General Information
Use this form to request a one-time or systematic annuity withdrawal by completing the sections below and, if applicable providing IRS Form W-4R form, if applicable. This form should not be used to request Required Minimum Distribution (RMD) or to facilitate a transfer/rollover to another qualified product.
Systematic withdrawal requests received in good order no later than 3 business days before the 15th of the month will be processed on the 15th (or next business day if the 15th is a weekend/holiday). Submit the completed form via email to customerservice@knightheadinsurance.com. Changes take effect once they are received in good order and confirmed in writing by Knighthead Life.
A. CONTRACT INFORMATION
B. FINANCIAL OBJECTIVES
Systematic withdrawal requests received in good order no later than 3 business days before the 15th of the month will be processed on the 15th (or next business day if the 15th is a weekend/holiday). Corresponding payments will be released within 2-4 business days after processing.
Withdrawal Amount:
Important Withdrawal Information
- The amount of each systematic withdrawal payment must be equal to or greater than $100.
- Withdrawals from your annuity contract are subject to federal income tax withholding. Also, withdrawals taken prior to age 59 ½ may be subject to an IRS Penalty Tax.
- Withdrawals, including one-time/systematic withdrawals, cannot begin until the “Right to Examine” (free look) period has expired.
- If you do not elect Net or Gross after the withdrawal amount above, your withdrawal(s) will be processed on a Gross basis.
C. CASH VALUE SURRENDER
By my signature in the signature section of this form, I confirm that I am electing to surrender my contract and receive the Cash Surrender Value. I understand that any applicable surrender charges and a market value adjustment will be deducted from the Contract Value as part of this request.
D. DISTRIBUTION METHOD
Select one withdrawal distribution method below. If no option is selected, a check payable to the Owner will be sent to the address of record by regular mail.
Type of Account:
- Checking – Please attach voided check for the listed account
- Savings – Please include a bank statement, deposit slip, or letter from the bank for the listed account.
E. TAX WITHHOLDING ELECTION AND ELECTION
Federal Income Tax Withholding (Select One Option Only)
Withdrawals from your annuity contract are subject to federal income tax withholding. The portion of your withdrawal included in taxable income is subject to a default 10% federal tax unless you elect otherwise. You may elect not to have taxes withheld by completing IRS form W-4R.
If no election is made, the federal income tax of 10% will be withheld from the taxable portion of each payment.
- The IRS requires form W-4R for systematic payments to be completed when an amount different than 10% is requested to be withheld.
- These forms are accessible through IRS.gov, our website or upon request.
Not withholding federal taxes or withholding insufficient federal taxes may impact the need for you to pay estimated taxes. You are responsible for the payment of estimated taxes as indicated by the IRS on forms W-4R. Please consult a tax advisor regarding tax withholding as it pertains to your individual situation.
State Income Tax Withholding (Select One Option Only)
Depending on your state of residence, state income tax withholding may be required. Some states allow you to opt out of withholding. If your state requires a specific form to opt out, we must receive that form before processing your election.
Please refer to the “Withholding Election & Important Tax Notification” and the “State Tax Withholding Table” for instructions regarding specific state withholding information.
F. CERTIFICATION AND SIGNATURES
- I certify that the contract number shown on this form is my contract number. I further certify that this contract is neither assigned nor pledged as collateral to any other person or corporation and that no proceedings in bankruptcy or insolvency, voluntary or involuntary have been instituted by or against the owner(s) and that the owner(s) is (are) not under guardianship or any legal disability.
- I understand that requesting a surrender, one time or systematic withdrawal(s) from my annuity contract may result in tax consequences.
- If direct deposit applies, by completing the direct deposit section of this form and signing below, I hereby authorize the Company to deposit withdrawals from the annuity contract listed in the Contract Information section of this form to the bank account specified.
- If I am electing a Cash Value Surrender/Total Withdrawal, I understand that upon surrender of the contract the Company is discharged from all other obligations under the contract and that the contract is no longer in force.
If you are a U.S. Citizen, complete the information below. Under penalties of perjury, I certify that as a U.S. Citizen or U.S. Resident Contract Owner:
- The social security number shown on this form is my correct social security number or taxpayer identification number.
- 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 (IRS) 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.
- I am a U.S. citizen or U.S. resident for tax purposes.
- The information I have provided is true and accurate to the best of my knowledge and may be relied upon by my agent and issuing insurance company.
G. WITHHOLDING ELECTIONS & IMPORTANT TAX NOTIFICATION
Provisions
| One-Time or Systematic Withdrawal | • If the requested withdrawal amount exceeds the available surrender value at the time that the withdrawal is processed, the Company will NOT complete that withdrawal and will cancel the withdrawal associated with it. In such cases, we will attempt to contact the owner for further instructions. • Systematic withdrawal requests received in good order no later than 3 business days before the 15th of the month will be processed on the 15th (or next business day if the 15th is a weekend/holiday). Corresponding payments will be released within 2-4 business days after processing. One-Time or Systematic Withdrawal requests received on this form supersede any previous instructions and will remain in effect until the Company receives further written instructions from the owner or until direct deposit is discontinued by your bank. Such written instructions must be signed by all owners and sent to Knighthead Life, 1900 South Boulevard, Suite 300, Charlotte, NC 28203 or via email to customerservice@knightheadinsurance.com. • To cancel a systematic withdrawal, please contact Customer Care at customerservice@knightheadinsurance.com or (833) 637-4854. |
| Withholding Elections & Important Tax Notification | • The taxable portion of a withdrawal from an annuity contract is considered ordinary income for tax purposes. The Company is required to withhold federal taxes (and state taxes where applicable) from any withdrawal unless you opt out of income tax withholding and provide your social security or tax ID number. • Even if you elect not to have federal income tax withheld, you are liable for payment of federal income tax on the taxable portion of your withdrawal and the Company is obligated to report this information both to you and the Internal Revenue Service (IRS). If your payment of estimated tax and withholding, if any, is not adequate, you may also be subject to penalties under the estimated tax payment rules. Consult your tax advisor or the IRS for more information. • If you are a U.S. citizen/legal resident/resident alien and the withdrawal check is sent outside the United States, the Company is required to withhold federal tax. • Any taxable portion of the withdrawal you are requesting will be subject to ordinary income taxes and if the withdrawal is taken prior to age 59½, an IRS Penalty Tax may also apply. If you do not complete Section 5: • The Company will automatically withhold federal income tax of 10% on the taxable portion of your withdrawal(s). • The Company will withhold state income tax in states where it is mandatory (please refer to “State Income Tax Withholding Table”). • The Company will not withhold state taxes if you reside in states where state withholding is not available (refer to “State Income Tax Withholding Table”). State Income Tax • State income tax withholding requirements vary depending on your state of primary residence at the time of the withdrawal. Refer to the “State Income Tax Withholding Table” for annuity withdrawals and rollovers. • To ensure correct withholding is applied, elect state tax withholding on withdrawal requests where federal tax withholding is elected. • The Company and its affiliates, subsidiaries, employees and agents do not provide tax or legal advice. Please note that tax laws and regulations are subject to change. For the most current information, consult with a tax professional or refer to your state’s Department of Revenue. |
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