Non Qualified Annuity Claimant s Statement

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Non Qualified Annuity Claimant’s Statement

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 (non-returnable).

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.

The Lincoln National Life Insurance Company (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” Contract Number: ___________________________

The Lincoln National Life Insurance Company

Service Office P.O. Box 7880 Fort Wayne, IN 46801-7880 Phone: 800-454-6265, Ext.*8200 www.LincolnFinancial.com

Overnight Address:

Lincoln Financial Group Death Claims - IA 1300 S Clinton St. Fort Wayne, IN 46802

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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: _______________________________________________________________________________________________

Social Security Number: ___________________ Date of Birth: ___________________ Date of Death: ______________

Citizenship: Was deceased a U.S. Citizen?

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Yes

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No Country of Citizenship: _________________________________

Address: _____________________________________________________________________________________________

City: ____________________________________________________ State: _________ Zip: _______________________

Claimant Information

Relationship _____________________ Gender:

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Male

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

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An individual who is a named beneficiary under the policy. Social Security Number: ___________________________

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A Trustee of a Trust which is a named beneficiary under the policy. Trust TIN Number:__________________________

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An Executor of an Estate which is a named beneficiary under the policy. Estate TIN: ___________________________

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Other: _________________________________ Tax ID Number: _________________________________________

Name: ___________________________________________________________ Date of Birth: ________________________

Citizenship: Under penalties of perjury, I certify that:

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The number shown on this form is my correct taxpayer identification number, I am not subject to backup withholding and I am a US citizen or other US person

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I am not a US Citizen. Country of Citizenship: __________________________________

If you are a resident of a foreign country, a W-8BEN or a W-9 must be completed.

This form can be found at: http://www.irs.gov/pub/irs-pdf/fw9.pdf or http://www.irs.gov/pub/irs-pdf/fw8ben.pdf

Address: _____________________________________________________________________________________________

City: ____________________________________________________ State: _________ Zip: _______________________

Primary Telephone No: _____________________________________ Secondary Telephone No: ______________________

Email Address: _________________________________________________________________________________________

You can help expedite the payment of your claim by completing all of the information on this page.

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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 payment 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.)

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LUMP SUM – Three options are provided

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

METHOD A: CHECK (If no method of distribution is selected, will default to check.)

Select One:

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Regular Mail (No Fee)

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Overnight Mail ($25 fee, subject to change)

Select One:

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Claimant’s Address

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Alternate Address (complete mailing information below)

Name: ___________________________________________________________________________________

Address: ___________________________________________________________________________________

City: __________________________________________ State:________ Zip: _______________________ METHOD B: DIRECT DEPOSIT (ACH, no fee) A check will be issued if all of the direct deposit requirements are not complete. Cannot do direct deposit to a foreign or overseas account.

Select One:

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Checking - Must attach a copy of a “voided” check. Account must be in the same name as the beneficiary.

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

d Routing Number

d Account Number

d Accountholder’s Name

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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)

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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

Please proceed to the tax withholding section on page 7. Contract Number: ___________________________

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Option 2

– (Only Available for Spousal Beneficiaries) 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.

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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 means a spouse as defined under 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. The term “spouse” does not include a domestic partner, civil union partner, or other status that is not recognized as a spouse under Federal law. Therefore, the payment option, Assume Ownership, is only available to a surviving spouse of a lawful marriage.

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 or the other of the following:

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

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

Option 3

(Please proceed to the election of beneficiary section on page 8 to change the beneficiary(ies) of this contract. If you do not name a beneficiary, the beneficiary will be your estate.)

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THEi4LIFE®_{ADVANTAGE –}_{(Please be aware an additional form is required to be completed with this option.)}

Start a new i4Life program (a separate election form is needed) d This option must begin within one year of the date of death.

d The regular income will be a combination of gain (taxable) and return of the original investment (non-taxable). The

minimum account value necessary to elect i4LIFE®_{Advantage is $50,000 and the death benefit must be the}

Account Value.

d Please note, there is a charge associated with this option.

Option 4

(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.)

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5 YEAR DEFERRAL

This option is available for death benefits of $10,000 or more. The claimant must surrender and take full distribution of the proceeds no later than 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 policy. Distributions are taxable as they are made and will be reported as ordinary income on IRS Form 1099-R. You may name your beneficiary(ies) in the election of beneficiary section. The death

benefit payable to your beneficiary at your death is the account value, with appropriate interest credited.

Option 5

(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.)

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EXTENDED PAYOUT - (This option may not be available on all fixed products.) For Fixed Contracts a New Application is Required

This option is available for death benefits of $10,000.00 or more. With this option, distributions based on the claimant’s life expectancy must begin by the first anniversary of the decedent’s death. Distributions are reported to the claimant for the year in which they are made on IRS Form 1099-R. All or a portion of each distribution may be taxable and reported as ordinary income; distributions typically come from taxable earnings before coming from the cost basis in the contract. Distributions may be accelerated, but may not be decreased or

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Option 6

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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 7

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ESTABLISH YOUR OWN CONTRACT

This option is available to non-spouse claimants. This option is taxable. The earnings in the contract are reported as ordinary income to the claimant on IRS Form 1099-R. The cost basis in the contract will be adjusted to reflect the amount that has been taxed. A new application is required for each claimant making this election and a new contract will be issued.

Option 8

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1035 EXCHANGE - (This option allows the transfer of funds to another Lincoln contract or another financial/ institution carrier.)

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Exchange to another Lincoln contract:Additional forms required for a 1035 - Application for the new policy

- ACORD 1035 Exchange Rollover and Transfer Form (ACORD 951)

- Disclosure Notice

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Exchange to another financial institution/carrier:Additional forms required for a 1035 - 1035 Exchange form from other financial institution/carrier

- Acceptance letter from other financial institution/carrier

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Automatic Withdrawal Service Information

(This service is not available for annuitization options.)

Please complete this section if payment option 5 was selected. This section is optional if payment options 2 or 4 were selected.

Automatic Withdrawal Options - Select ONE (“Required Minimum Distribution” (RMD) will be the default amount if amount not specified)

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Withdraw $ _________________ per payment frequency

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Required Minimum Distribution (RMD)/ Life Expectancy Payment rules

Payment Information

Requested Start Date (month/year)_________________________ (Start Date of withdrawl defaults to 5th_{if Date option not selected, but}

recurring withdrawl date defaults to 20th_{if option not selected.)} Frequency:

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

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Quarterly

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Semi-Annually

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Annually Date of Withdrawal:

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5th

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10th

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

Payment Deposit Information (If no payment option is completed, a check will be mailed to the client’s address of record.)

Select One:

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

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

d Routing Number

d Account Number

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

d Routing Number

d Account Number

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Contract Number: ___________________________

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.

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Select to withhold the minimal Federal tax and minimal State tax (if applicable).

Option 1: Federal tax withholding for payout options 1, 2, 4 and 5.

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I elect to have no federal income tax withheld.

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I elect to have __________% federal income tax withheld. (Minimum of 10%) Option 2: Federal tax withholding for i4Life Payments only

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Do not withhold federal income.

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Withhold federal income tax based on the following exemptions:

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A. Single with_____allowances (if left blank, default will be married plus 3 allowances)

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B. Married with_____allowances (if left blank, default will be married plus 3 allowances)

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C. Amount to be withheld in addition to specified exemptions $_________________

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: ___________________

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Voluntary tax amount: $___________________OR____________%

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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: ______

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

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OPT OUT (Do not withhold state income tax)

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Election of Beneficiary Section

(If Claimant does not elect a Beneficiary payment will default to the Claimant’s estate.)

Primary (you must have at least one primary beneficiary)Please use whole percentages. Itemized percentages must equal 100%

Name: __________________________________ Relationship:______________ Percentage: ______________________

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

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Male

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Female

Address: _____________________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ______________________

Telephone Number: _____________________________________________________________________________________

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Primary

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Contingent

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Male

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Female

Address: _____________________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ______________________

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Primary

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Contingent

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Male

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Female

Address: _____________________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ______________________

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Primary

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Contingent

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Male

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Female

Address: _____________________________________________________________________________________________

City: ____________________________________________________ State: ________ ZIP: ______________________

If designating a trust as beneficiary, complete the following:

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Primary

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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

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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.

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Contract Number: ___________________________

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

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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.

This form is not complete until it is signed by the Claimant

____________________________________________________________ Claimant’s Full Legal Name (Please Type or Print) Always required to be completed

____________________________________________________________ __________________________________

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