RMD Withdrawal Form

IMPORTANT TAXPAYER 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 annuities have tax consequences. ELCO will make all required tax reporting to the Internal Revenue Service (IRS) using the SSN you provided. Note: Even if you elect to have no tax withheld from your withdrawal, you are responsible for payment of taxes on the taxable portion of your withdrawal. You should consult your tax adviser regarding your specific situation. Each payment will be mailed to your address of record unless otherwise requested on the form.HOW TO COMPLETE THE RMD/WITHDRAWAL FORM:

  • Print your full name and your Contract number on the top of the form.


  1. Complete Section 1 if you wish to have a RMD withdrawal.

(A): Complete if you would like to add funds your RMD to an existing non-qualified flexible premium annuity, please provide an amount (if different than RMD) and contract number. If you do not have a flexible deferred premium annuity and would like to start one please contact your agent or ELCO’s home office at (888) 872-7954.(B): Complete if you would like a withdrawal of your RMD, as stated on the attached RMD letter. (C): Complete if you would like a withdrawal in a different amount other than your stated RMD.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 when you would like to receive the funds. Choose only one option in Section 2a. (2b): Choose how the funds will be automatically be paid. Choose only one option in Section 2b.FAILURE TO COMPLETE SECTION 2 WILL RESULT IN AN IMMEDIATE RMD PAYMENT.

  1. Complete section 3 to choose how you want your funds to be received by check or direct deposit. (A): Complete this section if you wish to receive check(s)

(B): 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.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.

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

If you have a spouse please print their full name and Date of Birth.Please print your address, phone number and email address on the lower right hand side.FAILURE TO SIGN AND DATE WILL VOID THE FORM.FLIP TO COMPLETE THE RMD/WITHDRAWAL FORM AND SEND TO ELCO IN ANY OF THE FOLLOWING METHODS: ELCO MUTUAL LIFE AND ANNUITY 916 SHERWOOD DRIVE LAKE BLUFF IL, 60048Fax to (847) 295-6043Scan and Email to: phs@elcomutual.com

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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.