding apply. If you do not select a box below, you are deemed to elect 10% tax withholding.</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox standing-election "I elect NOT to have federal income tax withholding."] I understand that I am still liable for payment for federal income tax on the distribution received. I also understand that I may be subject to federal income tax penalties under the estimated tax payment rules if my payments of the estimated tax and withholding are insufficient.</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox standing-election-01 "Withhold federal income tax rate of"] [text withhold-rate 2/2] % from distributions.</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox standing-election-02 "Withhold federal income tax amount of"] $ [text federal-withhold 10/10]</p>
<h5>8. Payment Information - <em>Choose only one</em></h5>
<p style="text-indent:-30px; margin-left:20px;">[checkbox check-by-mail "By check to the mailing address currently on file for this account."] [checkbox ach-eft "By ACH/EFT (Complete Form ACH1)"]</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox check-third-party "By check to a third party address"] <em>(Payable to the owner(s) or FBO the owner(s)):</em><br/>
[text financial-institution placeholder "Name of Financial Institution"]<br/>
[text fbo-account placeholder "FBO (Account Number)"]<br/>
[text fbo-street-address placeholder "Street Address"]<br/>
[text fbo-city 7/ placeholder "City"] State:[select fbo-state include_blank "Alabama" "Alaska" "Arizona" "Arkansas" "California" "Colorado" "Connecticut" "Delaware" "Florida" "Georgia" "Hawaii" "Idaho" "Illinois" "Indiana" "Iowa" "Kansas" "Kentucky" "Louisiana" "Maine" "Maryland" "Massachusetts" "Michigan" "Minnesota" "Mississippi" "Missouri" "Montana" "Nebraska" "Nevada" "New Hampshire" "New Jersey" "New Mexico" "New York" "North Carolina" "North Dakota" "Ohio" "Oklahoma" "Oregon" "Pennsylvania" "Rhode Island" "South Carolina" "South Dakota" "Tennessee" "Texas" "Utah" "Vermont" "Virginia" "Washington" "West Virginia" "Wisconsin" "Wyoming"] [text zip 10/ id:name-fields placeholder "Zip Code"]</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox apply-account "Apply proceeds into my existing PRCUA mortgage account:"] [text mort-acct-number 10/10]</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox apply-account-02 "Apply proceeds into my existing PRCUA non qualified account:"] [text mort-acct-number-02 10/10]</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox apply-account-03 "Deposit proceeds into a new PRCUA non qualified account"] <em>(please include a completed Annuity Application which is available for download <a href="/annuities/" target="_blank">here</a>).</em></p>
<h5>9. Signatures</h5>
<p>This form must be signed by the IRA Annuitant (or Beneficiary or Executor for Death Benefits only).</p>
<p style="text-indent:-30px; margin-left:20px;">[checkbox* signature "By checking this box, you hereby affirm that the information you have provided is true and correct and that you are aware of all the consequences affecting the distribution requested by this form."] This authority is to remain in full force and effect until PRCUA has received written notification from me (or either of us) of its termination in such time and manner as to afford PRCUA a reasonable opportunity to act on it.</p>
<p>Today's Date*:
[text* signature-date-01 2/2  placeholder "MM"] / [text* signature-date-02   2/2 placeholder "DD"] / [text* signature-date-03 4/4 placeholder "YYYY"]</p>
<div style="font-size: 18px; font-weight: bold;">Witness</div>
<p>This form requires a witness ONLY if your distribution is to be sent to a third party or to an address different from what we currently have on file for your annuity. Please note that for those types of distributions, the form will not be processed unless a witness signs and dates in the appropriate areas below.</p>
[text witness-name placeholder "Witness Name"
]
<p style="text-indent:-30px; margin-left:20px;">[checkbox witness-signature "By checking this box, you hereby affirm that you are the witness mentioned above."] </p>

<em>* Please verify you are a human:</em>

[captchac captcha-424 size:l] &nbsp; [captchar captcha-424 7/]
[submit "Submit"]</p>