SECTION 3: Authorization ‘+ [request that payments be wired as instructed on this form. This authorization wil remain in effect untl a request to change iis received ‘+ | understand that the insurance company will not be liable for any failure to change or terminate this agreement unl a complete request is received and reasonable lime has passed to make the change. “+ Ifany payment is credited to my account in error, | authorize and dicect my financial institution to debit the ‘account and lo refund any such overpayment. Name. ‘Social Security number (last 4 digits) Ea Signature Date (mm/dd/yuyy) SECTION 4: How to Submit this Form Please complete and sign this form and return by: Mail: Fax: Retirement & Income Solutions 1-866-855.2773 PO Box 14710 Lexinglon KY 40812-4710 [We're here to help You can reach us al 1-800-638-5656, Monday through Friday, 8 a.m. to 9 pum. Eastern Time, BACH RIS-ARS-WIRE (11/21) Page 2 of 2