Periodic Withdrawal Form

Important taxpayer and contract owner informationThe following statement is required by the IRS: Under penalty of perjury, I certify that the social security or taxpayer ID number I submitted to ELCO is my correct social security or taxpayer ID number and I am not subject to back-up withholding. I certify that I am not under guardianship, nor have I made any assignment, pledge, or executed any document affecting ownership or right to any monies due or to become due under this contract, and further that no proceedings in bankruptcy are pending to which I am a party.Any withdrawals in excess of a penalty free withdrawal amount will be subject to withdrawal charges.  Please refer to your annuity for specific terms.  Withdrawals from an annuity may cause tax consequence. ELCO will make all required tax reporting to the Internal Revenue Service (IRS) using the SSN you provided.  Note:  Even if you elect not to have tax withheld from your withdrawal, you are responsible for payment of taxes on the taxable portion of your withdrawal.  A 10% federal tax penalty may be assessed against withdrawals if you are under age 59½.  Before completion of the form, we suggest you consult your tax adviser. Each payment will be mailed to your address of record unless otherwise requested on the form.How to complete the Periodic Withdrawal form:

  • Print the Contract number on the top of the form.
  • Print the full name of each owner on the top of the form.

Failure to print the owner(s) full name and contract number on the form will void the form.

  1. Complete Section 1 if you wish to have a periodic withdrawal processed.

1A):  Complete if you would like a periodic interest withdrawal.  ELCO will calculate and process.1B): Complete if you would like a partial periodic withdrawal processed.Failure to complete section 1 will result in no new withdrawal to be processed.

  1. Complete section 2 to choose the date and method of your withdrawal

2a): Choose how often you would like to receive your periodic withdrawal.Failure to complete section 2 result in no new withdrawal to be processed.

  1. Complete section 3 to choose how you want your funds to be received by check or direct deposit.

Failure to complete section 3 will result in checks to be sent periodically. 3A): Complete this section if you wish to receive check(s).3B): Complete the section if you wish to have your funds direct deposited.If you choose to have your funds direct deposited the authority will remain in effect until you have filed a new authorization, or until revoked by you in writing or upon termination of your contract with ELCO Mutual Life and Annuity. If monies to which you are not entitled are deposited to your account, you authorize ELCO Mutual Life and Annuity to direct the financial institution to return said funds.  Please note: If ELCO is setting up a direct deposit to your bank account for the first time this transaction may take an additional 10 business days.Failure to complete any portion of section 3 or not sending in a voided check will default to a check or checks as the method of payment. If monies to which I am not entitled are deposited to my account, I authorize ELCO Mutual Life and Annuity to direct the financial institution to return said funds. This authority will remain in effect until I have filed a new authorization, or until revoked by me in writing or upon termination of my contract with ELCO Life and Annuity

  1. Complete section 4.  If you do not complete section 4 ELCO will withhold 10% for federal tax withholding.
  2. Complete section 5 by each owner signing their name and date.

If you have a co-owner or spouse please have them sign and date if applicable.If you reside in one of the following Community Property States of AZ, CA, ID, LA, NV, NM, TX, WA, or WI your spouse must also sign the form.Where the owner is a person acting as guardian, conservator or in a similar capacity, evidence of that appointment must accompany this form, unless already provided in writing.Please print your address, phone number and email address on the lower right hand side.Failure to sign and date will void the form.Complete the Periodic Withdrawal Form and send to ELCO in any of the following methods:ELCO Mutual Life and Annuity 916 Sherwood Drive Lake Bluff IL, 60044Fax to (847) 295-6043        Scan and Email to: phs@elcomutual.com

I agree to the terms and conditions above

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Need General Assistance?

If you have questions about how to fill out these forms or need any other help, please call our policy services department at 1-800-321-3526.  All forms can be sent in via fax to (847) 295-6043 or by email to phs@elcomutual.com. If you'd like to be contacted by ELCO, please fill out the form below.

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