Delaware Life Gs 0084 Wdv Form

O. Box 758581 Topeka KS 66675-8581 By express mail Mail Zone 581 5801 SW 6th Avenue Topeka KS 66636 Online www. WITHDRAWAL ALLOCATION Proportionally from all existing allocations From the following subaccounts or fixed accounts at the percentage s shown below Subaccount/fixed account name whole number Total must 100 If you do not make a selection we will take withdrawals proportionally from all existing investment allocations. If you are invested in an asset allocation model we will take the withdrawal proportionally from all existing investment allocations. 2016 Delaware Life Insurance Company. All rights reserved. Page 1 of 4 GS 0084 WDV Rev 12-2016 WITHDRAWAL AMOUNT select one Full withdrawal this will close the contract and end all of your benefits. Delaware Life Insurance Company of New York is authorized to transact business in New York and Rhode Island. Investment allocations. In the list above if you include percentages with decimals we will round them to the nearest whole number. No additional paperwork will be required for the change. Please change my Secured Returns living benefit from the Guaranteed Minimum Accumulation Benefit GMAB plan to the Guaranteed Minimum Withdrawal Benefit GMWB plan. Delaware Life Insurance Company is authorized to transact business in all states except New York as well as in the District of Columbia Puerto Rico and the U.S. Virgin Islands. OWNER S SIGNATURE X DATE MM/DD/YYYY CO-OWNER S SIGNATURE IF APPLICABLE / / PLEASE PRINT NAME BELOW SIGNATURE GUARANTEE STAMP CONTACT US By mail P. Taking withdrawals including withdrawals to pay advisory fees can reduce or eliminate your living benefits. Withdrawals in excess of the guaranteed withdrawal amount called excess withdrawals will result in a permanent reduction in future guaranteed withdrawal amounts. ADDRESS CITY STATE In case we need to contact you about this request ZIP CODE DAYTIME PHONE SECURED RETURNS OPTION Complete this section ONLY if you have an annuity with a Secured Returns living benefit. Go to section 5. Partial withdrawal amount Optional Please send me the exact withdrawal amount shown* I understand that any additional fees adjustments tax withholding amounts and/or delivery costs that result from this withdrawal will be charged separately to my contract. Free amount This is the maximum amount you can withdraw without a withdrawal charge. Taking the free amount may reduce your living benefits. Entire stored income balance if it applies to your living benefit One-time access withdrawal amount if it applies to your living benefit withdrawal will be charged separately to my contract. If I choose to have taxes withheld section 5 or to pay the 25 fee for a wire transfer section 6 those amounts will be deducted from the amount I have indicated* withdrawal request. TAX WITHHOLDING The tax withholding options that you select will remain in effect until revoked in writing. If you do not indicate a value and we do not have a previous tax withholding election on file we will automatically withhold the required amount for federal income taxes.