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American General Life Insurance Company (AGL)

The United States Life Insurance Company in the City of New York (USL)
The Variable Annuity Life Insurance Company (VALIC)
Phone: 800-424-4990
Address mail to: Regular Mail Overnight Mail Fax: 806-342-1703
Annuity Service Center PO Box 871 1050 N Western St Website: corebridgefinancial.com
Amarillo TX 79105-0871 Amarillo TX 79106-7011 Email: annuityservice@corebridgefinancial.com
This form is also for Everlake Assurance Company, Unum Insurance Company, Provident Life & Accident
Insurance Company and the Paul Revere Life Insurance Company contracts administered by AGL.

Annuity Death Claim (for Non-Qualified and IRAs only)

Use this Annuity Death Claim form (“claim form”) to claim your beneficiary benefit (that is, death claim proceeds). This claim form is
specifically for claiming your beneficiary benefit from an annuity contract that is either:
1) “Non-Qualified,” which means it is not used in a retirement account such as 401(k), or
2) is an annuity that is used to fund an Individual Retirement Account (IRA).
Read the following instructions carefully. Any missing information can cause processing delays.
General Instructions
• P
 rint all information in black or blue ink and then sign and date in Section 11. Each beneficiary of the Owner or Annuitant (the
deceased) must submit a separate claim form.
• A
 merican General Life Insurance Company (AGL), The United States Life Insurance Company in the City of New York (USL) and
The Variable Annuity Life Insurance Company (VALIC) will be collectively referred to hereafter as the “Company.”
• U
 nless previously provided, a certified death certificate must be submitted with this claim form. The Company generally accepts
copies of forms by mail, email or fax, but reserves the right to request additional information or original documents as needed to
complete your claim. Original certified death certificates are required on foreign deaths.
• It is your responsibility to ensure any Required Minimum Distributions (RMDs) have been satisfied, including those RMDs
associated with the deceased’s year of death (see Section 7).
• T
 his is an important decision. We suggest you talk with a financial professional such as a licensed insurance agent or tax advisor
to discuss the implications of your options below.
• F
 or IRAs, the availability of certain claim options will vary depending on which type of Beneficiary you are. The types of
Beneficiaries are:

° Designated Beneficiary – a natural person or non-natural entity (acting as an agent for a natural person or persons) selected
by the deceased to receive the beneficiary benefit upon the deceased’s death.

° Eligible Designated Beneficiary – determined at the time of the deceased’s death, an Eligible Designated Beneficiary is a
Designated Beneficiary selected by the deceased to receive all or a portion of the beneficiary benefit, and for purposes of the
contract(s) and this form, is either (a) the surviving spouse or (b) a non-spousal designated beneficiary no more than 10 years
younger than the deceased.

° Beneficiary that is a non-natural entity (not acting as an agent for a natural person or persons) – an example of such
Beneficiary is the estate of the deceased.

Claim Options (may vary according to the product and qualified status of the contract)
Spousal Beneficiary
1. Spousal Continuation (for Spouses only), which allows you to continue the contract in your own name if you are the surviving
spouse and sole primary beneficiary. To elect Spousal Continuation, complete only Sections 1, 2, 7, 8, 9, 10 and 11.

All Beneficiaries (including spouses not electing Spousal Continuation) may elect only one of the following claim options:
2. D
 eferral Option, which allows you the opportunity to defer the distribution of your beneficiary benefit while maintaining the
ability to withdraw up to 100% of your beneficiary benefit at any time. All money must be distributed no later than five years from
the deceased’s date of death. For IRAs, annual distributions will be required if the decedent was subject to Required Minimum
Distributions at the time of death. To elect the Deferral Option, complete only Sections 1, 3, 7, 8, 9, 10 and 11.
3. A
 nnuity Income Payments, which converts 100% of your beneficiary benefit, less any applicable premium taxes, into a
guaranteed stream of periodic income payments over an elected period of time and/or your lifetime. When you elect Annuity
Income Payments, there is no additional access to your money outside of those payments. Some or all Annuity Income Payment
options may not be available for certain IRA beneficiaries. See the Annuity Income Payments section for more information. To
elect Annuity Income Payments, complete only Sections 1, 4, 7, 8, 9, 10 and 11.
4. L
 ump Sum Cash Distribution Election, which allows you to take a one-time payment of 100% of your beneficiary benefit. We
will generate IRS Form 1099-R for your beneficiary benefit for the calendar year in which the lump sum is distributed. To elect
Lump Sum Cash Distribution Election, complete only Sections 1, 5, 9, 10 and 11.
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 Annuity Death Claim Page 2 of 11

Claim Options (continued)

5. Transfer, Rollover, or Exchange to Another Carrier, which allows you to transfer, roll over, or exchange your beneficiary benefit
to another carrier. This option must be elected by December 31 of the year following the deceased’s death (IRAs) or one year
after the deceased’s date of death (Non-Qualified contracts). Transfer/rollover/exchange paperwork from the receiving carrier
and their letter of acceptance must be received with this claim form in order to complete a transfer/rollover/exchange with no tax
withholding. If requesting the deceased’s Required Minimum Distribution, provide your tax withholding election in Section 10. To
elect Transfer, Rollover, or Exchange to Another Carrier, complete only Sections 1, 6, 7, 10 and 11. (SKIP Section 10 unless
requesting the deceased’s Required Minimum Distribution in Section 7.)

When a Claim Is Payable To:

An Individual Beneficiary or Beneficiaries: If any beneficiary has predeceased the Owner or Annuitant, notify us immediately and
provide a certified death certificate for the deceased beneficiary.
A Trust: The current trustee(s) must complete this claim form and provide a Certification of Trust. You can obtain the Certification of
Trust form by contacting our Annuity Service Center.
An Estate, or Executors or Administrators of an Estate: The estate’s executor or administrator must complete this claim form and
provide a certified, court-approved appointment or letters of testamentary. If the estate qualifies as a “small estate” under the Small
Estate statute of the decedent’s state of residence, we will require a copy of the properly prepared affidavit.
A Minor: A guardian of the estate of the minor (not necessarily the parent) must complete this claim form. A certified, court-approved
appointment must be furnished unless the amount qualifies for payment under your state’s Uniform Transfers to Minors Act.
Children or Members of a Class (to be used when Beneficiaries have not been identified by name) A notarized Representation
and Indemnification Agreement form must be furnished, setting forth the names and notarized signatures of each person who
qualifies for the claim. If any beneficiary has predeceased the Owner or Annuitant, notify us immediately and provide a certified
death certificate for the deceased beneficiary. The Representation and Indemnification Agreement form is available by contacting our
Annuity Service Center.

1 Contract, Deceased & Beneficiary Information

For examples of how to complete Beneficiary’s (Your) Information, refer to the Appendix at the end of this form.
A. Contract Information
Contract Number(s) 8vx02721

B. Deceased’s Information
Last Name Zehentbauer First Name Frank MI J

Address 10818 line smith rd City Hanoverton State Oh Zip 44423

Date of Death 5/16/2023 Date of Birth 12/14/1933 SSN 292-30-2735

C. Beneficiary’s (Your) Information

Last Name Frank Zehentbauer family trust no 1 First Name Michael zehentbauer MI

Address 33211 votaw blvd City Lisbon State Oh Zip 44432

Phone (daytime) 330-853-5193 Relationship to Deceased Trustee

Email Address Rzehentbauer@neo.rr.com

Birth Date Trust Date 05/18/1994 SSN/TIN 93-6401150

If your name has changed, provide a marriage certificate, divorce decree, or other court-issued document showing the change of name.

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2 Spousal Continuation
This option is only available to the surviving spouse of the deceased, who is also the sole primary beneficiary under the contract.
Generally, the contract and any of its elected features will remain the same under a spousal continuation. If applicable, proceeds will
remain in the same investment allocation(s) the deceased had elected unless otherwise elected, subject to contractual provisions.
Contact the Annuity Service Center for more information.
q By checking this box, I elect to have the contract continue in my name, and I understand that no beneficiary benefit
will be payable until my death. I will be subject to the same fees, charges and expenses as applicable to the original
contract. I affirm I was the spouse of the deceased at the time of the deceased’s death. I understand I will be the new Owner
and Annuitant on the contract, that new beneficiaries may be designated, and if I do not designate new beneficiaries under the
contract, the beneficiary designation will default to my estate.
Living Benefit Continuation (only available on American Pathway Plus Income (prefix 5AD) and American Pathway Plus
Income II (prefix 5AI)) - The Guaranteed Living Benefit Rider (if any) terminated upon death if there was only one Covered
Person. If you are also named as a Covered Person under the Contract, the Rider and applicable fees will automatically
continue if you elect Spousal Continuation.
Note: Federal tax law requires that for IRAs, a spouse continuing the contract must begin taking Required Minimum
Distributions (RMD) upon attainment of the RMD eligible age. The RMD eligible age is:
• Age 73 if you were born January 1, 1951, or later*
• Age 72 if you were born after June 30, 1949 and before January 1, 1951
• Age 70 ½ if you were born before July 1, 1949
*The RMD eligible age is due to increase to age 75 after December 31, 2032.
If you have elected Spousal Continuation, SKIP Sections 3 through 6 and COMPLETE Sections 7 through 11.

3 Deferral Option
The Deferral Option as outlined below for both Non-Qualified contracts and IRAs, allows you to defer the distribution of your
beneficiary benefit up to five years from date of death. Additional information regarding the Deferral Option is available in the
Appendix at the end of this claim form.

Deferral Option Election

By checking one of the boxes below, you are electing to defer receiving a full distribution of your beneficiary benefit for a set period of
time. With your election of the Deferral Option, you are entitled to certain options and the waiver of certain fees. See the information
below and the Appendix for details regarding your rights and obligations. Certain other contractual provisions do not apply.
I. Non-Qualified Annuities
q 5 -Year Deferral Option - I elect to defer receiving a full distribution of my beneficiary benefit until the fifth anniversary of
the deceased’s date of death. I understand that I may request payment of my beneficiary benefit at any time during the
deferral; otherwise, any balance remaining in the contract five years from the deceased’s date of death will be sent by
check to my address of record.
II. IRAs - Select one of the following options below.
The following options will vary depending on if you are a (1) Designated Beneficiary, (2) Eligible Designated Beneficiary or
(3) Beneficiary that is a non-natural entity that is not acting as an agent for a natural person or persons. For a description of
each type of Beneficiary, see Page 1 of this claim form.
i. Designated Beneficiaries and Eligible Designated Beneficiaries
q 5 -Year Deferral Option - I elect to defer receiving a full distribution of my beneficiary benefit until the fifth anniversary
of the deceased’s date of death. I understand that if the decedent was subject to Required Minimum Distributions
at time of death, I must continue those distributions annually. (Contact the Annuity Service Center to request a
Beneficiary Required Minimum Distribution form.) I understand that I may request payment of my beneficiary benefit
at any time during the deferral; otherwise, any balance remaining in the contract five years from the deceased’s date
of death will be sent by check to my address of record.)
ii. Beneficiaries that are a non-natural entity (not acting as an agent for a natural person or persons)
q 5 -Year Deferral Option (only available if the deceased had not begun taking Required Minimum Distributions)- I
elect to defer receiving a full distribution of my beneficiary benefit until the fifth anniversary of the deceased’s date of
death. I understand that I may request payment of my beneficiary benefit at any time during the deferral; otherwise,
any balance remaining in the contract five years from the deceased’s date of death will be sent by check to my address
of record.
Note: If the deceased had begun taking Required Minimum Distributions, the Deferral Option is not available and you may
only elect either Annuity Income Payments (see Section 4), a Lump Sum Cash Distribution (see Section 5) or Transfer,
Rollover or Exchange to Another Carrier (see Section 6)
If you have elected Deferral Option, SKIP Sections 4 through 6 and COMPLETE Sections 7 through 11.
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4 Annuity Income Payments

Annuity Income Payments provide you with periodic payments over the time period you select. The annuity income option and
payment frequency you select will determine the amount of your annuity payments. To exercise this option, you must begin
Annuity Income Payments by December 31 of the year following the deceased’s date of death for IRAs and within one year of
the deceased’s date of death for Non-Qualified contracts. The amount of the annuity income payments will be determined on the
payment start date by applying the Contract Value, less any applicable premium taxes, to the factor that applies to the income
payment option you select. It will take up to 30 days to receive your first payment after receipt of your election in good order. Once
Annuity Income Payments begin, you will no longer have access to your money outside the income payments. Some income
options may not be available to non-natural beneficiaries.
Amounts paid will be reported to the IRS in the year distributed.
A. Annuity Income Payment Options
Select only one option from those listed below. Once an option is selected, you cannot change it. If you select an annuity income
option that includes lifetime payments, provide a copy of one of the following: valid driver’s license/ID, birth certificate, or passport.
q Income for a Specified Period Guaranteed*: Upon your death, if annuity income payments have been made for less than
the specified period, as selected at the time an Annuity Income Plan commences, the remaining guaranteed annuity income
payments will be paid to your Beneficiary(ies). The specified period cannot exceed your life expectancy. If you select a specified
period that exceeds your life expectancy, we will adjust the specified period based on the applicable life expectancy tables.
If you want to select this option, specify the number of years (from as few as 5 to as many as 30) over which you would like to
receive payments.
Note: For IRAs, any remaining payments to your designated beneficiary(ies) will be limited to no more than 10 years after
your death.
q Designated Amount*: $ Payments will be made at the amount requested for at least a minimum of 5 years.
• F or IRAs, if you are a Designated Beneficiary, payments will be limited to no more than 10 years. If you are an Eligible
Designated Beneficiary, your payments will be limited based on your life expectancy. If your death occurs during the
designated period, payments will continue to your designated beneficiary(ies) and will be limited to no more than 10 years
after your death.
• For Non-Qualified Contracts, the designated period may not exceed your life expectancy.
q Life Income Annuity, Lifetime Payments Guaranteed**: Payments will be made for your lifetime. Upon your death, no
further Annuity Income Payments will be made.
By selecting this option and initialing this section, you acknowledge that you understand upon your death, no matter the
time frame after processing your claim, the beneficiary benefit is considered paid in full; no benefits will be payable to your
beneficiary(ies). (Initial only if selecting this option.)
q L ife Income Annuity With Specified Period Guaranteed**: Payments will be made for the longer of the specified period or
your lifetime. If, at your death, annuity income payments have been made for less than the specified period guaranteed, as
selected at the time an Annuity Income Plan commences, the remaining guaranteed annuity income payments will be paid to
your Beneficiary(ies). If, at your death, annuity income payments have been made for at least the specified period guaranteed,
as selected, no further payments will be made to your Beneficiary(ies). The specified guaranteed period may not exceed your
life expectancy and in some cases we may need to adjust your guaranteed period to less than 10 years.
Specify the number of years (5-30):
Note: For IRAs, any remaining payments to your designated beneficiary(ies) will be limited to no more than 10 years after
your death.
q Life Income Annuity with Cash Refund**: Payments will be made for your lifetime, based on your life expectancy. Upon your
death, a lump sum payment will be made to your beneficiary of any remaining death claim proceeds.
q Life Income Annuity with Installment Refund**: Payments will be made for your lifetime, based on your life expectancy.
Upon your death, payments will continue to be made to your beneficiary until all remaining death claim proceeds are depleted.
For IRAs, the installment refund period will be limited to no more than 10 years after your death.
* On IRAs the guaranteed period cannot exceed 10 years unless you are an Eligible Designated Beneficiary.
** Only available on IRAs if you are an Eligible Designated Beneficiary.
Note: The life income option offers higher income payments than income options with a guaranteed period, but does not
guarantee a minimum number of payments; payments stop upon your death.
B. Frequency of Payments
Select the frequency of payments: q Monthly q Quarterly q Semi-Annually q Annually
Note: the minimum payment amount must be $50. If the payment amount is less than $50 based on the requested frequency, the
frequency of payments will be adjusted to meet the $50 minimum requirement.
If you have elected Annuity Income Payments, SKIP Sections 5 and 6 and COMPLETE Sections 7 through 11.

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 Annuity Death Claim Page 5 of 11

5 Lump Sum Cash Distribution Election

✔ By checking this box, I elect a Lump Sum Cash Distribution. I understand this beneficiary benefit payment will be reported on
q
IRS Form 1099-R for the calendar year in which the lump sum is distributed.
If you have elected Lump Sum Cash Distribution, SKIP Sections 6 through 8 and COMPLETE Sections 9 through 11.

6 Transfer, Rollover, or Exchange to Another Carrier

q By checking this box, I elect to send my beneficiary benefit to another carrier. I understand transfer/rollover/exchange paperwork
from the receiving carrier and their letter of acceptance will be required to process this option. Note: If we do not receive transfer/
rollover/exchange paperwork and a letter of acceptance from the receiving carrier, we will treat this request as not in good order.
For Spousal Beneficiary (IRAs only)
• If you are a spouse and the beneficiary benefit is being paid into an account in your name at another carrier, the transfer
paperwork must show your name (being the surviving spouse) as the Owner.
For Spousal and Non-Spousal Beneficiaries
• If the beneficiary benefit is being paid into a Beneficiary IRA at another carrier, the rollover paperwork must be styled in a
manner substantially similar to “Inherited IRA for John Doe as Beneficiary of Jane Doe, Deceased.”
• F
 or a Non-Qualified 1035 Exchange, the exchange paperwork must indicate the new contract will be set up as an Inherited
Non-Qualified annuity and the exchange paperwork must be styled in a manner substantially similar to “John Doe as
Beneficiary of Jane Doe, Deceased.” Note: a Non-Qualified 1035 Exchange may not be available in certain circumstances;
discuss with your tax advisor.
If you have elected a Transfer, Rollover, or Exchange, SKIP Sections 8 and 9 and COMPLETE Section Sections 7 (IRAs only),
10 (only if requesting the deceased’s Required Minimum Distribution in Section 7), and 11.

7 Deceased’s Required Minimum Distributions (IRAs only)

If the deceased had not taken the Required Minimum Distribution for the year in which he/she died, that distribution, calculated
based on the deceased’s life expectancy, must be taken. Select one of the options below to address the deceased’s final Required
Minimum Distribution processed with this claim form. Note: taking the RMD may impact the amount of the beneficiary benefit due
to you.
q Calculate and distribute the RMD for the year of death (default, if no other option is selected)
q Distribute $ to satisfy the RMD for the year of death (may not exceed the RMD calculated for this annuity only)
q No distribution is needed as the RMD has already been satisfied for the year of death

8 Beneficiary Designation Change (required for Spousal Continuation, Deferral Option, and Annuity
Income Payments)
Designate your new beneficiary(ies) below. If you do not complete this section or if the information you provide
is unclear, then the beneficiary designation will default to your estate. Note the following when designating your
beneficiary(ies).
• A beneficiary may be an individual, institution, estate, trust or other non-natural entity.
• W
 hen there are multiple beneficiaries and one predeceases you, the proceeds will be divided among the remaining
beneficiaries in that type/class (i.e., Primary or Contingent), unless you add a “Per Stirpes” designation after a beneficiary’s
name. A “Per Stirpes” designation allows the descendants of a deceased beneficiary to receive that beneficiary’s portion.
• F
 or each type/class of beneficiary, percentages must equal 100%. If no percentage(s) is indicated, your beneficiary benefit will
be paid equally to the listed beneficiaries in that class/type that survive you.
• If designating a trust as beneficiary, include the full name of the trust, the trustee name(s) and trust date below.
• If designating a minor beneficiary, include the name of the custodian for the benefit of the minor beneficiary. Once the minor
reaches the age of majority, the custodian will be disregarded.
Primary Beneficiaries: Primary receive the beneficiary benefit, if applicable, upon your death. If you elected annuity income
payments, primary beneficiaries will receive any remaining guaranteed annuity income payments.
Contingent Beneficiaries: Generally, contingent beneficiaries receive the beneficiary benefit or any remaining guaranteed
annuity income payments, as applicable, only if all primary beneficiaries predecease you.
To ensure beneficiaries are identified and paid in a timely manner, remember to include each beneficiary’s name, address, phone
number, birth/trust date and SSN/TIN.

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8 Beneficiary Designation Change (continued)

PRIMARY BENEFICIARY DESIGNATION – any percentage split must be in whole numbers and equal 100%

1. Beneficiary Name

Address City State Zip

Relationship Beneficiary % SSN/TIN Phone

Birth/Trust Date Email q Male q Female

2. Beneficiary Name

Address City State Zip

Relationship Beneficiary % SSN/TIN Phone

Birth/Trust Date Email q Male q Female

CONTINGENT BENEFICIARY DESIGNATION – any percentage split must be in whole numbers and equal 100%

1. Beneficiary Name

Address City State Zip

Relationship Beneficiary % SSN/TIN Phone

Birth/Trust Date Email q Male q Female

2. Beneficiary Name

Address City State Zip

Relationship Beneficiary % SSN/TIN Phone

Birth/Trust Date Email q Male q Female

q Check here if you have named additional beneficiaries on a separate sheet, signed, dated and attached to this form. Print your
name and contract number at the top of each separate sheet attached

Custodian for Beneficiary Who is a Minor

If you named a beneficiary who is a minor, please designate a custodian for the beneficiary under your state’s Uniform Transfers
(Gifts) To Minors Act or contact a local attorney regarding other alternatives to guardianship requirements. If you have multiple
beneficiaries who are minors, please designate a custodian for each on a separate signed and dated sheet and attach to this form.
AGL/USL will not pay claims to beneficiaries who are minors. Once the minor reaches the age of majority, the custodian will be
disregarded.

Name of Custodian

Name of Beneficiary who is a Minor

State of Uniform Transfers (Gifts) To Minors Act

9 Payment Delivery Method (Select only one of the following two options)
• If no method is indicated below and/or financial institution verification is unsuccessful, a check will be made payable to you
(the beneficiary) and mailed to the address stated in Section 1C under “Beneficiary’s Information.”
• A check or EFT cannot be made payable to third parties.
• For EFTs, enclose a voided check or an account verification form. Deposit slips will not be accepted.
• EFT is not available on all products or for non-U.S. banks or certain non-human beneficiaries such as estates and corporations.
• For EFTs to a brokerage account, a Letter of Instruction from the brokerage firm with the routing number, brokerage account
number, and account type is required. The Letter of Instruction must be signed by a representative at the brokerage firm and
should include their title, signature, date, annuity contract number and the brokerage account holder’s signature.

q 1. Electronic Fund Transfer (EFT) - direct deposit the money to my financial institution. Complete the information below and
include a copy of a voided check. Note: Your name and U.S. SSN/TIN in Section 1C “Beneficiary’s Information” must match
the financial institution’s account information.

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 Annuity Death Claim Page 7 of 11

9 Payment Delivery Method (continued)

Financial Institution Name

Financial Institution Account Holder’s Name

Financial Institution Address

City State ZIP

Financial Institution Account # ABA Routing # (obtain from financial institution)

✔ 2. Mail check(s) for my beneficiary benefit to address as stated in Section 1C “Beneficiary’s Information” (default).


10 Federal and State Tax Withholding Information

The Internal Revenue Code Sec. 401(a)(9) mandates certain distributions from qualified annuity contracts. These are known as
Required Minimum Distributions or RMDs. A nondeductible penalty tax may be imposed on any RMD amount required but not
distributed each calendar year. The Company is not responsible for the satisfaction of RMDs. We recommend that you consult with
your tax advisor as to your obligations with regard to the distributions from the annuity contract.
The distribution(s) you receive from the Company may be subject to federal income tax withholding unless you are eligible to elect
out of withholding on a Form W-4P or Form W-4R (as applicable) or below, and thereby not have withholding apply. (Note: We must
have your correct U.S. Taxpayer Identification Number [TIN] in order for you to elect into or out of withholding.) Withholding will only
apply to the taxable portion of your distribution. Your withholding election will remain in effect until you revoke it. The Company
will withhold 10% of the taxable amount for non-periodic payments or for periodic payments, the Company will withhold
based on the current wage withholding default of single with no adjustments, unless you elect otherwise on a Form W-4P
or Form W-4R (as applicable) or below.
States with a state income tax either require mandatory withholding or allow voluntary withholding. If your state requires mandatory
withholding, we will withhold the mandatory amount no matter your election below. If your state allows for voluntary withholding but
does not provide a default amount, and you elect state income tax withholding but don’t fill in a specific amount or percentage, we
will withhold 5% of the taxable portion of your distribution for state income tax purposes. Should your state of domicile require
a specific state withholding form, your state income tax withholding election on this form will not be taken into account
(and we will withhold based on the state mandatory withholding rate or our default state income tax withholding) until the
required form is received at our Annuity Service Center. For information regarding your resident state’s specific withholding
requirements and mandatory withholding percentages (if applicable), please consult with your tax advisor.
Withholding Election – If you are eligible to elect out of and thereby not have federal or state income tax withheld, please be
advised that you may be liable to pay the federal or state income tax on your distribution as deemed appropriate by the Internal
Revenue Service or state taxing authority, regardless of your election. You may also be subject to tax penalties if your payments of
estimated tax and withholding, if any, are not adequate. If at any point in time after submitting this form you would like to change your
tax withholding election, please send our Annuity Service Center an updated Form W-4P or Form W-4R, as applicable to change
your federal election. For changes to your state withholding election, you may provide updated elections on a new copy of this form,
unless your state requires a specific state withholding form, in which case you must use that specific form. Please consult your
tax advisor for further information.
The taxable portion of the distribution(s) will be subject to a default 10% federal tax withholding for non-periodic payments
or the current wage withholding default of single with no adjustments for periodic payments, unless you complete and
submit a Form W-4P or W-4R (as applicable) with this administrative form or elect out of withholding below.

FOR LUMP SUM DISTRIBUTION AND OTHER NON-PERIODIC DISTRIBUTIONS

Federal Withholding Election State Withholding Election
(Select only one option below) (Select only one option below)
❑ I elect to withhold federal income taxes as indicated on ✔ I elect not to withhold any state income taxes unless
❑
the accompanying Form W-4R. The current Form W-4R is mandated by law.
available on the IRS website at www.IRS.gov.
❑ I elect to withhold the federal income tax default rate of 10% ❑ I elect to withhold state income taxes in the amount of
from the taxable portion of my distribution and will not be $ or % (cannot be less than any
providing a Form W-4R. mandatory withholding).
✔ I elect not to withhold federal income taxes unless mandated
❑
by law.
Note: If you check the box above to elect the federal income tax
default withholding rate or elect out of withholding and provide
the Company with a completed Form W-4R, the Company will
utilize the election instructions provided on the Form W-4R.

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10 Federal and State Tax Withholding Information (continued)

FOR ANNUITY INCOME PAYMENTS ONLY
Federal Withholding Election State Withholding Election
(Select only one option below) (Select only one option below)
❑ I elect to withhold federal income taxes as indicated on ❑ I elect not to withhold any state income taxes from my
the accompanying Form W-4P. The current Form W-4P is periodic income payments.
available on the IRS website at www.IRS.gov.
❑ I elect to withhold the current federal income tax wage ❑ I elect to withhold state income taxes from my periodic
withholding default of single with no adjustments from the income payments in the amount of (complete either
taxable portion of my distribution and will not be providing A or B below):
a Form W-4P. Withhold taxes based on:
❑ I elect not to withhold federal income taxes unless mandated A.  (Enter number) Number of Withholding
by law. Allowances
Note: If you check the box above to elect the federal income tax Marital Status (check one):
default withholding rate or elect out of withholding and provide ❑ Single ❑ Married
the Company with a completed Form W-4P, the Company will
I want an additional amount withheld of $
utilize the election instructions provided on the Form W-4P.
(please indicate the dollar amount)

B. $ or %
Notice to non-resident aliens – A payment to a non-U.S. person/entity may be subject to federal income tax withholding at a rate
of 30% of the taxable portion of the distribution, unless the payee submits a completed IRS Form W-8BEN (or if applicable, a Form
W-8BEN-E) and the payment is eligible for reduced federal income tax withholding. If the payee is an entity, it will be considered a
foreign entity and subject to a mandatory 30% federal tax withholding of the gross payment until a completed Form W-9 showing that
it is a U.S. entity or a Form W-8 (of some variety) is provided.
Notice for payments made outside the U.S. – A payment to a U.S. person/entity and delivered to an address outside the United
States and its possessions is subject to the current federal income tax wage withholding default of single with no adjustments for
periodic payments or at a rate of 10% for non-periodic payments and cannot be reduced.
The Company will provide you and the Internal Revenue Service with an informational tax form; generally, the form will be provided
after the close of the calendar year.

11 Affirmations/Signatures
By signing this form, I acknowledge the following:
• All statements made on this claim form are true to the best of my knowledge.
• I have read, understand and agree to the terms and conditions of this claim form.
• I understand that this transaction may result in tax or other financial consequences. I have sought tax, financial or legal advice, if
necessary, regarding any options I may have associated with this claim.
• I understand AGL, USL, VALIC, its agents and representatives do not provide legal, tax or other advice.
• I understand that if I’m electing a deferred claim option, the agent of record from the deceased’s account will have access to my
personal account information in order to provide service, including facilitating transactions upon my request, unless I check the
box below.
q Remove the agent of record on my account.

TAX CERTIFICATION (Substitute Form W-9) – Applicable to U.S. persons (including U.S. citizens and resident aliens). If you
are not a U.S. person, you are required to submit the applicable IRS Form W-8 series (BEN, BEN-E, ECI, EXP or IMY).
Under penalties of perjury, I certify to the following:
1. T
 hat the taxpayer identification number listed on this form is my correct SSN/TIN and I am a U.S. Citizen or other U.S. person
(including resident aliens);
2. I further certify that I am exempt from and have not been notified by the Internal Revenue Service (IRS) that I am subject to
backup withholding; and
3. I am exempt from Foreign Account Tax Compliance Act (FATCA) reporting.
Certification Instructions: You must cross out any statement in 1-3 above that does not apply to you. For instructions on how to
complete this certification, please see the General Instructions for the IRS Form W-9 on www.irs.gov. If you can complete a Form
W-9 (Request for Taxpayer Identification Number) and you are a U.S. Citizen or U.S. resident alien, FATCA reporting may not apply
to you. Please consult your own tax advisor with any questions you may have regarding this certification.

The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.

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11 Affirmations/Signatures (continued)
Fraud Warning - New York: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

MUST SIGN HERE Date

❑ Individual ❑ Executor ❑ Trustee ❑ Custodian ❑ Power of Attorney ❑ Entity

IF APPLICABLE, SIGN HERE Date

❑ Co-Executor ❑ Co-Trustee

Note that as required by state laws and regulations, the Company may have to disclose your personal information, including
information concerning the annuity contract and the claim payment, to government agencies, including but not limited to state
departments of revenue.

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Appendix
The following are samples of how various types of beneficiaries should complete Section 1C at the beginning of this claim form:

Individual Beneficiary

Last Name: Smith First: Jane MI R

Address: 123 Main St City: Any Town State: CA Zip: 99999

Phone (daytime): 999-333-5555 Relationship to Deceased: Spouse

Date of Birth: 01-01-1948 SSN or TIN: 999-99-9999

Minor Beneficiary

Last Name: Jane R Smith, Guardian FBO First: John T. Smith, Minor MI

Address: 123 Main St City: Any Town State: CA Zip: 99999

Phone (daytime): 999-333-5555 Relationship to Deceased: Son

Date of Birth: 01-01-2010 SSN or TIN: 999-99-9999 (Minor’s SSN)

Trust or Estate Beneficiary

Last Name: Jane R. Smith, Trust/Estate First: John T. Smith, Trustee/Executor MI

Address: 123 Main St City: Any Town State: CA Zip: 99999

Phone (daytime): 999-333-5555 Relationship to Deceased: Trust/Estate

Date of Birth: N/A SSN or TIN: 999-99-9999

Deferral Option
Provided below is additional information regarding how the Deferral Option works.

Interest
• Upon election of the Deferral Option, your beneficiary benefit proceeds will earn interest at rate(s) we determine until withdrawn.
Limitations
• You cannot make additional contributions to the contract.
• N
 o living benefits are available under the Deferral Option. Any living benefits that may have been elected by the deceased are not
available.
• T
 he death benefit provisions applicable to the deceased no longer apply. The total claim received by you under the Deferral
Option will be based on the current beneficiary benefit amount payable at the time of this election. Upon your death, any amounts
remaining in the contract will be distributed to your designated beneficiary(ies).
• The contract may not be assigned and ownership may not be changed or jointly owned.
Fees and Charges
• You are not subject to any upfront or deferred sales charges and Market Value Adjustments (MVA) on any partial or full withdrawal.
• A
 ny fees and charges applicable to the Death Benefit and Living Benefit elected by the deceased will no longer be deducted. (as
applicable)

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Fraud Warning
The following fraud warning applies to claims filed in all states except the states noted below:
In some states we are required to advise you of the following: Any person who knowingly intends to defraud or facilitates a fraud
against an insurer by submitting an application or filing a false claim, or makes an incomplete or deceptive statement of a material
fact, may be guilty of insurance fraud.
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or
any combination thereof.
Alaska: A person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false,
incomplete or misleading information may be prosecuted under state law.
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal
and civil penalties.
Arkansas, Louisiana, Rhode Island, Texas and West Virginia: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false
or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and
may be subject to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,
incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting
to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Delaware, Idaho, Indiana and Oklahoma: WARNING - Any person who knowingly and with intent to injure, defraud or deceive any
insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia, Maine, and Tennessee: WARNING - It is a crime to provide false or misleading information to an insurer
for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony in the third degree.
Kentucky, Pennsylvania and New Mexico: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose
of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
Maryland: Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly OR willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim
containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided
in RSA 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal
and civil penalties.
Ohio: Any persons who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement is guilty of insurance fraud.
Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or
presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than
one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty
of a fine of not less than five thousand dollars ($5,000) and not more than ten thousand ($10,000), or a fixed term of imprisonment for
three (3) years, or both penalties. Should aggravating circumstances are present, the penalty thus established may be increased to a
maximum of five (5) years, if extenuating circumstances be present, it may be reduced to a minimum of two (2) years.
Virginia & Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

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