Pre-Authorized Payment Form

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P.O. Box 10343
Des Moines, IA 50306-0343
888-221-1234
life.american-equity.com
Overnight Address: 6000 Westown Parkway, West Des Moines, IA 50266
Fax 515-226-3129
Reset
Pre-Authorized Payment Form
Direct Deposit to Annuity
Contract Number(s) ____________________________ Contract Owner(s)______________________________________________
Please complete all information and sign this form to authorize recurring Electronic Funds Transfers (EFT) from the bank
account you designate below directly to your American Equity Annuity Contract. New instructions automatically replace
existing instructions.
As a convenience to me, I authorize American Equity Investment Life Insurance Company® (“American Equity”) to electronically
debit my bank account named below in order to apply funds to my annuity contract:
Name of Financial Institution:
Address of Financial Institution:
Phone Number of Financial Institution: (
)
Type of Account:  Checking  Savings
Name(s) on Bank Account*:
Account Number:
Routing Number:
*Your American Equity Annuity and your Bank Account must have at least one owner in common.
Payment Information
Amount: $_________________
Frequency: ___Monthly
Date of Debit: _________________
___Annually
TRUST ACCOUNTS. This section must be completed if your American Equity Annuity or your Bank Account is owned by a
trust. You may be required to submit a copy of the trust. The trustee(s) must sign below as the bank account owner, in
their capacity(ies) as trustee(s).
Name of Trustee(s): ____________________________
Relationship Between Annuity Owner and Bank Account Owner: ____________________________
Corporate Accounts: If a corporate bank account is funding an individually owned Annuity Contract, we require proof of
the authorized signer(s) on the bank account.
If you are signing on behalf of someone as their Attorney-in-Fact, Guardian, or Conservator, American Equity
requires a copy of the applicable Power of Attorney, Letters of Guardianship, or Letters of Conservatorship.
In signing below and authorizing the direct deposit to the annuity contract indicated above, I agree to the
following:
• I understand that American Equity will have access to this bank account for the purpose of making debit entries. I authorize
American Equity to credit this account in order to recover any amount debited in error.
• I understand these instructions will apply only to the above named annuity contract.
X
Contract Owner’s Signature
X
Bank Account Owner’s Signature
(If different than contract owner)
Date
X
Joint Contract Owner’s Signature
(if applicable)
Date
Date
X
Joint Bank Account Owner’s Signature
(If different than contract owner)
Date
IN ORDER TO COMPLETE YOUR REQUEST, IN ADDITION TO COMPLETING AND RETURNING THIS FORM, YOU
MUST ALSO INCLUDE A VOIDED PERSONAL CHECK. American Equity will not accept “starter checks” or deposit
slips in lieu of a voided check. If you do not have checks or do not have access to checks, please submit a letter of
instruction from your bank, on bank letterhead, including your account number and routing number.
ORIGINAL FORM NOT REQUIRED - FAXED COPIES ARE ACCEPTABLE
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