062415%20surrender%20request%20form.pdf 5c6ht

Phoenix Life Insurance Company PHL Variable Insurance Company Phoenix Life and Annuity Company

Mail to: PO Box 8027 Boston MA 02266-8027 OR

Full Surrender Request

Fax: 816-221-9674

A. Information Policy/Contract Number

Insured/Annuitant Name(s): Please print full name

11188147

Gerald & Sue Friedman

Daytime Telephone Number (Include area code)

Advisor’s Telephone Number (Include area code)

B. Transaction Type 䡺 Full Surrender 䡺 Direction to Pay A Third Party (Financial Institution Only. This does not constitute a 1035 Exchange.) Please indicate name and address of Financial Institution Name

______________________________________________________________________________________

Address

____________________________________________________________________________________

City/State/ZIP Code ____________________________________________________________________________

C. Taxes (If no election is made we will withhold Federal taxes at a minimum rate of 10%) 䡺 Do Not withhold taxes

䡺 Withhold taxes at 10%

䡺 Withhold taxes at a rate of ______% (minimum of 10%)

The distributions paid from your contract may be subject to Federal Income Tax. The Company is required by the Internal Revenue Code to withhold 10% Federal Income Tax on distributions deemed to be taxable, unless you meet certain requirements and elect not to have withholding apply. If you do not have sufficient Federal Income Tax withheld from your distribution, you may incur penalties under the estimated tax rules. Phoenix will not withhold Federal Taxes on Pensions, Profit Sharing, Keogh Plans or Annuities owned in IRA s outside Phoenix. I am aware that there may be tax consequences resulting from this transaction. Under penalty of perjury, I certify that the correct Social Security/Taxpayer Identification Number is shown below.

Your Social Security / Taxpayer Identification Number is REQUIRED; 佡

Social Security Number: _____ / ____ / _________ or Taxpayer Identification Number: _____ / _______________

D. Tax-Sheltered Annuity Contract Additional Requirements (Must be completed for all Section 403(b) Tax-Sheltered Annuities) The Internal Revenue Code limits the conditions under which a distribution may be made from a Section 403(b) annuity contract. Surrender or partial withdrawal is only permitted when: (please check one) 䡺 The employee attains age 59½, has a severance from employment, dies or becomes disabled. (Documentation and completed form OL3049 required.) (Documentation for age includes birth certificate, port, driver’s license; documentation for severance from employment includes written materials from employer sponsoring 403(b) Plan referencing severance, resignation, retirement.) 䡺 A hardship exists. (Employer approval and completed form OL4395 required.) (The amount distributed in a hardship case cannot include any income earned under the contract.) Distributions not paid directly to an eligible retirement plan (including an IRA) in a direct rollover are subject to 20-percent mandatory income tax withholding. See “Special Tax Notice Regarding Section 403(b) Tax-Sheltered Annuity Plan Payments” for more information and other exceptions relating to the withholding requirement. The mandatory withholding and surrender/partial withdrawal restrictions are required under the Internal Revenue Code and Phoenix is required to abide by these guidelines. 20150617141545823000 Business Use Only: __________________________________________

11188147 Policy/Contract Number: ______________________________________ Form Void If Altered OL4212

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