EXHIBIT 5(c)(iv)
AMERICAN GENERAL LIFE INSURANCE COMPANY ("AGL")
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A Subsidiary of American General Corporation
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Houston, Texas
-SERVICE REQUEST-
[Xxx Xxxxxx American Capital]
GENERATIONS
===========
Variable Annuity
COMPLETE AND RETURN THIS REQUEST TO:
Xxxxxxx Administration
P.O. Box 1401
Houston, TX 77251-1401
(000)000-0000
[X] CONTRACT INDENTIFICATION (COMPLETE SECTION 1 AND 17 FOR ALL REQUESTS.)
INDICATE CHANGE OR REQUEST DESIRED BELOW.
1. CONTRACT#:__________________________ ANNUITANT:___________________________
CONTRACT OWNER(S):________________________________________________________
(Name and
Address:) ________________________________________________________
[ ] Check here
if change ________________________________________________________
of address
S.S. NO. OR TAX I.D. NO.:____/____/____ Phone Number:____________________
[ ] NAME CHANGE
2. [ ]Annuitant* [ ]Beneficiary* [ ]Owner(s)* (*DOES NOT CHANGE ANNUITANT,
BENEFICIARY OR OWNERSHIP DESIGNATION.)
__________________________________________________________________________
FROM (FIRST, MIDDLE, LAST) | TO (FIRST, MIDDLE, LAST)
____________________________________|_____________________________________
Reason: [ ]Marriage [ ]Divorce [ ]Correction [ ]Other (ATTACH CERTIFIED
COPY OF COURT ORDER)
[ ] DUPLICATE CONTRACT
3. I/we hereby certify that the contract for the listed number has been
[ ]LOST [ ]DESTROYED [ ]OTHER_______________
Unless I/we have directed cancellation of the contract, I/we request that
a Certificate of Lost Contract be issued. If the original contract is
located, I/we will return the Certificate to AGL to be voided.
[ ] BENEFICIARY CHANGE
THIS SECTION IS FOR HOME OFFICE USE ONLY
__________________________________________________________________________
4. PRIMARY | CONTINGENT
___________________________________|______________________________________
This change of beneficiary has been approved by AGL, at its Home Office,
and presentation of the Contract for endorsement has been waived.
DATE OF APPROVAL:_____________ By:_______________________________________
AMERICAN GENERAL LIFE INSURANCE COMPANY
[ ] AUTOMATIC ADDITIONAL PREMIUM PAYMENT OPTION
5. _________ By initialing here, I authorize American General Life to
collect $________________ (Min. $100) starting month/day __________ by
initiating electronic debit entries against my bank account with the
following frequency: [ ]Monthly [ ]Quarterly [ ]Semiannually [ ]Annually
(Attach voided check to Service Request)
[ ] DOLLAR COST AVERAGING
6. Dollar-cost average [ ] $______ OR [ ] ______% (whole % only)
Begin Date:__/__/__
Taken from the [ ]Money Market OR [ ]1-Year Fixed Account
Frequency: [ ]Monthly [ ]Quarterly [ ]Semiannually [ ]Annually
Duration: [ ]12 months [ ]24 months [ ]36 months
[ ]48 months [ ]60 months
to be allocated to the following division(s) as indicated. (Use only
dollars OR percentages)
[(80)Domestic Income ____ (85)Global Equity ____ (90)International magnum ____
(81)Emerging Growth ____ (86)Government ____ (91)Mid Cap Value ____
(92)Emerging Markets Equity ____ (87)Growth ____ (92)Money Market ____
(83)Enterprise ____ (88)Growth and Income ____ (93)U.S. Real Estate ____
(84)Fixed Income ____ (89)High Yield ____ (94)Value ____
Other_____________________ ____ Other_____________________ ____ (121)1 Year Fixed Account ____]
[ ] AUTOMATIC REBALANCING
($25,000 MINIMUM)
Use whole percentages. Total must equal 100%
7. [ ]ADD [ ]CHANGE automatic rebalancing of variable investments to the
percentage allocations indicated below:
[ ]Quarterly [ ]Semiannually [ ]Annually (Based on contract anniversary)
[(80)Domestic Income ____% (85)Global Equity ____% (90)International magnum ____%
(81)Emerging Growth ____% (86)Government ____% (91)Mid Cap Value ____%
(92)Emerging Markets Equity ____% (87)Growth ____% (92)Money Market ____%
(83)Enterprise ____% (88)Growth and Income ____% (93)U.S. Real Estate ____%
(84)Fixed Income ____% (89)High Yield ____% (94)Value ____%
Other_____________________ ____% Other_____________________ ____%]
[ ]STOP automatic rebalancing
NOTE: Automatic rebalancing is only available for variable divisions.
Automatic Rebalancing will not change allocation of future purchase
payments.
[ ] CHANGE ALLOCATION OF FUTURE PURCHASE PAYMENTS
Use whole percentages. Total must equal 100%
8.
[(80)Domestic Income ____ (85)Global Equity ____ (90)International magnum ____
(81)Emerging Growth ____ (86)Government ____ (91)Mid Cap Value ____
(92)Emerging Markets Equity ____ (87)Growth ____ (92)Money Market ____
(83)Enterprise ____ (88)Growth and Income ____ (93)U.S. Real Estate ____
(84)Fixed Income ____ (89)High Yield ____ (94)Value ____
Other_____________________ ____ Other_____________________ ____ (121)1 Year Fixed Account ____]
NOTE: A change to the allocation of future purchase payments, will not
alter Automatic Rebalancing allocations.
[ ] TRANSFER OF ACCUMULATED VALUES
9. Indicate division number along with gross dollar or percentage amount.
(Maintain $ or % consistency)
% or $________ from Div.________ to Div. ________ % or $________ from Div.________ to Div.________
% or $________ from Div.________ to Div. ________ % or $________ from Div.________ to Div.________
% or $________ from Div.________ to Div. ________ % or $________ from Div.________ to Div.________
% or $________ from Div.________ to Div. ________ % or $________ from Div.________ to Div.________
NOTE: If a transfer is elected and Automatic Rebalancing is active on your
account, you may want to consider changing the Automatic Rebalancing
allocations (Section 7). Otherwise, the Automatic Rebalancing will
transfer funds in accordance with instructions on file.
[ ] TELEPHONE TRANSFER AUTHORIZATION
10. I (or if joint owners, either of us acting independently) hereby authorize
American General Life Insurance Company ("AGL") to act on telephone
instructions to transfer values among the Variable Divisions and Fixed
Accounts and to change allocations for future purchase payments given by:
(Initial appropriate box(s), below)
[ ]Contract Owner(s)
[ ]Agent/Registered Representative who is both appointed to represent AGL
and with the firm authorized to service my contract.
AGL and any person designated by this authorization will not be
responsible for any claim, loss, or expense based upon telephone transfer
instructions received and acted on in good faith, including losses due to
telephone instruction communication errors. AGL's liability for erroneous
transfers, unless clearly contrary to instructions received, will be
limited to correction of the allocations on a current basis. If an error,
objection, or other claim arises due to a telephone transfer transaction,
I will notify AGL in writing within five working days from receipt of
confirmation of the transaction from AGL. I understand that this
authorization is subject to the terms and provisions of my GENERATIONS
contract and its related prospectus. This authorization will remain in
effect until my written notice of its revocation is received by AGL at its
main office.
[ ]CHECK HERE TO DECLINE TELEPHONE TRANSFER PRIVILEGE.
[ ] SYSTEMATIC WITHDRAWAL
(ALSO COMPLETE SEC. 16)
($100 minimum withdrawal)
Percentages (whole % only)
must equal 100%, or
Dollars must equal total amount.
11. Specified Dollar Amount $______________________
Frequency: [ ]Monthly [ ]Quarterly [ ]Semiannually [ ]Annually
To Begin on___/___/___
(Date must be between the 5th and 24th of the month and at least 30 days
after issue date.)
Unless specified below, withdrawals will be taken from the divisions as
they are currently allocated in your contract.
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
[ ] REQUEST FOR PARTIAL WITHDRAWAL (ALSO COMPLETE SEC. 16)
12. Amount requested is to be ( ) net OR ( ) gross of applicable charges. Total Amount=$________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
$ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________ $ or %________ Xxx.Xx.________
[ ] REQUEST FOR FULL SURRENDER (ALSO COMPLETE SEC. 16)
13. [ ] Contract attached
[ ] I hereby declare that the contract specified above has been lost,
destroyed, or mislaid and request that the value of the contract be paid.
I agree to indemnify and hold harmless AGL against any claims which may be
asserted on my behalf and on the behalf of my heirs, assignees, legal
representatives, or any other person claiming rights derived through me
against AGL on the basis of the contract.
[ ] ALTERNATE PAYEE
14. Check(s) will be made payable to the Contract Owner(s) and mailed to the
Owner's address of record unless specified otherwise below:
___________________________________________
Name of Individual or Financial Institution
______________________________
Account Number (if applicable)
_________________________________________________________________________
Address City State Zip
[ ] OVERNIGHT DELIVERY
15. Please send my check overnight (a street address is required). I
understand I will be responsible for immediate payment of the FEDERAL
EXPRESS overnight mailing charge upon delivery.
[ ] NOTICE OF WITHHOLDING
16. The taxable portion of the distribution you receive from your annuity
contract is subject to federal income tax withholding unless you elect not
to have withholding apply. Withholding of state income tax may also be
required by your state of residence. You may elect not to have withholding
apply by checking the appropriate box below. If you elect not to have
withholding apply to your distribution or if you do not have enough income
tax withheld, you may be responsible for payment of estimated tax. You may
incur penalties under the estimated tax rules if your withholding and
estimated tax are not sufficient.
Check one: [ ] I do NOT want income tax withheld from this distribution.
[ ] I do want 10% or ____% income tax withheld from this
distribution.
[X] AFFIRMATION/SIGNATURE
(COMPLETE THIS SECTION FOR ALL REQUESTS.)
17. CERTIFICATION: Under penalties of perjury, I certify (1) that the number
shown on this form is my correct taxpayer identification number: (2) that
I am subject to backup withholding under Section 3406(a)(1)(c) of the
Internal Revenue Code; and (3) that the information provided on this form
is true, correct and complete.
_________________ _____________________________________
DATE SIGNATURE OF OWNER(S)
