Qualified Annuity Claimant s Statement

(1)

Service Office Overnight Address: P.O. Box 7880 Lincoln Financial Group Fort Wayne, IN 46801-7880 Death Claims - IA Phone: 800-454-6265, Ext.*8200 1300 S Clinton St. www.LincolnFinancial.com Fort Wayne, IN 46802

Instructions – Important Information – please read carefully and completely

Annuity Death Claim Items that are always required:

d Certified death certificate showing the manner of death

d Claimant’s Statement completed and signed by each beneficiary. Each beneficiary must have a separate

Claimant’s Statement.

Additional documentation and instructions may be required when the beneficiary is a(n):

d Estate

d Trust

d Guardian (minors and incompetent beneficiaries)

d Corporation

d Partnership

d Assignment to third parties

Please refer to the Distinctive Payee Arrangements form (number CL05984A) for full instructions.

Power of Attorney: If an attorney-in-fact under a Power of Attorney is completing the Annuity Claimant’s Statement on behalf of the claimant, a copy of the Power of Attorney document must be provided. If the Power of Attorney document was executed more than three years ago, additional information from the attorney-in-fact may be required. The Social Security number of the person who granted the Power of Attorney must be used. The attorney-in-fact’s Social Security number may not be used.

Other Possible Requirements (please note that failure to include this information where applicable may cause delay in processing the claim.):

d Deceased Beneficiary – if any named beneficiary of the contract is deceased, a copy of the death

certificate of such deceased beneficiary must accompany this form.

d Foreign Death – if death of the owner/annuitant/participant occurred outside of the United States, we will

require a Report of the Death of an American Citizen Abroad and a Foreign Death Questionnaire. A Translated Certified Copy of the Death Certificate may also be required.

d Consent to transfer or a state tax waiver – A form for consent or notice is required in some states. When

consent is required, the state must give approval before the death benefit can be paid. If this form is required, it will be provided to the beneficiary by us.

Variable Annuities: If the contract has money in variable sub-accounts, the money is subject to market fluctuations. You may be able to transfer money to different sub-accounts or to a Fixed account with written authorization signed by all beneficiaries and a copy of the death certificate.

Lincoln Financial Group (Lincoln) does not require that the policy(ies) be returned to Lincoln for filing of a

claim. However, Lincoln does ask that the relevant policy(ies) be destroyed once payment is received.

* - “Policy” may be referred to as “Contract” or “Certificate”

(2)

Required Minimum Distribution

The Internal Revenue Service (IRS) requires that a distribution begin by April 1st_{of the year following the year in}

which the owner/annuitant/participant reaches age 70½_{. The distributions that the owner/annuitant/participant must}

receive are known as “Required Minimum Distributions”. The date by which the owner/annuitant/participant must start receiving payments is known as the “Required Beginning Date”. If the owner/annuitant/participant had reached the Required Beginning Date prior to death, a distribution is required for the year in which death occurred unless the required distribution had already been taken by the decedent. Please indicate whether or not the Required Minimum Distributions for the year of death has been taken.

h

The Required Minimum Distribution for the year of death has been taken.

h

Please withdraw the Required Minimum Distribution for the year of death.

The IRS requires that Required Minimum Distributions continue after the owner/annuitant/participant’s death at least as rapidly as they were being distributed prior to the death. Failure to receive distributions at least as rapidly

as required can result in a 50% penalty on the amount not distributed.If you have any questions concerning

Required Minimum Distributions, please consult your tax advisor.

Deceased’s Information

If the deceased was known by any other names, such as maiden name, hyphenated name, nickname, derivative form of the first and/or middle name, please include them below:

Name: _____________________________________________________________________________________ Address: ___________________________________________________________________________________

City: ___________________________________________________ State: _______ Zip: __________________

Date of Birth: ___________________________________ Date of Death: _______________________________

Social Security Number: _______________________________________________________________________

Citizenship: Was deceased a U.S. Citizen?

h

Yes

h

No Country of citizenship: _______________________

Claimant Information

Name: _____________________________________________________________________________________ Address: ___________________________________________________________________________________

City: ___________________________________________________ State: _______ Zip: __________________

Social Security or Tax ID Number: ______________________ Date of Birth: ____________________________

Daytime Telephone No: ______________________________ Evening Telephone No: ____________________

Email Address (optional): ________________________________________________________________________

Claimant’s relationship to Decedent: I am filing this claim as:

h

An individual who is a named beneficiary under the policy

Relationship _____________________ Gender:

h

Male

h

Female

h

A Trustee of a Trust which is a named beneficiary under the policy

h

An Executor of an Estate which is a named beneficiary under the policy

h

Other: ______________________________________________________________________________

Citizenship: Are you a U.S. Citizen?

h

Yes

h

No Country of citizenship: _____________________________

(3)

For your convenience and assistance when your claim is approved, pages 3 through 5 offer you the ability

to receive your death benefits or place your funds into one of the other settlement options. Please read

your options carefully and know that Lincoln is available to address any questions that you may have. The options are numbered for your convenience.

Payment Options:

Please select one of the following options. Please Note: If the owner of the Contract/Certificate has previously designated a payment option, Lincoln is required to disburse funds pursuant to that designation.

Option 1

– (Option 1 is a Taxable Event.)

h

LUMP SUM – Three options are provided

Method Of Distribution - Select ONE distribution method – A, B or C METHOD A: CHECK

Select One:

h

Regular Mail(No Fee)

h

Overnight Mail ($25 fee, subject to change)

Select One:

h

Claimant’s Address

h

Alternate Address (complete mailing information below)

Name: __________________________________________________________________________ Address: _________________________________________________________________________

City: __________________________________________ State:________ Zip: _____________

METHOD B: DIRECT DEPOSIT (ACH, no fee)

Select One:

h

Checking - Must attach a copy of a “voided” check

h

Savings - Must attach the following information on the Financial Institution’s letterhead:

d Routing Number

d Account Number

d Accountholder’s Name

h

_{Brokerage Account -}Must attach the following information on the Financial Institution’s letterhead:

d Routing Number

d Account Number

METHOD C: WIRE DEPOSIT (wire fees: $25 for domestic; $40 for foreign; all fees subject to change)

h

Wire Deposit- Must attach the following information on the Financial Institution’s letterhead:

d Routing Number

d Account Number

d Financial Institution’s Name and full Address

d Further Credit to Account Number

If no method of distribution is selected, will default to check.

Please proceed to the tax withholding section on page 7.

(4)

Option 2

– (Only Available for Spousal Beneficiaries, not available for 403(b) or 457 contracts)

h

ASSUME OWNERSHIP

As the surviving spouse and sole primary beneficiary of this annuity policy, I wish to be designated as the successor owner. I understand that the policy will remain in force with the original effective date with no change of policy provisions and no death benefit distribution will occur. I also understand this ownership change is not taxable. Note that the term “spouse” as used in this Claimant’s Statement includes a civil union partner as recognized

under individual state laws, however those state laws do not alter current federal law, which only confers marriage rights and privileges and certain tax benefits to lawfully married couples. Current federal law defines the term “spouse” to include an individual married to a person of the same or opposite gender if the individuals are lawfully married under state law. Therefore, the payment option, Assume Ownership, is only available to a surviving spouse of a lawful marriage and not to a surviving civil union partner.

If the Dollar Cost Averaging program or the Automatic Withdrawal Service program was established under the original contract, it will be terminated. As surviving spouse, you may start a new program. If so, please select one of the following:

h

Start a new Dollar Cost Averaging program (a separate election form is needed).

h

Start a new Automatic Withdrawal Service program and complete page 6.

h

Continue the existing i4Life that is currently on the contract (complete form CL07414)

h

Start a new i4Life program (a separate election form is needed)

Option 3

h

5 YEAR DEFERRAL - (This option is not available if the date of death of the Owner/Annuitant is on April 1st or later of the year following the year in which the owner reached age 70½.)

This option is available for death benefits of $10,000 or more. As provided by Section 401(a) (9) of the Internal

Revenue Code, the claimant must surrender and take full distribution of the proceeds no later than December 31st

following the fifth anniversary of the decedent’s date of death. A Five-Year Deferral postpones payment of the proceeds for up to five years from the original owner’s date of death. No additional money may be added to the contract. Distributions are taxable as they are made and will be reported as ordinary income on IRS Form 1099-R. If electing

a Five-Year Deferral, it is not necessary to return the contract to us. You may name your beneficiary(ies) below. The

death benefit payable to your beneficiary at your death is the account value, which may be subject to market fluctuation.

Please proceed to the election of beneficiary section on page 8 to change the beneficiary(ies) of this policy. If you do not name a beneficiary, the beneficiary will be your estate. Please review the automatic withdrawal service information section on page 6 and proceed to the election of beneficiary(ies) section on page 8 to change the beneficiary(ies) under this policy. If you do not name a beneficiary, the beneficiary will be your estate.

(5)

Option 4

h

ANNUITIZATION OPTION – (Requires completion of Annuitization Form)

This option is available for death benefits of $5,000 or more. This option must begin within one year of the

Death of the Owner/Annuitant. The selection of this option is irrevocable. Some of the options may not be available in some instances due to IRS regulations or possible restrictions of the plan in which you may have been participating. Please refer to the Prospectus or to your plan.

Life Options:

Life Only: Proceeds are paid in installments as long as you are living. Payments cease at your death.

Life with Period Certain: Proceeds are paid in installments as long as you are living. If you die within the time period you elected after payments start, we will continue payments to your beneficiary for the balance of the time period elected.

Life with Unit Refund(Variable payout only): Proceeds are paid in installments as long as you are living. If you die

prior to the return of all units, remaining units will be returned to your beneficiary as a lump sum.

Life with Cash Refund(Fixed payout only): Proceeds are paid in installments as long as you are living. If you die

prior to the return of your premium, remaining funds will be returned to your beneficiary as a lump sum.

Life with Installment Refund: Proceeds are paid in installments as long as you are living. If you die prior to the return of full premium, we will continue payments to your beneficiary until the premium has been satisfied. Non-Life Options:

Installment for a Designated Period: Proceeds are paid in equal installment for any number of years you select. (Restrictions may apply)

Installment for a Designated Amount(100% Fixed payout only): Payments are made in equal installments of an

amount you select until the proceeds are exhausted.

Option 5

h

DECEASED IRA/403(B) (For fixed annuities a new application is required.)

This option is available to spouse and non-spouse claimants for death benefits of $10,000 or more. With this

option, distributions based on the claimant’s life expectancy must begin by December 31st_{of the year following}

the year of the owner/annuitant/participant’s death. (A spouse beneficiary can defer distributions until December 31st_{of the}

year the decedent would have reached age 70½). Distributions may be accelerated, but may not be decreased or stopped.

The death benefit payable to your beneficiary at your death is the account value, which may be subject to market fluctuation.

Option 6

h

DIRECT ROLLOVER

This option allows the transfer of funds to another Lincoln contract or another financial/institution carrier.

d Additional forms required for a direct rollover to another Lincoln contract:

- Application for the new contract

- Request for Qualified Retirement Account Transfer/Direct Rollover - Disclosure Notice

d Additional forms required for a direct rollover to another financial institution/carrier:

- Direct rollover form from other financial institution/carrier

- Acceptance letter from other financial institution/carrier

- Required minimum distributions must be taken before the rollover can occur

Please complete the automatic withdrawal service information section on page 6 and proceed to the election of beneficiary(ies) section on page 8 to change the beneficiary(ies) under this policy. If you do not name a beneficiary, the beneficiary will be your estate.

(6)

Automatic Withdrawal Service Information

(This service is not available for annuitization options.)

Automatic Withdrawal Options - Select ONE

h

Withdraw $ _________________ per payment frequency

h

Required Minimum Distribution (RMD)/ Life Expectancy Payment rules

Payment Information

Requested start date (month/year)_________________________

Frequency:

h

Monthly (If frequency is not selected, it will be monthly.)

h

Quarterly

h

Semi-Annually

h

Annually Date of Withdrawal:

h

5th

h

10th

h

20th (If date is not selected it will be the 20th_.)

Payment Deposit Information

Select One:

h

Checking - Must attach a copy of a “voided” check

h

Savings - Must attach the following information on the Financial Institution’s letterhead:

d Routing Number

d Account Number

h

Brokerage Account - Must attach the following information on the Financial Institution’s letterhead:

d Routing Number d Account Number d Accountholder’s Name If no payment option is completed, a check will be mailed to the client’s address of record. This section is optional if payment options 2 or 3 were selected. was selected.

(7)

Tax Withholding Section

Tax withholding election will remain in effect unless Lincoln is notified of a change. You may change your election at any time. If you opt out of tax withholding, you are still liable for applicable taxes on your distribution. You may also incur penalties under the estimated tax payment rules if your withholding and estimated tax payments are not

sufficient. You may wish to discuss your withholding election with a qualified tax adviser.

If tax information is not provided, federal and applicable state taxes will be withheld. Federal tax withholding:

(Note: It is mandatory that 20% federal income tax be withheld from a 403(b).)

h

I elect to have no federal income tax withheld.

h

I elect to have __________% federal income tax withheld. (Minimum of 10%)

State Tax Withholding Options

Option 1: All States Except CA and VT

If federal income tax is withheld, state income tax may be withheld depending on your state of residence. AK, AZ, FL, HI, NV, NH, RI, SD, TN, TX, WA, WY: No state income tax.

DC, IA, ME, MA, NE, OK, VA: If federal income tax is withheld, mandatory state tax withholding is required. AR, OR: If federal tax is withheld, you may opt out of state withholding.

DE, KS: If subject to mandatory federal tax withholding, then state income tax is also required. Otherwise, you may opt out of state income tax withholding.

MI: Must elect or opt out of state income tax withholding on form MI W-4P.

NC: Mandatory withholding will apply unless form NC-4P is submitted to opt out or withhold more than the minimum.

All Other States: Tax withholding is voluntary. State of residence: ___________________

h

Voluntary tax amount: $___________________OR____________%

h

OPT OUT (Do not withhold state income tax)

Option 2: CA and VT

CA: If federal tax is withheld, you may opt out of state withholding. If state tax withholding is elected, the

minimum withholding must equal 10% or more of the federal withholding amount.

VT: If federal income tax is withheld, mandatory state tax withholding is required and must equal 24% or more

of the federal withholding amount. State of residence: ______

h

______% this will be based on the taxable portion of the gross distribution

(8)

Election of Beneficiary Section

Primary (you must have at least one primary beneficiary)

Name: __________________________________ Relationship:______________ Percentage: ____________

Social Security/Tax ID Number: _______________ Date of Birth: _____________ Gender:

h

Male

h

Female

Address: ___________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ____________

Telephone Number: ___________________________________________________________________________

h

Primary

h

Contingent

h

Male

h

Female

Address: ___________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ____________

h

Primary

h

Contingent

h

Male

h

Female

Address: ___________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ____________

h

Primary

h

Contingent

h

Male

h

Female

Address: ___________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ____________

If designating a trust as beneficiary, complete the following:

h

Primary

h

Contingent

Name: ____________________________________________________________ Percentage: ____________

Trustee’s Name: ____________________________________________________ Date of Trust: ___________

Telephone Number: ___________________________ Social Security/ Tax ID Number: ____________________ Address: ___________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ____________

If additional beneficiaries are to be named, please check here

h

and attach on a separate sheet which must be signed and dated by you. You may also make additional copies of this page if necessary.

Please complete this section if payment option 2, 3, 5 were selected. Use whole percentages. Must total 100%

(9)

Telephone/Internet Authorization (check box if this option is not desired.)

For your convenience, the Company will accept certain account changes via telephone or the internet. You may opt out by checking the box below. This telephone/internet authorization remains in effect until written cancellation signed

by the Contract Owner(s) is received by the Company’s Servicing Office.

I/We hereby authorize and direct the Company to accept instructions via telephone or the internet from any person including my/our registered representative who can furnish proper identification to exchange units from sub account to sub account, change the allocation of future investments, and/or clarify any unclear or missing administrative information contained on the application at the time of issue. I/We agree to hold harmless and indemnify the Company and its affiliates and any mutual fund managed by such affiliates and their directors, trustees, officers, employees and agents for any losses arising from such instructions.

If you DO NOT want Telephone/Internet Authorization check this box

h

Signature

The Internal Revenue Service does not require your consent to any provision of this document other than the

certification required to avoid backup withholding.

You understand that by furnishing a claim form, the Company does not acknowledge that there is a contract in force or that you are the designated beneficiary. If necessary, the Company may ask for more information to confirm this claim. By signing below, you certify that you:

Authorize the direct deposit of the payment into the account identified on this form. This authorization requires the

financial institution to be a member of the National Automated Clearing House Association (NACHA). Lincoln is also

authorized to initiate corrections, if necessary, to any amounts credited or debited to your account in error. You also agree to hold Lincoln harmless for the date funds are actually credited to your account by your financial institution. This authorization will remain in effect until your funds are depleted or you notify Lincoln of change in sufficient time to act. Understand and assume full responsibility for meeting the Internal Revenue Code requirements to qualify for this distribution. You further agree to hold Lincoln harmless for any adverse tax ramifications that may arise based on the information provided on this form.

Fraud Warning for New York Residents:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. ____________________________________________________________

Claimant’s Full Legal Name (Please Type or Print)

____________________________________________________________ ________________________

Claimant’s Signature Date

____________________________________________________________ ________________________

Employer’s Signature (if applicable) Date

Always required to be completed

(10)

Warning – Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files a statement of claim containing any false, incomplete or misleading information or conceals, for the purpose of misleading, information concerning any fact material to the claim, commits a fraudulent insurance act, which may be a crime, and in certain states a felony. Penalties may include imprisonment, fines, denial of insurance and civil damages.

These states require the following fraud warnings:

California(For your protection, California law requires this to appear.) – Any person who knowingly presents false or fraudulent

claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado – It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.

Kentucky – Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Minnesota – A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire – Any person who, with a purpose to injure, defrauds or deceives any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and

punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. Subsection 638:20.

New Jersey – Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties.

Pennsylvania – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Puerto Rico – Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon

conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand ($5,000) dollars

and not more than ten thousand ($10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties.

Should aggravating circumstances are present, the penalty thus established may be increased to a maximum of five