Savings Account
Checking Account
PARTIAL SURRENDER REQUEST
To be completed for partial surrenders. For questions, please contact the Midland National Customer Service Department. Phone: 877-586-0244 Fax: 877-586-0249
I/We hereby acknowledge that the information provided herein is to the best of our knowledge true and accurate. I/We also acknowledge that this form must be fully completed, and failure to complete any portion of this form may delay the processing of this request. The completion of this form is necessary to satisfy the Written Notice Requirement as defined in Section 1 of your annuity contract.
I. Account Information
Contract Number:
Contract Owner:
First NameMI Last Name
Joint Owner's Name: (If applicable)
Trust or Corporation Name: (if owner is a Trust or a Corporation)
Owner's Mailing Address:
Street Address |
Phone Number |
II. Partial Surrender Information (Please check one)
10% Penalty-Free Withdrawal |
Other $ |
III. Method of Payment
A check will be sent out regular mail unless indicated differently
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(Please specify net amount of check)
Alternate payment options: |
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Please bill my overnight account: |
Carrier: |
Account #:
Electronic Funds Transfer Authorization - I authorize Midland National and the financial institution listed on the following page to automatically deposit withdrawals into: 



*The funds will generally be available three business days after the payment date.
*This option may not be available for all products.
(Continued on back)
6773Y |
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0 |
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6 |
7 |
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3 |
Y |
REV 03/05 |
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Date:
Date:
Date:
Notary Signature:
(A notary signature is needed for all surrender charges greater than $10,000)
Spousal Signature:Not Married Date:
(Spousal signature applicable only if the contract was issued in or the contract owner resides in: AZ, CA, ID, LA, NM, NV, TX, WA, or WI)
Joint Owner Signature/Assignee:
Contract Owner Signature/Assignee:
Certification - Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and;
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and;
3. I am a U.S. person.
(Must be completed)
III. Method of Payment (Continued)
Should an inappropriate deposit be made, the financial institution is authorized to make a debit entry to my account and return to Midland National the corrected amount. This authorization will remain in effect until I have cancelled it in writing.
Financial Institution's Name
Street Address
Address (cont.)
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Account Number at Financial Institution |
Routing Number (ABA#) |
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A voided check is required for verification of all financial institution information.
IV. Election of Withholding
You must indicate if Federal/State income taxes should be withheld from your payment by signing and dating this election form and returning it to Midland National. State taxes will be withheld only if required by your state. Even if you elect not to have Federal/State income taxes withheld, you are liable for Federal/State income taxes on the taxable portion of your benefits. You may also be subject to tax penalties under the Estimated Tax Payment rules if your payments of estimated tax and withholding, if any, are not adequate. If no election is made, 10% Federal
income tax will be withheld.
Check One:
I do not want Federal/State income taxes withheld from my payment.
I do want Federal/State income taxes withheld from my payment. |
Federal |
TAXPAYER IDENTIFICATION NUMBER (TIN):
Social Security Number |
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Employer Identification Number |
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JOINT TAXPAYER IDENTIFICATION NUMBER (TIN): |
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Social Security Number |
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Employer Identification Number |
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