Service Forms

Complete the entire form. Please type or print.

1. Complete this form and any applicable state-required replacement forms.
2. Please contact the current carrier for any requirements it may have for transferring money to another company.
3. Upon receiving this material Security Benefit will send an acceptance letter to the carrier.
4. If you are completing this form for a 403(b) or 403(b)(7) account/contract please contact your employer for any processing instructions the employer or third party administrator may require.

Complete each section of the form.

• This transaction will be processed as of the valuation date Security Benefit receives the request in proper form.
• Charges may apply to withdrawals.
• A copy of a blank voided check is required in order for funds to be distributed electronically. See Section 8.
• Please note: if you currently have a Required Minimum Distribution (RMD) program established on your account any additional withdrawals taken from your account will be considered part of the RMD for the current year. The number of remaining payments and/or the amount of your systematic RMD may change due to this withdrawal request.
• If your account is a retirement savings or governmental 457 plan, please refer to the applicable Special Tax Notice attached for a summary of the options available to you. Due to strict IRS regulations governing investment accounts we recommend that you evaluate your situation carefully and/or consult with your tax advisor to maintain the status of your account and/or to avoid any potential penalties.
• Tax Sheltered Account withdrawals may not be made from earnings credited after December 31, 1988, unless the withdrawal is due to any of the reasons indicated in Section 2.
• To initiate payments under the Guaranteed Lifetime Withdrawal Benefit (GLWB) rider, please use the Guaranteed Lifetime Withdrawal Benefit Income Election form.
• To initiate RMD payments, please use the Required Minimum Distribution form.

Complete the entire form. Please type or print.