In This Form, the "Company" Refers to the Insurance Company Whose Name is Checked above

Policy Number s Company Code Financial Network Use Only Required Insured/Annuitant Name s SSN/ITIN or EIN Owner Name s SSN/ITIN or EIN SSN/ITIN or EIN Address Primary Phone Alternate Phone Check here if this is a permanent address change Email Address Assignee Irrevocable Beneficiary Other Name if applicable SSN/ITIN or EIN SECTION B - CASH SURRENDER I hereby apply for the Cash Surrender value of the above described Policy. I am a U.S. citizen or other U.S. person and 4. The FATCA code s entered on this form if any indicating that I am exempt from FATCA reporting is correct enter exemption from FATCA reporting code if applicable. A mandatory 30 withholding from any gross distribution will apply to any FATCA withholdable amount unless you provide the appropriate US Tax 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. If eligible I elect not to have federal income tax withheld from the taxable portion of my distribution check. No other Company is responsible for such obligations or payments. Mailing Instructions Send form s to Standard Address PO Box 305355 Nashville TN 37230-5355 Fax 615-749-2941 Variable Life Service Center PO Box 305600 Nashville TN 37230-5600 Fax 713-620-6653 SECTION A - POLICY INFORMATION Please fill out all applicable information below. Elect one of the disbursement options available or indicate rider to cancel on the space provided. Select desired Income Tax Withholding. Please elect ownership type and fill out all applicable information. All required signatures must be written in ink using full legal names. Contact your appropriate state taxing authority for more information. I elect to have state income tax withheld from the taxable portion of my distribution check reducing the indicated amount by the Page 1 of 3 AGLC108877 SECTION E - SIGNATURE AND DATE The Policy Owner s warrants that the above-referenced policy withdrawal or loan is not subject to any prior agreements contractual obligations legal proceedings or court/administrative orders including but not limited to divorce or bankruptcy proceedings Obligations which restrict limit or otherwise prohibit such withdrawals and loans as contemplated. The Policy Owner s acknowledges and agrees that in the event any obligations become known subsequent to the above-referenced withdrawal or loan being made which if then-known to the Company would have caused the Company not to disburse the withdrawal or loan on the policy or not to disburse the withdrawal or loan without the consent of a party other than the Policy Owner s the withdrawal or loan plus interest will become immediately due and payable to the Company by the Policy Owner s and the Policy Owner s shall indemnify and the Company harmless from any and all losses associated with the withdrawal or loan including costs of recovery and reasonable attorney fees. The Company shown above is solely responsible for the obligation and payment of benefits under any policy that it may issue.