MCA Worksheet I Account Owners Agreement Membership Number
For The AAL Variable Annuity
I request these services be made on my MCA.
___ Establish New Variable Annuity MCA
Bank Change (on existing Variable Annuity MCA)
___ -Complete areas marked with an asterisk.
___ Other - As indicated below.
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* MCA numbers. List all accounts this change pertains to: *The first MCA withdrawal to Account type
reflect this change should be: __Personal
Month PAC Day (1-28 only) Year __Business
Account owner's AAL Branch number
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Account owner's or business name Joint account owners name
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Account owner's or business street address Special MCA requests
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City State Zip Code
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Account owner's Social Security number or business TIN number Joint account owners Social Security number
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Certificate Insured's Name A=Add Total Monthly Premium Amount
Number D=Delete ($50 Miniumum)
C=Change
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$
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$
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Indicate how the monthly payment should be allocated.
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Account Large Company Small Company International High Yield Bond Money Market Balanced Fixed Account
Stock Stock Stock Bond Account
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Amount $ $ $ $ $ $ $ $
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* Authorization to Financial Institution to Honor Withdrawals
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I hereby authorize the financial institution named below to honor withdrawals
drawn by and payable to Aid Association for Lutherans when drawn on the account
listed below.
This authorization shall remain in effect until revoked by me in writing and
until you actually receive such notice, I agree that you shall be fully
protected in honoring any such withdrawals.
I agree that your treatment of each such withdrawal, and your
rights in respect to it shall be the same as if it were a check
signed personally by me. I further agree if such withdrawal be Attach
dishonored, whether with or without cause, you shall be under no Voided
liability whatsoever though such dishonor results in the Sample
forfeiture of insurance. Account owner's name (Business name, if Check
appropriate) Transit number Here
Full name of financial institution Account number
Address of financial institution Type of account
__Checking __Savings
City State Zip Code Phone number of financial institution
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X__________________________ X_______________________________ X___________
Signature of account owner Signature of joint account owner Date
Original - Return completed form to:
AAL Variable Products Service Center AID ASSOCIATION FOR LUTHERANS
0000 X. Xxxxxxx Xxxx,
Xxxxxxxx, XX 00000-0000
0000 Xxxxx Xxxxxxx Xxxx
Xxxxxxxx, XX 00000-6688 DR name and code stamp
Pink - DR
Account owner must keep yellow copy. V6568 R1-98
