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The Midland National form serves as a crucial document for individuals seeking to make partial surrenders from their annuity contracts. This form is designed to facilitate the process of withdrawing funds while ensuring compliance with regulatory requirements. It includes sections for account information, where users must provide details such as contract numbers and owner names. The form allows for the selection of the withdrawal type, including options for penalty-free withdrawals. Additionally, it outlines methods of payment, offering choices between traditional checks and electronic funds transfers. Acknowledgment of the accuracy of the information provided is mandatory, as incomplete submissions may lead to delays in processing requests. The form also addresses tax implications, requiring users to indicate their preferences regarding federal and state income tax withholding. Proper completion of this form is essential to meet the Written Notice Requirement outlined in the annuity contract, emphasizing the importance of thoroughness and attention to detail in the application process.

Midland National Example

Savings Account
Checking Account

Clear Form

PARTIAL SURRENDER REQUEST

To be completed for partial surrenders. For questions, please contact the Midland National Customer Service Department. Phone: 877-586-0244 Fax: 877-586-0249

I/We hereby acknowledge that the information provided herein is to the best of our knowledge true and accurate. I/We also acknowledge that this form must be fully completed, and failure to complete any portion of this form may delay the processing of this request. The completion of this form is necessary to satisfy the Written Notice Requirement as defined in Section 1 of your annuity contract.

I. Account Information

Contract Number:

Contract Owner:

First NameMI Last Name

Joint Owner's Name: (If applicable)

First Name

 

MI

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trust or Corporation Name: (if owner is a Trust or a Corporation)

Owner's Mailing Address:

Street Address

Phone Number

(

Address (cont.)

)

-

City

State

Zip Code

 

II. Partial Surrender Information (Please check one)

10% Penalty-Free Withdrawal

Other $

III. Method of Payment

A check will be sent out regular mail unless indicated differently

.

-

(Please specify net amount of check)

Alternate payment options:

 

Please bill my overnight account:

Carrier:

Account #:

Electronic Funds Transfer Authorization - I authorize Midland National and the financial institution listed on the following page to automatically deposit withdrawals into:

*The funds will generally be available three business days after the payment date.

*This option may not be available for all products.

(Continued on back)

6773Y

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REV 03/05

 

 

 

 

 

 

 

 

 

Date:
Date:
Date:
Notary Signature:
(A notary signature is needed for all surrender charges greater than $10,000)
Spousal Signature:Not Married Date:
(Spousal signature applicable only if the contract was issued in or the contract owner resides in: AZ, CA, ID, LA, NM, NV, TX, WA, or WI)
Joint Owner Signature/Assignee:
Contract Owner Signature/Assignee:
Certification - Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and;
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and;
3. I am a U.S. person.
(Must be completed)

III. Method of Payment (Continued)

Should an inappropriate deposit be made, the financial institution is authorized to make a debit entry to my account and return to Midland National the corrected amount. This authorization will remain in effect until I have cancelled it in writing.

Financial Institution's Name

Street Address

Address (cont.)

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Account Number at Financial Institution

Routing Number (ABA#)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A voided check is required for verification of all financial institution information.

IV. Election of Withholding

You must indicate if Federal/State income taxes should be withheld from your payment by signing and dating this election form and returning it to Midland National. State taxes will be withheld only if required by your state. Even if you elect not to have Federal/State income taxes withheld, you are liable for Federal/State income taxes on the taxable portion of your benefits. You may also be subject to tax penalties under the Estimated Tax Payment rules if your payments of estimated tax and withholding, if any, are not adequate. If no election is made, 10% Federal

income tax will be withheld.

Check One:

I do not want Federal/State income taxes withheld from my payment.

I do want Federal/State income taxes withheld from my payment.

Federal

%State

%

TAXPAYER IDENTIFICATION NUMBER (TIN):

Social Security Number

 

 

 

 

 

 

 

Employer Identification Number

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

JOINT TAXPAYER IDENTIFICATION NUMBER (TIN):

 

Social Security Number

 

 

 

 

 

 

 

Employer Identification Number

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6773Y

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File Breakdown

Fact Name Description
Form Purpose This form is used for requesting a partial surrender from an annuity account.
Customer Service For assistance, customers can contact Midland National at 877-586-0244.
Written Notice Requirement Completion of this form satisfies the Written Notice Requirement outlined in Section 1 of the annuity contract.
Account Information Users must provide the contract number and owner details, including mailing address and phone number.
Withdrawal Options Withdrawals can be 10% penalty-free or other specified amounts.
Payment Method Payments are typically sent by regular mail unless otherwise specified by the account holder.
Tax Withholding Account holders must indicate if they want federal or state taxes withheld from their payment.
Notary Requirement A notary signature is required for surrender charges exceeding $10,000.
Spousal Signature In certain states, a spousal signature is necessary if the contract was issued there or the owner resides in those states.
Financial Institution Verification A voided check is required to verify the financial institution information for electronic funds transfers.

Guide to Using Midland National

Filling out the Midland National form is an important step in processing your partial surrender request. To ensure that your request is handled smoothly, it is essential to provide accurate and complete information. Below are the steps to guide you through the process of filling out the form.

  1. Begin by entering your Contract Number in the designated field.
  2. Fill in the Contract Owner's Name including first name, middle initial, and last name.
  3. If applicable, provide the Joint Owner's Name in the same format as above.
  4. If the owner is a trust or corporation, include the Trust or Corporation Name.
  5. Complete the Owner's Mailing Address including street address, city, state, and zip code.
  6. Provide a Phone Number for contact purposes.
  7. In the Partial Surrender Information section, check the appropriate box for either a 10% penalty-free withdrawal or other amount.
  8. Specify the Method of Payment. Indicate if you want a check sent by regular mail or provide details for alternate payment options.
  9. If choosing electronic funds transfer, fill out the financial institution information, including the name, address, account number, and routing number.
  10. Attach a voided check for verification of your financial institution information.
  11. Decide on the Election of Withholding. Check the appropriate box to indicate if you want federal/state income taxes withheld.
  12. Provide your Taxpayer Identification Number (TIN), including Social Security Number or Employer Identification Number.
  13. If applicable, include the Joint Taxpayer Identification Number (TIN) as well.
  14. Sign and date the form where indicated. If surrender charges exceed $10,000, ensure a notary signature is included.
  15. If the contract was issued in certain states, include a spousal signature if required.

After completing these steps, review the form for accuracy before submitting it to Midland National. This will help to avoid any delays in processing your request.

Get Answers on Midland National

What is the purpose of the Midland National form?

The Midland National form is primarily used for requesting a partial surrender of funds from your annuity account. This form ensures that all necessary information is collected to process your request accurately and efficiently. It also satisfies the Written Notice Requirement as defined in your annuity contract, which is essential for compliance and record-keeping.

What information do I need to provide on the form?

When completing the Midland National form, you will need to provide the following information:

  • Your contract number.
  • Your name and, if applicable, the joint owner's name.
  • Mailing address and contact information.
  • The amount you wish to withdraw and whether it is a 10% penalty-free withdrawal or another specified amount.
  • Method of payment preference, such as check or electronic funds transfer.

Make sure to double-check all entries for accuracy, as incomplete forms may delay processing.

What happens if I do not complete the form correctly?

Failing to complete the Midland National form correctly can lead to delays in processing your partial surrender request. If any section is left blank or unclear, Midland National may need to reach out for clarification, which can extend the time it takes to receive your funds. To avoid this, ensure that every part of the form is filled out completely and accurately before submission.

Are there any tax implications for partial surrenders?

Yes, there can be tax implications when you request a partial surrender. Federal income tax may be withheld from your payment unless you specify otherwise on the form. If you choose not to have taxes withheld, you are still responsible for any taxes owed on the taxable portion of your withdrawal. Additionally, you might face penalties if your estimated tax payments are insufficient. Therefore, it's important to consider your tax situation when completing the withholding election section of the form.

How can I contact Midland National for assistance?

If you have questions or need assistance while filling out the Midland National form, you can reach out to their Customer Service Department. They are available at:

  • Phone: 877-586-0244
  • Fax: 877-586-0249

Don't hesitate to contact them if you need help or clarification on any part of the form.

Common mistakes

Completing the Midland National form accurately is essential to ensure a smooth processing experience. However, many individuals make common mistakes that can lead to delays or complications. Here are six mistakes to avoid when filling out the form.

One frequent error is neglecting to provide complete account information. It is crucial to fill in all required fields, including the contract number, owner’s name, and mailing address. Missing information can lead to processing delays, as Midland National requires all sections to be fully completed. Always double-check that every necessary detail is included before submitting the form.

Another mistake is incorrectly selecting the type of partial surrender. The form offers options such as a 10% penalty-free withdrawal or another specified amount. Failing to check one of these options can create confusion and may result in an incomplete request. Ensure that you clearly indicate your choice to avoid any misunderstandings.

People often overlook the method of payment section. A common oversight is not specifying how you want to receive your funds. If you prefer a method other than regular mail, such as electronic funds transfer, be sure to indicate that preference clearly. Remember, a voided check is required for verification if you choose to set up direct deposits.

Tax withholding is another area where mistakes frequently occur. Many individuals either forget to indicate their preferences for federal and state tax withholding or misunderstand the implications of their choices. If you do not make an election, Midland National will automatically withhold 10% for federal income tax. It is important to understand your tax obligations and make an informed decision on this matter.

Additionally, individuals sometimes fail to provide the necessary signatures. The form requires signatures from the contract owner, joint owner, and, in certain cases, a spouse. Not obtaining all required signatures can lead to the rejection of the form. Review the signature requirements carefully to ensure compliance.

Lastly, many people forget to include a voided check when authorizing electronic funds transfers. This check serves as verification of the financial institution information provided. Without it, the processing of your request may be delayed. Always remember to attach this important document to avoid unnecessary hold-ups.

By being aware of these common mistakes, individuals can help ensure that their Midland National form is completed accurately and efficiently, leading to a smoother transaction process.

Documents used along the form

When dealing with the Midland National form, there are several other documents and forms that are often required to ensure a smooth process. These documents help clarify account details, confirm identities, and facilitate transactions. Below is a list of five commonly used forms that accompany the Midland National form.

  • Identification Verification Form: This form is used to confirm the identity of the contract owner. It typically requires personal information such as Social Security numbers and addresses, ensuring that the request is legitimate and protecting against fraud.
  • Tax Withholding Election Form: This document allows the contract owner to specify whether they want federal and state taxes withheld from their payments. It is essential for tax purposes and helps avoid potential penalties for underpayment.
  • Change of Beneficiary Form: If there are changes to who will receive benefits upon the owner's death, this form must be completed. It ensures that the correct individuals are designated as beneficiaries and that their information is up to date.
  • Direct Deposit Authorization Form: This form authorizes Midland National to deposit funds directly into the owner's bank account. It streamlines the payment process and ensures that funds are received promptly.
  • Spousal Consent Form: Required in certain states, this form confirms that the spouse agrees to the terms of the contract and any withdrawals. It protects the rights of both parties and is necessary for compliance with state laws.

Each of these documents plays a crucial role in managing your account effectively. Ensuring that they are completed accurately and submitted alongside the Midland National form can help prevent delays and complications in processing your requests.

Similar forms

The Midland National form is similar to several other financial documents. Each of these documents serves a specific purpose in managing accounts and transactions. Below are five documents that share similarities with the Midland National form:

  • Withdrawal Request Form: Like the Midland National form, this document allows account holders to request withdrawals from their accounts. It typically requires personal information, account details, and the amount to be withdrawn.
  • Change of Beneficiary Form: This form enables policyholders to update the beneficiaries on their accounts. Similar to the Midland National form, it requires identification details and signatures to process changes effectively.
  • Account Closure Form: When closing an account, this form is necessary. It shares similarities with the Midland National form in that it requires personal information, account numbers, and instructions on how to handle remaining funds.
  • Direct Deposit Authorization Form: This document allows individuals to authorize direct deposits into their accounts. Much like the Midland National form, it requires banking information and consent to ensure proper processing.
  • Tax Withholding Election Form: This form is used to indicate preferences for tax withholding on payments. It parallels the Midland National form in that both require the taxpayer's identification and a clear indication of withholding preferences.

Dos and Don'ts

When filling out the Midland National form, it is essential to follow certain guidelines to ensure a smooth process. Here’s a list of what to do and what to avoid:

  • Do provide accurate information for all fields.
  • Do double-check your contract number and owner details.
  • Do specify the method of payment clearly.
  • Do sign and date the form where required.
  • Do include a voided check for verification of financial institution details.
  • Don't leave any sections blank; incomplete forms may delay processing.
  • Don't forget to indicate if you want taxes withheld.
  • Don't use a pencil; fill out the form in ink for clarity.
  • Don't ignore the notary requirement if surrender charges exceed $10,000.

Misconceptions

Understanding the Midland National form can be challenging, and several misconceptions may arise. Here are eight common misunderstandings about this form, along with clarifications to help you navigate it more easily.

  • Misconception 1: The form is only for full surrenders.
  • This form is specifically designed for partial surrender requests, allowing you to withdraw a portion of your funds rather than the entire amount.

  • Misconception 2: I don’t need to provide my taxpayer identification number.
  • Providing your taxpayer identification number is mandatory. This information helps ensure that any tax obligations are correctly handled.

  • Misconception 3: I can skip sections of the form if I think they don’t apply to me.
  • Every section of the form must be completed. Omitting any information can delay the processing of your request.

  • Misconception 4: I can choose any amount for withdrawal without restrictions.
  • While you can request a partial surrender, there may be limits based on your contract terms, including penalties for amounts exceeding certain thresholds.

  • Misconception 5: I can submit the form without a notary signature.
  • A notary signature is required for surrender charges greater than $10,000. This adds an extra layer of verification to your request.

  • Misconception 6: I don’t need to worry about tax withholding if I don’t want any withheld.
  • Even if you choose not to have taxes withheld, you are still responsible for any applicable taxes on the taxable portion of your withdrawal.

  • Misconception 7: The payment method I select is not important.
  • The method of payment you choose affects how quickly you receive your funds. If you prefer expedited options, be sure to indicate this on the form.

  • Misconception 8: The form is the same for all Midland National products.
  • Different products may have unique requirements. Always ensure you are using the correct form for your specific contract to avoid complications.

Key takeaways

When filling out and using the Midland National form, consider the following key takeaways:

  • Complete the Form Fully: Ensure every section is filled out completely. Missing information can delay processing.
  • Understand Partial Surrender Options: You can choose between a 10% penalty-free withdrawal or another specified amount.
  • Payment Method: A check will typically be sent via regular mail unless you specify otherwise. Consider alternate payment options if needed.
  • Tax Withholding: You must indicate whether you want federal or state taxes withheld from your payment. Default withholding is 10% if no election is made.
  • Notary Signature Required: If your surrender charges exceed $10,000, a notary signature is necessary.
  • Certification of Taxpayer Identification: You must certify your taxpayer identification number and confirm that you are not subject to backup withholding.
  • Voided Check for Verification: A voided check is required to verify the financial institution's information if you choose electronic funds transfer.

Following these guidelines will help ensure that your request is processed smoothly and efficiently.