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The Horace Mann Annuity Surrender form is a crucial document for individuals looking to withdraw funds from their annuity contracts. This form facilitates various types of transactions, including full surrenders and net or gross withdrawals. It outlines the necessary steps for submitting a request, whether by mail or fax, and emphasizes the importance of accuracy in completion. Failure to provide the required information can lead to delays or complications in processing. Additionally, the form highlights tax implications, particularly for those under certain age thresholds, and warns of potential penalties associated with early withdrawals. Individuals must also navigate specific conditions based on their contract type, such as 403(b) or 457(b) plans, to ensure compliance with IRS regulations. Clear instructions guide users through selecting their desired withdrawal method and specifying the amount, while also addressing any existing loans against the contract. Furthermore, the form requires signatures from both the annuity owner and, in some cases, their spouse or plan administrator, underscoring the need for proper authorization. Overall, understanding the components of the Horace Mann Annuity Surrender form is essential for a smooth withdrawal process.

Preview - Horace Mann Annuity Surrender Form

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Horace Mann Life Insurance Company

P.O. Box 4657

Springfield, IL 62708-4657

Fax 877-832-3785

SUR ANCHGRPOC

Annuity surrender/withdrawal request (not for hardship withdrawal or direct

rollover transactions - see attached tax notice)

A.Your instructions

Your request can be made by mail or by fax, however, if your request is received by fax and is for an amount of $250,000 or more, our office will contact you by phone to verify the request.

Please read this form carefully. If you have any questions about completing this form accurately or with regard to your supporting documentation, please call a Customer Care Center Representative at 800-999-1030. If you do not completely and accurately complete this form or if the required documentation is insufficient, your funds may be delayed and you may need to start the process over. Requests for transactions that are ambiguous or in conflict with other requests will be held until clarification is received.

The Internal Revenue Service (IRS) has placed restrictions on when funds can be withdrawn from annuity contracts. If the contract owner is under age 59 ½ (or 70 ½ if 457(b) contract) when the request is signed, the distribution may be subject to an additional IRS 10% early withdrawal penalty tax. Please consult with your local IRS agency or personal tax advisor to determine if the transaction will be subject to taxes or penalties. Please read the attached related special tax notices.

B.About your surrender/withdrawal

I understand that any applicable Horace Mann contract charges or penalties and/or withholding taxes will apply and withholding taxes may reduce the requested distributed amount. I understand that non-qualified contracts, when issued in the same tax year, must aggregate their cost basis values for any distributions.

A net withdrawal allows you to receive a specific amount after taxes are withheld which will result in a larger amount withdrawn than you originally requested. A gross withdrawal will reduce the amount you requested by the taxes withheld. If no method is selected or if the selected method will not fulfill your request, we will pro-rate against the current holdings. If the request would allow the contract’s value to fall below $100, a maximum withdrawal will be processed.

If there is a defaulted loan against your contract and the qualifying event in Section E allows, we will foreclose on the loan prior to distribution. If there is an active loan and you are requesting a full surrender and the qualifying event in Section E allows, we will pay off the loan balance using value from your contract/certificate and forward the remaining funds effective as of the next business day. If the annuity has a current loan that must remain in place, only the available amount will be withdrawn, and we will send you the reduced amount.

C.Your information

Name________________________________________________ Contract/Certificate # ______________________

Address ___________________________________ City _________________ State _________ ZIP ____________

Home phone # ___________________ Work phone # __________________ Last four digits of SSN _____________

D.Your requested amount (a reduced amount will be sent if your request exceeds the amount eligible for withdrawal)

1.surrender and terminate my contract, or

2.make a net withdrawal of $___________________ using the following method:

a.equally from each investment option, or

b.pro-rated against the current holdings, or

c.from the investment options indicated below**, or

3.make a gross withdrawal of $___________________ using the following method:

a.equally from each investment option, or

b.pro-rated against the current holdings, or

c.from the investment options indicated below**, or

4.withdraw only the free out amount (defined within my contract) pro-rated against the current holdings, or

5.withdraw the amount indicated on the attached employer form to buy back years of service; employer acceptance included, using the following method:

a.equally from each investment option, or

b.pro-rated against the current holdings, or

c.from the investment options indicated below**, or

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Contract/Certificate # ______________________

6.withdraw my over-contribution for tax year ________________, in the amount of $ ______________, which is in excess of the IRS allowable contribution, plus any earnings or minus any losses on this amount.

**For 2c, 3c or 5c, please indicate amount ($), percentage (%), maximum amount allowed (“max”) or “all” (investment option table attached) remainder is not acceptable.

_________ from ________

_________ from ________

_________ from ________

_________ from ________

_________ from ________

_________ from ________

_________ from ________

_________ from ________

_________ from ________

_________ from ________

_________ from ________

_________ from ________

E.Your contract is a 403(b), 457(b) or 401(a) qualified plan and the reason for this request is:

1. Cash value on account as of 12/23/88 (applies to withdrawal only)

2. Disability — Horace Mann requires the attached Disability declaration from you and your doctor verifying that you are currently disabled and have been for at least three months (can not apply to loan foreclosures).

3. Age—I certify that I am at least 59 ½ years of age for my 403(b) contract or 70 ½ for my 457(b) contract, and therefore qualify to withdraw tax-deferred funds without IRS restriction, however, I understand that my plan document may require additional authorization.

4. Severance from employment-I have severed my employment with the employer sponsoring this plan and have attached documentation to support this statement. I understand that my employer or their third party administrator’s authorization may also be required.

Date of severance ______________________________

F.Your tax withholding elections:

Federal income tax elections

Payments you receive from your annuity will be subject to federal income tax withholding as indicated below.

If your contract is a 401(a), 457(b) or 403(b) (includes Roth 403(b)), any portion of your distribution that is includable in income is subject to federal income tax withholding at a rate of 20 % and you may not elect out of this withholding requirement.

If your contract is a Non-qualified annuity, any portion of your distribution that is includable in income is subject to federal income tax withholding at a rate 10%. You may elect withholding not to apply.

If your contract is an IRA, Simple or SEP, the entire distribution, other than a return of excess contributions, is subject to federal income tax withholding at a rate 10%. You may elect withholding not to apply.

If your contract is a Roth, no federal income tax withholding is required.

If you elect not to have federal withholding apply to your annuity payments, or if you do not have enough federal income tax withheld, you may be responsible for payment of estimated tax and you may incur penalties under the estimated tax rules. Please consult your tax advisor for further information.

I do not want to have federal income tax withheld from my payment, if allowed.

I want federal income tax withheld from my payment as follows: $ ___________________________ or __________%.

State income tax election:

Some states require that we withhold state income tax when we withhold federal income tax and in these instances, we will calculate the amount of withholding for you. In some of these states, you may ask for no state income tax withholding (even though federal income tax was withheld) or you may specify the amount or percentage you want withheld. When you request an amount which is less than required by your state, we will withhold the required amount. In other states, no state income tax will apply unless you indicate the amount you want withheld.

State income tax withholding is not allowed in Alaska, Florida, Nevada, New Hampshire, South Dakota, Tennessee,

Texas, Washington and Wyoming.

I do not want to have state income tax withheld from my payment, if allowed in my state.

I want state income tax withheld from my payment as follows:

$____________________________ or __________ %.

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Contract/Certificate # ______________________

G. Your surrender/withdrawal proceeds delivery method

Send a check to my address.

Deposit funds by Direct Deposit (electronically deposit funds directly into my bank account).

Bank name ____________________________________________________________________________________

Bank address __________________________________________________________________________________

Name on the account ____________________________________________________________________________

ABA routing ________________________________ Bank account # ___________________________________

Checking (provide a copy of a voided check) OR Savings (provide a savings deposit slip). When submitting a deposit slip, please contact your bank before submitting, as the routing numbers on deposit slips are not always accurate for use in EFT transactions.

H.Your signature(s) (must be completed)

By signing this request, I certify that I have read the attached special tax notices regarding my payment from this tax sheltered annuity and waive the 30 day notice period, if applicable. I acknowledge full responsibility for any and all federal and state income taxes and penalties. Furthermore, by signing this Annuity surrender/withdrawal request, I certify to the validity of the representations made to Horace Mann Life Insurance Company (HMLIC). I hold HMLIC and any or all of its affiliates, agents/insurance producers, and employees harmless from any and all liability past, present, and future that may arise as a result of this transaction. I authorize Horace Mann to provide data regarding this request to my Employer or Plan Administrator or their designee, when requested.

Client signature_____________________________________________________ Date _______________________

Address ______________________________________________________________________________________

Street

City

State

ZIP

The address above is a permanent address change. If the address above is an address change or if you have made us aware of your address change within the past 15 days, we will send you a letter to confirm the new address change to both the previous and the new address. We will not release your distribution to you until the full 15 days following the address change has passed.

Spouse’s signature _____________________________________________________ Date ________________

If contract was issued in Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington or Wisconsin and the owner was married at the time of issue, the spouse’s signature is required.

Your plan administrator’s authorization

A plan administrator’s signature/authorization is required for all 401(a) or 457(b) contracts. If this contract is a 403(b), and your plan requires it, your plan administrator must authorize this request.

I authorize this surrender/withdrawal, as requested. I certify that I am authorized to act on behalf of the employer listed below. I have reviewed all records and have obtained all documentation required by the plan and certify that this transaction is authorized under the plan document. If severance was chosen as the reason for the distribution, the date of severance is ____________________________.

Name of employer or Third Party Administrator ________________________________________________________

Signature__________________________________________Title ________________________________________

Date _________________________

Your agent/insurance producer ______________________________________________ producer # ____________

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Disability declaration

Please have your physician read, sign and return this form with your request.

Client name ______________________________________________ Contract/Certificate number _________________

Residents of all states except Massachusetts:

Certification of disability as defined by the Internal Revenue Code Section 72(m)(7).

As the physician of the above named owner, I certify that he/she is disabled as defined by the following definition of disability

of IRC Section 72(m)(7):

“For purposes of this section, an individual shall be considered to be disabled if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in

death or to be long-continued and indefinite duration.”

____________________________________________

__________________________________________

Client signature/date

Physician signature/date

Residents of Massachusetts:

Certification of disability as defined by Massachusetts law:

As the physician of the above named owner, I certify that he/she is disabled as defined as any of the following conditions: (check one of the following)

Chronic Illness defined as a condition because of which an individual is (a) unable to perform at least two activities of daily living for a period of 90 days due to a loss of functional capacity, (b) having a level of disability similar to the level of disability described above, or (c) requiring substantial supervision to protect such individuals from threats to health and safety due to severe cognitive impairment.

Terminal Illness is defined as a condition that will reasonably be expected to result in death in 24 months or less.

Any medical condition including but not limited to acquired immune deficiency syndrome, coronary artery disease, major organ transplant, medical condition requiring continuous life support, permanent neurological deficit resulting from cerebral vascular accident, or other qualifying condition.

____________________________________________

_________________________________________

Client name signature/date

Physician signature/date

In cases that the individual qualifies for benefits because of Chronic Illness only, the benefit amount shall be payable only for expenses incurred for Qualified Long-Term Care Services defined as the necessary diagnostic, preventive, therapeutic curing, treating, mitigating and rehabilitative services, and maintenance or personal care services that are required by a chronically ill individual and are provided pursuant to a plan of care prescribed by a licensed health care practitioner.

I the owner, certify that any benefits paid solely due to Chronic Illness would be used to fund Qualified Long-Term Care

Services.

____________________________________________

Client signature/date

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The following pages are for your retention; not necessary to return to Horace Mann

Annuity contract investment options; certain group annuities may be further limited by their plan

Investment style

Investment option # Investment option name

Life Cycle

063

Wilshire VIT 2015 ETF Fund

 

064

Wilshire VIT 2025 ETF Fund

 

065

Wilshire VIT 2035 ETF Fund

Asset Allocation

076

Ibbotson Conservative ETF Asset Allocation Portfolio Class II

 

077

Ibbotson Income & Growth ETF Asset Allocation Portfolio Class II

 

078

Ibbotson Balanced ETF Asset Allocation Portfolio Class II

 

079

Ibbotson Growth ETF Asset Allocation Portfolio Class II

Large Company Value

080

Ibbotson Aggressive Growth ETF Asset Allocation Portfolio Class II

027

Davis Value Portfolio

 

055

T. Rowe Price Equity Income Portfolio VIP II

Large Company Core

014

Wilshire Large Company Value Portfolio

020

Fidelity VIP Growth and Income Portfolio (SC2)

 

021

Fidelity VIP Index 500 Portfolio (SC2)

 

069

JP Morgan Insurance Trust U.S. Equity Portfolio

 

012(010)

Wilshire 5000 Index Portfolio - (used prior to 9/5/00)

 

001

Wilshire VIT Equity Fund

Large Company Growth

033

AllianceBernstein VPS Large Cap Growth Portfolio

 

082

Delaware VIP 53 'ROWTHR3ERIES 3ERVICE Class

 

023

Fidelity VIP Growth Portfolio (SC2)

 

013(011)

Wilshire Large Company Growth Portfolio (used prior to 9/5/00)

Mid-size Company Value

056

AllianceBernstein VPS Small/Mid Cap Value

 

081

American Century VP Mid Cap Value Class I

 

037

Ariel Appreciation Fund

 

036

Ariel Fund

 

070

Goldman Sachs VIT Mid Cap Value

Mid-size Company Core

028

Wells Fargo Advantage VT Opportunity Fund

071

Calvert S & P Mid Cap 400 Index

 

051

Dreyfus Inv Portfolio: Mid Cap Stock Portfolio (SC)

 

022

Fidelity VIP Mid Cap Portfolio (SC2)

Mid-size Company Growth

031

Rainier Small/Mid Cap Equity Portfolio

048

Delaware VIP Smid Cap Growth Series SC

 

049

Lord Abbett Series Fund Growth Opportunities

 

075

Putnam VT Multi-Cap Growth Fund

 

054

Wells Fargo Advantage VT Discovery Fund

Small Company Value

053

Royce Capital Fund Small Cap Portfolio

 

017

T Rowe Price Small Cap Value Fund

Small Company Core

015

Wilshire Small Company Value Portfolio

068

Dreyfus: Small Cap Stock Index Portfolio SC

 

050

Goldman Sachs VIT Structured Small Cap Equity Fund

 

072

Lazard Ret US Small-Mid Cap Equity Portfolio

 

032

Neuberger Berman Genesis Fund (Advisor Class)

 

018

T Rowe Price Small Cap Stock Fund

Small Company Growth

057

AllianceBernstein VPS Small Cap Growth Portfolio

 

092

Lord Abbett Developing Growht Portfolio

 

016

Wilshire Small Company Growth Portfolio

 

009

Wilshire VIT Small Cap Growth Fund

International

073

Fidelity VIP Emerging Markets SC2

 

024

Fidelity VIP Overseas Portfolio (SC2)

 

008

Wilshire VIT International Equity Fund

Specialty

007

Wilshire VIT Socially Responsible Fund

Real Estate

067

Delaware VIP REIT Series (Service Class)

Bond Options

025

Fidelity VIP High Income Portfolio (SC2)

 

026

Fidelity VIP Investment Grade Bond Portfolio (SC2)

 

074

Templeton Global Bond Securities Fund

Balanced

003

Wilshire VIT Income Fund

002

Wilshire VIT Balance Fund

Money Market

059

T Rowe Price Prime Reserve Portfolio

Fixed

000

Fixed Account

 

805

5 year Guarantee Period Acct (variable group products only)

 

807

7 year Guarantee Period Acct (variable group products only)

 

810

10 year Guarantee Period Acct (variable group products only)

 

815

5 year Guarantee Period Acct (fixed group products only)

 

817

7 year Guarantee Period Acct (fixed group products only)

 

820

10 year Guarantee Period Acct (fixed group products only)

 

900

Special DCA Holding Account (unavailable to contracts issued in Oregon)

 

901

Special 3-month DCA Account (unavailable to contracts issued in Oregon)

 

902

Special 6-month DCA Account (unavailable to contracts issued in Oregon)

 

903

Special 12-month DCA Account (unavailable to contracts issued in Oregon)

 

998

Loan Account

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Special tax notice for payments NOT from a Designated Roth account

This notice is based, in part, on an Internal Revenue Service model notice and as a result, certain sections of the notice may not be applicable to your Plan.

Your rollover options

You are receiving this notice because all or a portion of a payment you are receiving from a Horace Mann Life Insurance Company annuity issued under a tax qualified plan, section 403(b) plan or governmental section 457(b) plan (the “Plan”) is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide whether to do such a rollover.

This section of the notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan, you should read the “Special tax notice for payments from a Designated Roth account” latter in this document, and the Plan administrator or the payor will tell you the amount that is being paid from each account.

Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section. Special rules that only apply in certain circumstances are described in the “Special Rules and Options” section.

General information about rollovers

How can a rollover affect my taxes?

You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59 1/2 and do not do a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59 1/2 (or if an exception applies).

Where may I roll over the payment?

You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the IRA or employer plan.

How do I do a rollover?

There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.

If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRS sponsor or the administrator of the employer plan for information on how to do a direct rollover.

If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a

60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are under age 59 1/2 (unless an exception applies).

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:

Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

Required minimum distributions after age 70 1/2 (or after death)

Hardship distributions

Corrective distributions of contributions that exceed tax law limitations

Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends)

Cost of life insurance paid by the Plan

Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment.

The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.

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If I don't do a rollover, will I have to pay the 10% additional income tax on early distributions?

If you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the payment not rolled over. The 10% additional income tax does not apply to the following payments from the Plan:

Payments made after you separate from service if you will be at least age 55 in the year of the separation.

Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

Payments made due to disability

Payments after your death

Corrective distributions of contributions that exceed tax law limitations

Cost of life insurance paid by the Plan.

Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment

Payments made directly to the government to satisfy a federal tax levy

Payments made under a qualified domestic relations order (QDRO).

Payments up to the amount of your deductible medical expenses

Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days.

If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?

If you receive a payment from an IRA when you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions from the IRA, unless an exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same as the exceptions listed above for early distributions from a plan. However, there are a few differences for payments from an IRA, including:

There is no exception for payments after separation from service that are made after age 55.

The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service.

The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).

There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and eligible to receive unemployment compensation but for self-employed status).

Will I owe State income taxes?

This notice does not describe any State or local income tax rules (including withholding rules).

Special rules and options

If your payment includes after-tax contributions

After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax contributions is generally included in the payment. If you have pre-1987 after-tax contributions maintained in a separate account, a special rule may apply to determine whether the after-tax contributions are included in a payment.

You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable portion of the after-tax contributions. If you do a 60-day rollover to an IRA of only a portion of the payment made to you, the after-tax contributions are treated as rolled over last. For example, assume you are receiving a complete distribution of your benefit which totals $12,000, of which $2,000 is after-tax contributions. In this case, if you roll over $10,000 to an IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is treated as being after-tax contributions.

You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled over.

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If you miss the 60-day rollover deadline Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).

If you have an outstanding loan that is being offset

If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The loan offset amount is treated as a distribution to you at the time of the offset and will be taxed (including the 10% additional income tax on early distributions, unless an exception applies) unless you do a 60-day rollover in the amount of the loan offset to an IRA or employer plan.

If you were born on or before January 1, 1936

If you were born on or before January 1, 1936 and receive a lump sum distribution that you do not roll over, special rules for calculating the amount of the tax on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.

If your payment is from a governmental section 457(b) plan

If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice generally apply, allowing you to roll over the payment to an IRA or an employer plan that accepts rollovers. One difference is that, if you do not do a rollover, you will not have to pay the 10% additional income tax on early distributions from the Plan even if you are under age 59 1/2 (unless the payment is from a separate account holding rollover contributions that were made to the Plan from a tax-qualified plan, a section 403(b) plan, or an IRA). However, if you do a rollover to an IRA or to an employer plan that is not a governmental section 457(b) plan, a later distribution made before age 59 1/2 will be subject to the 10% additional income tax on early distributions (unless an exception applies). Other differences are that you cannot do a rollover if the payment is due to an “unforeseeable emergency” and the special rules under “if you were born on or before January 1, 1936”, do not apply.

If you roll over your payment to a Roth IRA You can roll over a payment from the Plan made before January 1, 2010 to a Roth IRA only if your modified adjusted gross income is not more than $100,000 for the year the payment is made to you and, if married, you file a joint return. These limitations do not apply to payments made to you from the Plan after 2009. If you wish to roll over the payment to a Roth IRA, but you are not eligible

to do a rollover to a Roth IRA until after 2009, you can do a rollover to a traditional IRA and then, after 2009, elect to convert the traditional IRA into a Roth IRA.

If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax amounts) will be taxed. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within 5 years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that are rolled over to a Roth IRA, the taxable amount can be spread over a 2-year period starting in 2011.

If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a payment made after you are age 59 1/2 (or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent of earnings after the rollover, including the 10% additional income tax on early distributions (unless an exception applies). You do not have to take required minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).

You cannot roll over a payment from the Plan to a designated Roth account in an employer plan.

If you are not a plan participant Payments after death of the participant. If you receive a distribution after the participant's death that you do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this notice. However, the 10% additional income tax on early distributions do not apply and the special rule described under the section “If you were born on or before January 1, 1936” applies only if the participant was born on or before January 1, 1936.

If you are a surviving spouse.

If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the same rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat the IRA as your own or as an inherited IRA.

An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59 1/2 will be subject to the 10% additional income tax on early distributions (unless an exception applies) and required minimum distributions from your IRA do not have to start until after you are age 70 1/2.

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If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional income tax on early distributions. However, if the participant had started taking required minimum distributions, you will have to receive required minimum distributions from the inherited IRA. If the participant had not started taking required minimum distributions from the Plan, you will not have to start receiving required minimum distributions from the inherited IRA until the year the participant would have been age 70 1/2.

If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the participant's death and you are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA. Payments from the inherited IRA will not be subject to the 10% additional income tax on early distributions. You will have to receive required minimum distributions from the inherited IRA.

Payments under a qualified domestic relations order. If you are the spouse or former spouse of the participant who receives a payment from the Plan under a qualified domestic relations order (QDRO), you generally have the same options the participant would have (for example, you may roll over the payment to your own IRA or an eligible employer plan that will accept it). Payments under the QDRO will not be subject to the 10% additional income tax on early distributions.

If you are a nonresident alien

If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan is generally required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a 60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.

Other special rules

If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in the series (unless you make a different choice for later payments).

If your payments for the year are less than $200 (not including payments from a designated Roth account in the Plan), the Plan is not required to allow you to do a direct rollover and is not required to withhold for federal income taxes. However, you may do a 60-day rollover.

Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a designated Roth account in the Plan) will be directly rolled over to an IRA chosen by the Plan administrator or the payor. A mandatory cashout is a payment from a plan to a participant made before age 62 (or normal retirement age, if later) and without consent, where the participant's benefit does not exceed $5,000 (not including any amounts held under the plan as a result of a prior rollover made to the plan).

You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces' Tax Guide.

For more information

You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can find more detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590, Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from a local IRS office, on the web at www.irs.gov, or by calling 800-TAX-FORM.

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Special tax notice for payments from a Designated Roth account

This notice is based, in part, on an Internal Revenue Service model notice and as a result, certain sections of the notice may not be applicable to your Plan.

General information

A designated Roth contribution is an elective contribution under a cash or deferred arrangement that is (i) designated by the employee at the time of the cash or deferred election as a designated Roth contribution that is being made in lieu of all or a portion of the pre-tax elective contribution the employee is eligible to make under the plan, (ii) treated by the employer as includible in the employee's gross income at the time the employee would have received the amount in cash if the employee had not made the cash or deferred election, and (iii) maintained by the plan in a separate account.

Your rollover options

You are receiving this notice because all or a portion of a payment you are receiving from a Horace Mann Life Insurance Company annuity issued under a section 403(b) plan or governmental section 457(b) plan (the “Plan”) is eligible to be rolled over to a Roth IRA or designated Roth account in an employer plan. This notice is intended to help you decide whether to do a rollover.

This section of the notice describes the rollover rules that apply to payments from the Plan that are from a designated Roth account. If you also receive a payment from the Plan that is not from a designated Roth account, you should read the separate notice “Special tax notice for payments not from a Designated Roth account” provided earlier in this document, and the Plan administrator or the payor will tell you the amount that is being paid from each account.

Rules that apply to most payments from a designated Roth account are described in the “General Information About Rollovers” section. Special rules that only apply in certain circumstances are described in the “Special Rules and Options” section.

General information about rollovers

How can a rollover affect my taxes? After-tax contributions included in a payment from a designated Roth account are not taxed, but earnings might be taxed. The tax treatment of earnings included in the payment depends on whether the payment is a qualified distribution. If a payment is only part of your designated Roth account, the payment will include an allocable portion of the earnings in your designated Roth account.

If the payment from the Plan is not a qualified distribution and you do not do a rollover to a Roth IRA or a designated Roth account in an employer plan, you will be taxed on the earnings in the payment. If you are under age 59 1/2, a 10% additional income tax on early distributions will also apply to the earnings (unless an exception applies).

If the payment from the Plan is a qualified distribution, you will not be taxed on any part of the payment even if you do not do a rollover. If you do a rollover, you will not be taxed on the amount you roll over and any earnings on the amount you roll over will not be taxed if paid later in a qualified distribution.

A qualified distribution from a designated Roth account in the Plan is a payment made after you are age 59 1/2 (or after your death or disability) and after you have had a designated Roth account in the Plan for at least 5 years. In applying the 5-year rule, you count from January 1 of the year your first contribution was made to the designated Roth account. However, if you did a direct rollover to a designated Roth account in the plan from a designated Roth account in another employer plan, your participation will count from January 1 of the year your first contribution was made to the designated Roth account in the Plan or, if earlier, to the designated Roth account in the other employer plan.

However, if you do a rollover, you will not have to pay taxes currently on the earnings and you will not have to pay taxes later on payments that are qualified distributions.

Where may I roll over the payment?

You may roll over the payment to either a Roth IRA (a Roth individual retirement account or Roth individual retirement annuity) or a designated Roth account in an employer plan (a tax-qualified plan or section 403(b) plan) that will accept the rollover. The rules of the Roth IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the Roth IRA or employer plan (for example, no spousal consent rules apply to Roth IRAs and Roth IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the Roth IRA or the designated Roth account in the employer plan. In general, these tax rules are similar to those described elsewhere in this notice, but differences include:

If you do a rollover to a Roth IRA, all of your Roth IRAs will be considered for purposes of determining whether you have satisfied the 5-year rule (counting from January 1 of the year for which your first contribution was made to any of your Roth IRAs).

If you do a rollover to a Roth IRA, you will not be required to take a distribution from the Roth IRA during your lifetime and you must keep track of the aggregate amount of the after-tax contributions in all of your Roth IRAs (in order to determine your taxable income for later Roth IRA payments that are not qualified distributions).

Eligible rollover distributions from a Roth IRA can only be rolled over to another Roth IRA.

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Document Specifics

Fact Name Details
Company Information Horace Mann Life Insurance Company, P.O. Box 4657, Springfield, IL 62708-4657, Fax: 877-832-3785
Request Method Requests can be submitted via mail or fax. For amounts of $250,000 or more, verification by phone is required.
IRS Penalties If the contract owner is under age 59½, a 10% early withdrawal penalty may apply.
Withdrawal Types Options include surrendering the contract, net or gross withdrawals, and specific methods for fund allocation.
State-Specific Laws State income tax withholding rules apply, with exceptions for states like Alaska and Florida. Consult local regulations.
Signature Requirement Client and spouse signatures are required for certain states. A plan administrator's authorization is needed for 401(a) and 457(b) contracts.

Horace Mann Annuity Surrender: Usage Instruction

Completing the Horace Mann Annuity Surrender form requires careful attention to detail. Follow the steps outlined below to ensure that your submission is accurate and complete. After you fill out the form, it will be processed according to the instructions you provide.

  1. Begin by printing the form clearly.
  2. Provide your name and contract or certificate number in the designated fields.
  3. Fill in your address, including city, state, and ZIP code.
  4. Enter your home and work phone numbers, along with the last four digits of your Social Security Number.
  5. Indicate your requested amount for surrender or withdrawal by checking the appropriate box and filling in the amount if required.
  6. Select your preferred method for the withdrawal, such as equally from each investment option or pro-rated against current holdings.
  7. Choose the reason for your request from the options provided in Section E.
  8. Complete the tax withholding elections for both federal and state taxes, if applicable.
  9. Decide on the delivery method for your proceeds, either by check or direct deposit, and fill in the necessary bank information if applicable.
  10. Sign and date the form in the designated signature area, ensuring that all required signatures are included.
  11. If applicable, have your spouse sign the form, especially if the contract was issued in certain states.
  12. If required, obtain the plan administrator's authorization and signature.
  13. Attach any necessary documentation, such as a disability declaration if applicable.
  14. Mail or fax the completed form to Horace Mann Life Insurance Company at the address or fax number provided.

Learn More on Horace Mann Annuity Surrender

What is the purpose of the Horace Mann Annuity Surrender form?

The Horace Mann Annuity Surrender form is used to request the withdrawal or surrender of funds from your annuity contract. This form allows you to specify the amount you wish to withdraw, the method of withdrawal, and any applicable tax withholding preferences. It is important to fill out the form completely and accurately to avoid delays in processing your request.

How can I submit my surrender request?

You can submit your surrender request either by mail or by fax. If you choose to fax your request and it is for an amount of $250,000 or more, a representative from the office will contact you by phone to verify the request. It is crucial to ensure that all required documentation is included with your submission to prevent any processing delays.

What are the tax implications of withdrawing funds from my annuity?

Withdrawing funds from your annuity may have tax consequences. If you are under the age of 59½, you may be subject to a 10% early withdrawal penalty imposed by the IRS. Additionally, federal income tax withholding will apply to your distribution based on the type of annuity contract you have. For example, 20% withholding is mandatory for 401(a), 457(b), or 403(b) contracts. It is advisable to consult with a tax advisor to understand how your withdrawal will affect your tax situation.

What happens if I do not complete the form correctly?

If the Horace Mann Annuity Surrender form is not filled out completely or accurately, your request may be delayed. In some cases, you may need to start the process over. Ambiguous requests or those that conflict with other requests will be held until clarification is received. To avoid these issues, it is recommended to read the form carefully and reach out to a Customer Care Center Representative if you have any questions.

Common mistakes

Completing the Horace Mann Annuity Surrender form can be straightforward, but many individuals make common mistakes that can lead to delays or complications. One frequent error is failing to provide clear and legible information. The form explicitly requests that applicants print their information clearly. Illegible handwriting can result in misunderstandings or misprocessing of the request, potentially causing funds to be delayed.

Another mistake involves not selecting a specific withdrawal method. The form offers various options for how to withdraw funds, including net and gross withdrawals. If a method is not chosen or if the chosen method does not fulfill the request, the processing may default to a pro-rated option, which may not align with the individual's intentions. This can lead to receiving less than expected.

Inaccurate or incomplete information regarding personal details is also a common pitfall. Applicants must ensure that all fields are filled out accurately, including the contract number, address, and Social Security number. Omitting any of this essential information can lead to processing delays or even rejection of the request.

Another area where mistakes often occur is in the tax withholding elections section. Individuals may overlook the requirement for federal and state tax withholding. If the proper withholding is not indicated, it may result in unexpected tax liabilities later. Understanding the tax implications of the withdrawal is crucial, and consulting a tax advisor can help clarify these responsibilities.

Additionally, individuals may neglect to include necessary documentation when required. For example, if the reason for the withdrawal is due to disability, the form requires a physician’s declaration. Failing to attach this documentation can halt the process, requiring the individual to start over.

Finally, some applicants forget to sign the form. A signature is mandatory for processing the request. Without it, the form is incomplete, and the request cannot be fulfilled. Ensuring that all signatures, including that of a spouse if required, are included is essential for a smooth transaction.

Documents used along the form

When you're considering surrendering your annuity with Horace Mann, there are several other forms and documents you may need to complete or provide alongside the Annuity Surrender form. These documents help ensure that your request is processed smoothly and in compliance with regulations. Below is a list of commonly used forms that may accompany your surrender request.

  • Disability Declaration Form: This document is necessary if you are claiming a disability as the reason for your withdrawal. It requires verification from your physician that you meet the IRS definition of disability.
  • Tax Withholding Election Form: This form allows you to specify how much federal and state income tax should be withheld from your withdrawal. It’s crucial to understand the tax implications of your distribution.
  • Employer Authorization Form: If your annuity is part of a qualified plan, this form must be completed by your employer or plan administrator to confirm that your withdrawal request complies with plan rules.
  • Address Change Notification: If you have recently changed your address, this form ensures that your new address is updated in the system, which is important for receiving your funds and any correspondence.
  • Proof of Severance from Employment: If you are withdrawing due to severance from your employer, you will need to provide documentation that verifies your employment status.
  • Request for Direct Deposit Form: If you prefer to have your funds electronically deposited into your bank account, this form will collect your banking information to facilitate the transfer.
  • Investment Option Selection Form: This document allows you to specify how your withdrawal should be distributed among various investment options, ensuring that your preferences are met during the transaction.

Having these forms ready and understanding their purposes can significantly streamline the process of surrendering your annuity. Be sure to read through each document carefully and consult with a financial advisor if you have questions. This way, you can make informed decisions that align with your financial goals.

Similar forms

The Horace Mann Annuity Surrender form shares similarities with a 401(k) withdrawal request form. Both documents serve as official requests to withdraw funds from a retirement account. They require the account holder to provide personal information, such as their name and Social Security number, as well as details about the amount they wish to withdraw. Additionally, both forms often include tax implications and penalties for early withdrawals, ensuring that the account holder is aware of potential financial consequences.

Another comparable document is the IRA distribution request form. Like the Horace Mann Annuity Surrender form, the IRA distribution request form facilitates the withdrawal of funds from an Individual Retirement Account. Both forms require the account holder to specify the amount of money they wish to withdraw and may include options for tax withholding. Furthermore, they both emphasize the importance of understanding the tax implications associated with the withdrawal, particularly if the account holder is under a certain age.

The 457(b) plan withdrawal request form is also similar. This document allows employees of state and local governments to request distributions from their 457(b) retirement plans. Similar to the Horace Mann form, it requires personal information, the reason for the withdrawal, and acknowledgment of any applicable taxes or penalties. Both forms aim to ensure that the account holder is fully informed about the consequences of their withdrawal decision.

Additionally, the disability benefits application form bears resemblance to the Horace Mann Annuity Surrender form. Both documents require the individual to provide medical documentation or certification to support their request. In the case of the Horace Mann form, this is particularly relevant if the withdrawal is due to disability. Both forms emphasize the need for proper verification to ensure compliance with regulations and eligibility criteria.

Lastly, the hardship withdrawal request form is akin to the Horace Mann Annuity Surrender form. This document allows individuals to withdraw funds from their retirement accounts due to immediate and pressing financial needs. Both forms require detailed information about the individual’s situation and may necessitate supporting documentation. They also highlight the importance of understanding the potential long-term effects of withdrawing funds from retirement savings.

Dos and Don'ts

When filling out the Horace Mann Annuity Surrender form, keep these tips in mind:

  • Print clearly and legibly to avoid confusion.
  • Double-check that all required fields are filled in completely.
  • Provide accurate documentation to support your request.
  • Choose the correct withdrawal method to ensure your needs are met.
  • Contact customer support if you have any questions before submitting.

Avoid these common mistakes:

  • Do not leave any sections blank; incomplete forms can delay processing.
  • Don’t forget to sign and date the form where required.
  • Avoid submitting requests that conflict with previous requests.
  • Do not ignore tax implications; consult a tax advisor if needed.
  • Don’t submit the form without reviewing all attached notices and instructions.

Misconceptions

  • Misconception 1: The Horace Mann Annuity Surrender form can only be submitted by mail.
  • This is not true. You can submit your request by fax as well. However, if the amount is $250,000 or more, a phone verification will be required.

  • Misconception 2: You can withdraw any amount from your annuity without restrictions.
  • Withdrawals are subject to certain restrictions. If your request exceeds the amount eligible for withdrawal, a reduced amount will be processed.

  • Misconception 3: There are no tax implications when withdrawing funds from an annuity.
  • Funds withdrawn from an annuity may be subject to federal and state income taxes. It’s important to consult a tax advisor to understand any potential penalties or taxes.

  • Misconception 4: You can ignore the penalties for early withdrawals if you are over 59 ½ years old.
  • While being over 59 ½ may exempt you from some penalties, it’s essential to check the specific rules of your contract, as there may still be restrictions based on your plan type.

  • Misconception 5: The form is straightforward and doesn’t require any additional documentation.
  • In many cases, additional documentation is necessary, especially for claims based on disability or severance from employment. Failure to include required documents can delay processing.

  • Misconception 6: You can withdraw funds without considering existing loans against your contract.
  • If there is a defaulted loan or an active loan, the loan balance may need to be paid off before any withdrawal can be processed.

  • Misconception 7: The signature of a spouse is optional for all contracts.
  • In certain states, the spouse's signature is required if the contract was issued while the owner was married. This ensures that both parties are informed and consenting to the transaction.

  • Misconception 8: You can choose to have no taxes withheld regardless of your contract type.
  • For specific types of contracts, such as 401(a) or 457(b), federal income tax withholding is mandatory. Understanding the rules for your contract type is crucial.

  • Misconception 9: Once you submit the form, the funds will be available immediately.
  • There may be a waiting period, especially if there has been an address change recently. Funds will not be released until 15 days after an address change is confirmed.

Key takeaways

  • Ensure all information is printed clearly on the Horace Mann Annuity Surrender form to avoid processing delays.

  • Requests can be submitted via mail or fax. If the amount is $250,000 or more, a phone verification will follow.

  • Contact the Customer Care Center at 800-999-1030 for assistance with form completion or documentation questions.

  • Incomplete or inaccurate forms may result in delays or the need to restart the process.

  • Be aware of IRS restrictions on withdrawals, especially for those under age 59½ or 70½ for specific contracts.

  • Understand the difference between net and gross withdrawals; taxes will affect the amount you receive.

  • If your contract has a defaulted loan, it may be foreclosed before any distribution is processed.

  • Specify your delivery method for proceeds, either by check or direct deposit, and provide the necessary banking information.

  • Signatures are required from both the client and, if applicable, the spouse and plan administrator.

  • Review and understand the tax implications of your withdrawal, including federal and state withholding requirements.

  • Keep a copy of the form for your records, as it contains important details regarding your transaction.