28-02151-00-Registration Change form.qxd

Registration Change Form
Attn: NEA Valuebuilder Program - Select, Future and Multi-Flex
Please type or print in black ink. Questions? Call our Customer Service Center at 1-800-NEA-VALU.
1. General Account Information
3. Change Of Name
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Contract Number
Signature of Owner required in Section 9.
Changes Apply to:
____________________________________________________
Group Certificate (if applicable)
____________________ _____ _________________________
Name of Annuitant/Participant
(First)
(MI)
† Divorce † Marriage
† Other _________________________________
Reason:
(Last)
____________________________________________________
Address
† Annuitant/Participant
† Owner
† Joint Owner
New Name
____________________________________________________
____________________ _____ _________________________
City
Name
___ ___
___ ___ ___ ___ ___ - ___ ___ ___ ___
State
Zip Code
___ ___ ___ ___ ___ ___ ___ ___ ___
Tax I.D. Number / Social Security Number
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Phone Number (for confidential calls between 8:00am and 6:00pm CST)
(First)
(MI)
(Last)
4. Primary Beneficiaries
To be completed to change beneficiary designation or
information. Signature of Owner required in Section 9.
Community property states also require signature of
spouse. For multiple beneficiaries attach additional sheet.
Name
DOB
Relationship
to Owner
%
____________________________________________________
E-Mail Address
1. ____________________________________________
† Single † Married (please check one)
2. Change Of Address
Signature of Owner required in Section 9.
Changes Apply to:
† Annuitant/Participant
† Owner
† Joint Owner
2. ____________________________________________
3. ____________________________________________
4. ____________________________________________
5. Contingent Beneficiaries
Name
____________________________________________________
DOB
Relationship
to Owner
%
Address
1. ____________________________________________
____________________________________________________
2. ____________________________________________
City
___ ___
___ ___ ___ ___ ___ - ___ ___ ___ ___
State
Zip Code
___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Daytime Phone Number
NEA 215 (R5-02)
3. ____________________________________________
4. ____________________________________________
Use additional sheet if necessary.
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6. Change Of Owner/Joint Owner
8. Tax Identification Number
The signature of new and previous Owner and/or Joint
Owner is required in Section 9.
Changes Apply to: † Owner † Joint Owner
TAX IDENTIFICATION NUMBER CERTIFICATION
Address
Under Penalties of Perjury I Certify that:
1. The number shown on this form is my correct taxpayer identification number
(or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding; or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure
to report all interest or dividends; or (c) the IRS has notified me that I am no
longer subject to backup withholding.
____________________________________________________
X
____________________________________________________
____________________ _____ _________________________
New Owner’s Name
(First)
(MI)
(Last)
____________________________________________________
City
___ ___
___ ___ ___ ___ ___ - ___ ___ ___ ___
State
Zip Code
___ ___ / ___ ___ / ___ ___ ___ ___
Date of Birth
† Male
† Female
___ ___ ___ ___ ___ ___ ___ ___ ___
____________________ _____ _________________________
(MI)
(Last)
____________________________________________________
Joint Owner’s Address
____________________________________________________
City
X
____________________________________________________
Signature of Joint Owner
Date
In case of joint ownership, both must sign. If no form of ownership is indicated
then it will be assumed the ownership is as “joint tenants, with right of survivorship” and not as “tenants in common.”
9. Signatures
I have read, understand, and authorize the changes
requested on this form. If section 6 or 7 was completed,
the previous and new annuitant or Contractowner (and
Joint Owner, if applicable) must sign below.
X
____________________________________________________
Signature of Contractowner (new)
___ ___
___ ___ ___ ___ ___ - ___ ___ ___ ___
State
Zip Code
Date
X
____________________________________________________
___ ___ / ___ ___ / ___ ___ ___ ___
Joint Owner’s Date of Birth
† Male
† Female
___ ___ ___ ___ ___ ___ ___ ___ ___
Please certify your Tax ID/Social Security Number in Section 8.
The signature of new and previous Annuitant is required in
Section 9.
____________________ _____ _________________________
(Last)
__________________________________________________
Date
X
____________________________________________________
Date
X
____________________________________________________
Signature of Joint Owner (previous)
7. Change Of Annuitant
(MI)
Signature of Contractowner (previous)
Signature of Joint Owner (new)
Tax I.D. Number / Social Security Number
Name of Annuitant (First)
Date
Certification Instructions - You must cross out item (2) if you have been notified
by IRS that you are currently subject to backup withholding because of
underreporting interest or dividends on your tax return.
Tax I.D. Number / Social Security Number
New Joint Owner’s Name
(First)
Signature of Owner
Date
X
____________________________________________________
Signature of Spouse (if Community Property State)
(AZ, CA, ID, LA, NM, NV, TX, WA, WI)
Date
X
____________________________________________________
Signature of Registered Representative (optional)
Date
Address
____________________________________________________
City
___ ___
___ ___ ___ ___ ___ - ___ ___ ___ ___
State
Zip Code
___ ___ / ___ ___ / ___ ___ ___ ___
Date of Birth
† Male
† Female
___ ___ ___ ___ ___ ___ ___ ___ ___
Tax I.D. Number / Social Security Number
NEA Valuebuilder Variable Annuity issued by Nationwide Life Insurance Company.
Mail to: Security Benefit Group of Companies • PO Box 750497 • Topeka, Kansas 66675-0497
Fax to: 1-785-438-5177 • Also visit us online at www.neamb.com
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