RiverSource Life Insurance Company 70100 Ameriprise Financial Center Minneapolis, MN 55474
Annuity Systematic Payout Transaction
Request
Many transactions can be done by telephone: call 1.800.862.7919
For contract minimum balance requirements, surrender charge information and
other withdrawal or surrender provisions, please refer to your annuity contract.
Deferred Annuities-Annuity Systematic Payout Transaction - Use Parts 1, 2, 3,
4B, 5, and 6.
RAVA 5® products or Innovations Select - Use Parts 1, 2 (sub-Step 3 for
arrangement options), 3, 4A, 5 and 6.
Payout/Immediate Annuities - Use Parts 1, 4B, 5, and 6.
Must select a Product type to the right.
Failure to select a Product Type could result in processing delays.
DO NOT use this form for TSA Annuity Systematic Payout Transactions, please
use Form 200702.
DO NOT use this form for Qualified Plan (i.e., 401(a)) Annuity Systematic Payout
Transaction, please use Form 4292.
Not all funds are available in all products. Refer to Form 402023 for fund
availability within your policy/product.
Please verify the withdrawal provisions and conditions of your contract prior to
making selection. Make sure you understand the impact taking this withdrawal
will have on your rider benefit values. Certain riders contain features that may be
negatively impacted by taking a withdrawal.
For annuities with the SecureSource® Flex rider or SecureSource Stages® rider
any withdrawal during the 3 year waiting period will set your benefit values equal
to zero for the duration of the waiting period. At the end of the waiting period,
your benefit amounts will be re-established based on your contract value at that
time. Consult with your financial advisor to determine a withdrawal strategy that
is right for you.
If your annuity has the SecureSource Stages 2® rider, if any withdrawal is taken
during the first year of your contract, the "income bonus" will not be available for
the life of the contract. The "income bonus" provides an additional 1% income for
a given contract year; availability is determined annually.
Systematic Partial 1035 Exchanges are not allowed. For a one-time Partial 1035
Exchange use Form 33442.
Part 1
Select the Product Type for this request: (Required):
RAVA 5® products/Innovations Select:
Account Number
Other
Account Number
Failure to select a Product Type could result in
processing delays
Account Information
Contract Owner
Client ID
Name Of Trust Or Entity
Contract Co-Owner
Part 2
Client ID
Select Deferred Annuity Systematic Payout Transaction Type (Minimum Disbursement Amount is $50.00)
There can only be one active Annuity Systematic Payout Transaction arrangement per annuity.
Establishing a new Annuity Systematic Payout Transaction arrangement will inactivate an existing Annuity Systematic Payout Transaction
arrangement.
Annuity Systematic Payout Transaction arrangements are not allowed on Index 500 annuities.
If this annuity is a non-qualified annuity and a partial 1035 exchange has occurred to or from this annuity within the last 180 days, there
may be tax consequences. Contact your tax advisor before submitting your request.
Step 1 - Select One
Establish Arrangement
Replace Arrangement
Discontinue Arrangement
For Contracts without a Guaranteed Withdrawal Benefit Rider go to Step 2.
For RAVA 5 products and Innovations Select Contracts with a Guaranteed Withdrawal Benefit Rider go to Step 3.
For all other Contracts with a Guaranteed Withdrawal Benefit Rider go to Step 4.
Select Deferred Annuity Systematic Payout Transaction Type continued on next page..
Sign on Page 6
Fax # 1.866.432.9267
200054
© 2008-2013 RiverSource Life Insurance Company.
All rights reserved.
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Select Deferred Annuity Systematic Payout Transaction Type continued
Step 2 - Contracts without Guaranteed Withdrawal Benefit Riders
Fixed Dollar Amount
$
Unless specific instructions are provided below, scheduled surrenders will be made pro rata.
Specify the fixed dollar scheduled surrender (Optional):
Abbr
Subaccount/Fund name
Subaccount/Fund name
Dollar amount
Abbr
Dollar amount
$
$
$
$
$
$
Indicate the base amount. If no amount is indicated, the current account value
$
Earnings only
will be used.
*The Earnings only selection is not applicable for RAVA 5 products and Innovations Select products.
Earnings Only Arrangements
Amounts exceeding the stated amount will be surrendered on the scheduled pull date, provided it meets the $50 minimum scheduled
surrender requirement. Surrenders will be made pro rata. Surrender amounts will fluctuate and will not occur if earnings are less than
$50. For this reason, LTC and DI policies cannot be a destination for “Earnings Only” arrangements.
The earnings only option is not available for accounts that have a withdrawal benefit rider because the earnings may exceed the
allowable amount which would be subject to an excess withdrawal penalty.
Step 3 - For RAVA 5® and Innovations Select Contracts with the SecureSource Stages® rider, SecureSource Stages 2® rider or
SecureSource 3® benefit.
Only use this section for RAVA 5® and Innovations Select Contracts with the SecureSource Stages® rider, SecureSource Stages 2® rider or
SecureSource 3® benefit.
Using an incorrect section for your product may cause a delay in processing time.
A. Lifetime Income Guarantee - Total amount available for withdrawal each year.
Your payments will be reduced if your benefit decreases, which includes taking additional withdrawals during the contract year. Your
payments will increase if your benefit increases. Payments started during the contract year will be higher than in subsequent years if
necessary to ensure that the entire annual amount will be distributed. Refer to your product prospectus for age, eligibility and specific
payout percentages. For SecureSource Stages® rider: this option is available after the 3-year waiting period.
B. Dollar Amount - Up to the total benefit amount available without exceeding Lifetime Income Guarantee.
The dollar amount you have specified will be lowered to the maximum amount currently available as a level payment each year under
the Lifetime Income Guarantee if you have requested more than the maximum amount. SecureSource Stages® rider: this option is
available after the 3-year waiting period. Your payments will be reduced if your benefit decreases. In addition, your payments will be
increased up to your requested amount if your benefit increases.
Fixed Amount of
$
for each withdrawal. Once established, this amount will not increase
above requested amount.
Step 4 - Use for Contracts with Guaranteed Withdrawal Benefit Riders (Except RAVA 5 products or Innovations Select)
Do not use Step 4 arrangement selections for RAVA 5 products and Innovations Select
Using an incorrect section for your product may cause a delay in processing time.
Fixed Dollar Amount - Enter the specific dollar amount of the scheduled distribution.
The annualized amount of the scheduled distribution cannot exceed either the Lifetime Income Guarantee or the Principal
Back Guarantee.
The dollar amount you have specified will be lowered to the maximum amount currently available as a level payment each year for the
product if you have requested more than the maximum available benefit amount for your product. Your payments will be reduced if your
benefit decreases. In addition, your payments will be increased up to your requested amount if your benefit increases. Refer to your
product prospectus for the specific payout percentages. For SecureSource® Flex rider this option is available after the 3-year waiting
period.
Fixed Amount of
200054
$
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Part 3
Select Deferred Annuity Systematic Payout Transaction Frequency
Step 1- Select One
For RAVA 5 products and Innovations Select products the only available options are Monthly, Quarterly, Semiannual and Annual.
If frequency is not indicated, automated surrenders will be set up to take place on a monthly basis.
Annually (1/yr)
Every 4 months (3/Yr)
Bimonthly (6/Yr)
Bifortnightly (13/yr)
Biweekly (26/Yr)
Semiannually (2/Yr)
Quarterly (4/Yr)
Monthly (12/Yr)
Semimonthly (24/Yr)
Weekly (52/Yr)
Step 2
The surrender will be processed on the date of the month indicated.
If no start date is specified, the first scheduled surrender will occur on the 7th business day after the request is received in good order in the
corporate office.
If no end date is specified, the arrangement will continue until your request is received to discontinue the arrangement.
When?
Part 4A
Begin Scheduled Surrenders
and end Scheduled Surrenders
Delivery Options (RAVA 5® annuities ONLY)
Note: Part 4A is for RAVA5® annuities only. To set delivery options for other types of accounts - please complete 4B.
Select Option
Send check to client(s) at address of record
Name
For the Benefit of: (If applicable) (i.e. John Doe) Or Gift From
Address
State
City
ZIP code
Internal Delivery Options - Transfer proceeds to Ameriprise® account number:
For annuitization payments, RiverSource Life does not allow Tax Qualified to Tax Qualified Transfers.
Systematic Partial 1035 Exchanges are not allowed. For a one-time Partial 1035 Exchange use Form 33442.
$
or %
$
or %
Bank Delivery Options
Direct Deposit to Existing Bank/ Attached Bank Information
Financial institution account information and type:
Savings Account Owner(s)
Savings Account Number
200054
Checking (Complete information below)
Savings (Complete information below)
Name of Financial Institution
Financial Institution Routing Transit Number/ABA Number (9 Digits)
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Part 4B
Delivery Options (Deferred and Payout/Immediate Annuities)
Select Option
Send check to client(s) at address of record
Make check payable to special payee and/or to special address.
Note: All special payee annuity systematic payout transactions will be processed as a taxable surrender and may result in a taxable
event to the contract owner.
Name
For the Benefit of: (If applicable) (i.e. John Doe) Or Gift From
Address
State
City
ZIP code
Internal Delivery Options - Transfer proceeds to Ameriprise® account number:
For annuitization payments, RiverSource Life does not allow Tax Qualified to Tax Qualified Transfers.
Systematic Partial 1035 Exchanges are not allowed. For a one-time Partial 1035 Exchange use Form 33442.
$
or %
$
or %
Bank Delivery Options
Direct Deposit to Existing Bank/ Attached Bank Information
Financial institution account information and type:
Savings Account Owner(s)
Savings Account Number
200054
Checking (Complete information below)
Name of Financial Institution
Savings (Complete information below)
Financial Institution Routing Transit Number/ABA Number (9 Digits)
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Part 5
Annuity Tax Withholding Instructions (Deferred and Payout/Immediate Annuities)
Withholding Instructions
You are liable for income tax on the taxable portion of your distribution. If total withholding is not adequate, you may be required to make
estimated tax payments or pay tax penalties.
Different withholding rules apply if we do not have a valid Taxpayer Identification Number on the account, if payment is delivered outside
the United States or if you are a non-resident alien.
State withholding is required in many states and may apply to your annuity and/or insurance contract, regardless of federal withholding.
Any amounts withheld for federal or state income taxes pursuant to elections or under the tax law will not be refunded.
Please consult your tax professional for additional information regarding Federal and/or State withholding.
For all tax-qualified arrangements: Withholding is taken from the total amount distributed. (e.g., For a distribution of $10,000, 10% withholding
results in a net distribution sent to you of $9,000 even though part of the distribution may be non-taxable. The other $1,000 goes to the IRS in your
name.)
For non-qualified annuities: Withholding is taken from the taxable amount distributed. (e.g. For a distribution of $10,000, consisting of $4,000
taxable and $6,000 non-taxable, 10% withholding results in a net distribution sent to you of $9,600, with $400 going to the IRS in your name).
Deferred Annuities
If you have made a prior withholding election, it will continue unless otherwise instructed below. If you have not made a prior withholding election,
10% federal income tax will be withheld from the taxable amount distributed unless you make a different withholding election below (certain
exceptions apply).
Do not withhold
Withhold 10%
Withhold > 10%
Payout/Immediate Annuities
If you have made a prior withholding election, it will continue unless otherwise instructed below. If you have not made a prior withholding election,
federal income tax will be withheld from the taxable amount distributed based on the wage tables for a married individual with three exemptions unless
you make a different withholding election below (certain exceptions apply).
Select One
You elect NOT to have federal income tax withheld from your payments.
from each payment.
You elect that we withhold $
You elect that we withhold
% of each payment (fixed payouts only).
You elect to have federal income tax withheld from your payments calculated using the number of exemptions and marital status entered
below:
Number of exemptions
Marital Status
If this calculation indicates no withholding, please withhold $
Part 6
Married
Single
% per payment
or
Authorization and Acknowledgements
You have read and understand:
Changes to existing systematic payouts must be received in the corporate office at least 10 business days prior to the next disbursement date.
Requests received with less than 10 business days to the next disbursement date may be effective for the subsequent disbursement date.
Payments less than 10 business days old will NOT be included in the deferred annuity systematic payout transaction calculation.
If you have a living benefit rider on your annuity contract (e.g., the Guaranteed Minimum Withdrawal Benefit, Guaranteed Minimum
Accumulation Benefit, Accumulation Protector Benefit, Guarantor Withdrawal Benefit for Life® rider, SecureSource® rider, SecureSource® Flex
rider, SecureSource Stages® rider, SecureSource Stages 2® rider or SecureSource 3® benefit), it is important to understand the terms of the
living benefit rider with regard to surrenders. Surrendering money from a contract with a living benefit rider may impact the guaranteed benefits
provided by the rider. For information regarding the terms of your contract's riders, please refer to your annuity contract or the product
prospectus.
If this is a variable annuity with the SecureSource® rider, SecureSource® Flex rider, SecureSource Stages® rider or SecureSource Stages 2®
rider and you are invested in the aggressive or moderately aggressive Portfolio Navigator investment option, taking this withdrawal will move
the contract value into the moderate investment option. Once you take a withdrawal, you may invest in the conservative, moderately
conservative or moderate investment options without affecting your guaranteed benefit values. If you take this withdrawal and later choose to
move to one of the more aggressive investment options, your guaranteed benefit values will be reset based on the lesser of your contract
values or your guarantees at that time.
Authorization and Acknowledgements continued on next page..
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Authorization and Acknowledgements continued
This paragraph applies only to nonqualified annuities, and only if the annuity is or was part of a partial 1035 exchange from one annuity to
another annuity. IRS Revenue Procedure 2011-38 states if withdrawals are taken from either annuity within a 180-day period following a partial
1035 exchange, the IRS will apply general tax principles to determine the tax treatment of the previous exchange and the subsequent
withdrawal. For example, a distribution from either contract within 180 days of the exchange may result in additional taxable income related to
the contracts involved in the exchange. The IRS tax treatment may be different than what is reported on Form 1099-R. A tax advisor should be
contacted before any withdrawals are taken from either annuity contract during the 180-day period. This 180-day limitation on withdrawals does
not to apply to annuitized amounts if the annuitization is for life/lives or a period of 10 years or more.
Please verify the withdrawal provisions and conditions of your contract prior to making selection. Make sure you understand the impact taking
this withdrawal will have on your rider benefit values. Certain riders contain features that may be negatively impacted by taking a withdrawal.
If your annuity has the SecureSource® Flex rider, or SecureSource Stages® rider any withdrawal during the 3 year waiting period will set your
benefit values equal to zero for the duration of the waiting period. At the end of the waiting period, your benefit amounts will be re-established
based on your contract value at that time.
If your annuity has the SecureSource Stages 2® rider, if any withdrawal is taken during the first year of your contract, the "income bonus" will
not be available for the life of the contract. The "income bonus" provides an additional 1% income for a given contract year; availability is
determined annually. The first withdrawal will require the "Benefit Impact Acknowledgement Form" before your surrender can be processed. If
required, the "Benefit Impact Acknowledgement Form" will be mailed to you, or you may contact your advisor or the corporate office for
assistance.
Federal Tax law requires all non-qualified deferred annuity contracts issued by a company to a policyholder during the same calendar year be
treated as a single, unified contract (Serial Annuities). All income included and taxed in a distribution for one or more Serial Annuities are
aggregated with regard to any earnings and cost basis. If your annuity is a Serial Annuity, the tax information included with your check may not
include the Serial Annuity calculation. Tax information for a Serial Annuity distribution will be sent in a separate letter.
You understand that the decision to take this withdrawal is final.
You request and authorize RiverSource Life Insurance Company to deposit all future payments on your annuity contract to your account at the bank
listed above.
RiverSource Life Insurance Company will credit payments authorized for Electronic Deposit to the bank account you designate. Banking channels
require 10 business days for processing before Electronic Deposit authorizations become effective. If an Electronic Deposit fails because your bank
or bank account is closed, RiverSource Life Insurance Company will mail a check to you at the address of record on this account.
You authorize RiverSource Life Insurance Company to continue to deposit annuity payments to your account at the bank indicated above unless
the company is notified in writing at its corporate office in Minneapolis, MN, to change or cancel this authorization. RiverSource Life Insurance
Company offers this service at its discretion and may cancel the service at any time. RiverSource Life Insurance Company is authorized to cancel
direct deposits of annuity payments if the receiving bank or receiving bank account is closed or this account becomes inactive. You release
RiverSource Life Insurance Company and agree to hold it harmless from all liability for or in connection with payments paid through the Automated
Clearing House or any similar system to credit payments to the bank listed above. This agreement shall also be binding upon your personal
representatives, heirs, legatees, and assignees.
Contract Owner
Contract Owner Signature
Date (MMDDYYYY)
X
Contract Co-Owner
Contract Co-Owner Signature
Date (MMDDYYYY)
X
If signing as fiduciary, in what capacity are you acting?
POA
Conservator/Guardian
Other
Please call 1 (800) 862-7919 to ensure required Fiduciary documents are on file.
Is this transaction based on a recommendation by an Ameriprise financial advisor?
Yes
No
If yes, provide the Recommending Advisor Name and ID# below.
Name
200054
Advisor ID
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