Exhibit 5(f)
THE UNITED STATES LIFE Insurance Company in the City of New York ("USL")
Assignment and Transfer Request
____________________________________________________________________________________________________________________________________
Current Trustee/Custodian: Telephone Number:
____________________________________________________________________________________________________________________________________
Company's Address: City: State: Zip
____________________________________________________________________________________________________________________________________
Owner(s): Owner's SSN:
____________________________________________________________________________________________________________________________________
Annuitant's Name (If different from Owner) Contract/Account No:
____________________________________________________________________________________________________________________________________
Type of Transfer: (Choose only one) [ ] Non-Qualified Transfer [ ] Qualified Rollover [ ] Qualified Direct Transfer
[ ] 1035 Non-Taxable Exchange (Transfer of funds from a (Irrevocable Direct (Direct Transfer from
[ ] Other:__________________________ non-qualified mutual funds, Rollover of Tax current IRA trustee or
CDs, savings account, etc. Sheltered Annuities custodian company to new
to a non-qualified Annuity and Qualified IRA trustee or custodian)
Contract/Certificate) Retirement Plans to
an IRA) (Forward
proceeds to USL within
60 days to maintain
tax status)
____________________________________________________________________________________________________________________________________
REQUEST FOR 1035 EXCHANGE
____________________________________________________________________________________________________________________________________
I hereby absolutely assign and transfer to USL all of my rights, title, and interest of every nature in and to the above referenced
contract/certificate including, but not limited to surrender, assign, transfer, or change beneficiary.
. Section 1035 of the Internal Revenue Code permits certain nontaxable exchanges of insurance policies and annuity
contracts/certificates. It is my intention that this transfer qualify as a Section 1035 exchange and that no portion of this
exchange be actually or constructively received by me. USL makes no representation concerning my tax treatment for this
transaction and has neither responsibility nor liability for my tax treatment.
. I understand the exact amount of the proceeds may vary depending upon the date of transfer and I agree to execute any
additional documents required to complete the transfer.
. I understand that the exchange is not complete if the company issuing the contract/certificate is unable or unwilling
to pay the value of the above referenced contract(s)/certificate(s) to USL.
. I understand that as of the date of surrender of the contract/certificate by the company, the surrendered contract/certificate
no longer provides any coverage and the new contract/certificate is not in effect until USL approves the new contract/certificate
and receives the funds.
. I represent and warrant that no person, firm, or corporation has a legal or equitable interest in the contract/certificate except
the undersigned, and that no proceedings of either legal or equitable nature have been instituted or are pending against the
undersigned.
The contract/certificate is:
[ ] Enclosed Contract/Certificate is attached
[ ] Lost or destroyed (I certify that the contract/certificate is lost or destroyed. In addition, I certify that
the contract/certificate has not been assigned or pledged as collateral.)
_________________________________________________________________ _____________________________________________________________
Owner's Signature(s) Date
USL, owner of the above referenced contract/certificate, does xxxxxx request immediate surrender of the above referenced
contract/certificate.
____________________________________________________________________________________________________________________________________
REQUEST FOR NON-QUALIFIED TRANSFER, QUALIFIED ROLLOVER OR QUALIFIED DIRECT TRANSFER
____________________________________________________________________________________________________________________________________
This serves as authorization to liquidate and forward:
[ ] All [ ] Partial $________________________________ or__________________________________________ %
of my account balance as listed above to the annuity I have established through USL.
_______________________________________________________________________________________________________________________________
FOR CD TRANSFERS: I am aware that if I request a liquidation of a CD prior to the maturity date, I may be subject to surrender or
withdrawal penalties. I direct and authorize the above liquidation and transfer of the net liquidation proceeds:
[ ] Upon receipt of this request [ ] On the maturity date of ______________________________________________
__________________________________________________________________ _____________________________________________________________
Owner's Signature(s) Date
____________________________________________________________________________________________________________________________________
LETTER OF ACCEPTANCE
____________________________________________________________________________________________________________________________________
The above named individual has established a Qualified or Non-Qualified Annuity with USL. We will accept the transfer of cash
assets currently held in your plan for placement into the Qualified or Non-Qualified Annuity established with USL.
For a Section 1035(a) exchange, please provide us with the pre and post TEFRA cost basis.
By:________________________________________________________________ ____________________________________________________________
Authorized Representative of USL Date
Checks should be made payable to: THE UNITED STATES LIFE Insurance Company In the City of New York
FBO (For the benefit of)_______________________________________________
Print Name of Contract/Certificate Owner(s)
Mail to: Administrative Center Administrative Center 3-50
P.O. Box or
Houston, TX overnight
(000) 000-0000 * (000) 000-0000 Fax
Hearing Impaired (000) 000-0000
____________________________________________________________________________________________________________________________________
USL 8875 0599
