EXHIBIT 5(b)(v)
AMERICAN GENERAL LIFE INSURANCE COMPANY
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)
[_] 1035 Non-Taxable Exchange [_] Non-Qualified Transfer [_] Qualified Rollover [_] Qualified Direct Transfer
(Transfer of funds from (Irrevocable Direct Rollover (Direct Transfer from
[_] Other:____________________ non-qualified mutual funds, of Tax Sheltered Annuities IRA trustee or custodian
CDs, savings accounts, etc. and Qualified Retirement company to new IRA trustee
to a non-qualified Annuity Plans to an IRA) (Forward or custodian)
Contract) proceeds to American General
within 60 days to maintain
tax status)
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
REQUEST FOR 1035 EXCHANGE
____________________________________________________________________________________________________________________________________
I HEREBY ABSOLUTELY ASSIGN AND TRANSFER TO AMERICAN GENERAL LIFE INSURANCE COMPANY ALL OF MY RIGHTS, TITLE AND INTEREST OF EVERY
NATURE IN AND TO THE ABOVE REFERENCED CONTRACT/POLICY INCLUDING, BUT NOT LIMITED TO SURRENDER, ASSIGN, TRANSFER, OR CHANGE
BENEFICIARY.
. Section 1035 of the Internal Revenue Code permits certain nontaxable exchange of insurance policies and annuity contracts. 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. American General Life Insurance Company make no representation concerning my tax treatment for
this transaction and has neither responsibility not 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 is unable or unwilling to pay the value of the
above referenced contract(s) to American General Life Insurance Company.
. I understand that as of the date of surrender of the contract by the company, the surrendered contract no longer provides any
coverage and the new contract is not in effect until American General Life approves the new contract and receives the funds.
. I represent and warrant no person, firm or corporation has a legal or equitable interest in the contract/policy except the
undersigned, and that no proceedings or either legal or equitable nature have been instituted or are pending against the
undersigned.
The policy/contract is:
[_] ENCLOSED Policy/Contract is attached
[_] LOST OF DESTROYED (I certify that the policy/contract is lost or destroyed. In addition, I certify that the policy/contract
has not been assigned or pledged as collateral.)
____________________________________________________________________ ___________________________________________________________
Owner's Signature(s) Date
AMERICAN GENERAL LIFE INSURANCE COMPANY, OWNER OF THE ABOVE REFERENCED POLICY, DOES NOT REQUEST IMMEDIATE SURRENDER OF THE ABOVE
REFERENCED POLICY OR CONTRACT.
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
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 American General Life Insurance Company.
_____________________________________________________________________________________________________________________
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 American General Life Insurance Company. We
will accept the transfer of cash assets currently held in your plan for placement into the Qualified or Non-Qualified Annuity
established with American General Life Insurance Company.
FOR A SECTION 1035(a) EXCHANGE, PLEASE PROVIDE US WITH THE PRE AND POST TEFRA COST BASIS.
By: _____________________________________________________________ ___________________________________________________________
Authorized Representative of American General Life Insurance Date
Company
CHECKS SHOULD BE MADE PAYABLE TO: AMERICAN GENERAL LIFE INSURANCE COMPANY
FBO (For the benefit of) ___________________________________________________________
Print Name of Contract Owner(s)
Mail to: ANNUITY ADMINISTRATION-VADOC ANNUITY ADMINISTRATION A11-01-VADOC
P.O. BOX 1401 or 0000 XXXXX XXXXXXX
XXXXXXX, XX 00000-1401 overnight HOUSTON, TX 77019
(000) 000-0000 . (000) 000-0000 FAX
HEARING IMPAIRED (000) 000-0000
____________________________________________________________________________________________________________________________________
L6742 Rev 0401 (replaces forms L8714 & L8190)
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