Annuity/IRA/ESA withdrawal form Download Blank PDF Name *Policy # *SS1 *Social Security #SS2 *Social Security #SS3 *Social Security #Bitrhdate *FULL WithdrawalYesPARTIAL WithdrawalYesAmount to be Withdrawn *Executed Month & Date *Executed Year *Executed City & State *Address where to mail check *Printed Name of Annuitant *Printed Name of Witness ** NOTE: You MUST have this form NOTARIZED by a duly licensed Notary Public (attach Notary affidavit) UNLESS witnessed by a Luso-American Agent, Employee or Secretary.Print Filled PDF
