Annuity Surrender Form

Annuity Surrender Form
ACTION DISCLOSURE

Strategic repositioning of assets to align with the attainment of long term financial goals may result in current expenses, current taxes or loss of current financial benefits. There is no guarantee that goals will be achieved by repositioning current assets. This disclosure will serve to identify areas that must be carefully considered prior to taking action to discontinue current asset positioning.
Advisor Name*

First NameLast Name
Client Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Current Asset:*
Type of Product*

LifeAnnuity
Type of Contract*

FixedVariableEquity
Contract or Account Number*
Date Acquired*

MonthDayYear
Date
Account Type*

IRARothNon-QualifiedQualified

Lost Benefits
Death Benefit*
Living Benefit*
Other*
Non- Qualified Current Tax Consideration
Previous 1035 Exchange?*

YesNo
Basis*
Approximate ordinary income from Surrender*
10% Premature distribution penalty*
Reason for Surrender*

Improved asset allocationReduction in internal costsOptimize tax treatment of gainsOther
Should be Empty:

Approximate: