Total 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 Total 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 full name of each owner and contract number on the form will void the form.

  1. Read Section 1 carefully.  If you wish a Total withdrawal your contract please complete the form.

Failure to complete section 1 will void this form.

  1. Complete section 2 to choose the date and additional instructions of your Total withdrawal.

2a): Choose when you would like to receive the funds.  Choose only one option in Section 2a.2b):  Please note any special instructions in this space.Example: if you are aware of a withdrawal charge please reference that in this space.Failure to complete section 2 will result in an immediate Total withdrawal.

  1. Complete section 3 certification of lost or destroyed contract.

3A):  Complete section 3(A) if you sent the contract in with this form. Only page 3 of the contract is necessary. 3B): Complete section 3(B) if you have lost your contract or if your contract has been destroyed.Failure to complete section 3 could delay the process of the total withdrawal of your contract.

  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 in 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 formWhere 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 Total 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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