TSA/403(b) Loan Repayment Distribution
Athene Annuity & Life Assurance Company of New York
Contract Information
Contract Number
Name of Annuitant
Name of Contract Owner
Social Security Number
Street Address, City, State, Zip
Telephone Number
Qualification to Access Restricted Account Balance
Please check one of the following if it applies. Unless otherwise indicated, this withdrawal will be reported as a premature distribution – no known
Separated from service and attained age 55 or older. (Proof of Separation of Service is required. Prior to age 55, the disbursement is
allowed, however it will be reported as a premature distribution – no known exception.)
Qualify for Financial Hardship Distribution (Approval from Plan Administrator is required. Please attach approval – must be on company
letterhead.) Withholding is not required on a Financial Hardship Distribution. You may elect withholding in Section 2, however, if no election
is made, 20% federal income tax and any mandatory state income tax (as described below) will be withheld.
Do not withhold federal income tax.
Do not withhold state income tax.
Attained Age of 59½ or older
2. Income Tax Withholding
Mandatory withholding of 20% will be withheld in accordance with IRS Regulations, unless an exception applies as indicated in Section 1.
Withhold 20 %
Withhold another amount: $_____________ or _____% (Cannot be less than 20%, unless this is a Financial Hardship Distribution)
State Income Tax – If you reside in one of the following states - CA, DC, DE, GA, IA, KS, MA, ME, MI*, NE, NC, OK, OR, VT, VA - we will automatically
withhold for state tax. If your state allows, you may opt out. See the enclosed State Tax Withholding Information, to determine if your state allows you
to opt out. Check here, if you live in one of these states, and you DO NOT want to have State withholding.
Do not withhold State Income tax, unless required by law.
*MICHIGAN residents: Please refer to for information regarding the MI W-4P form for tax withholding or opt out
information. If this form is not received, State Income Tax will be withheld.
Notice: Federal law requires withholding a minimum of 10% federal income tax from taxable distributions, unless you elect not to have taxes
withheld, or specify a different withholding amount. Withholding will only apply to that portion of your distribution that is includable in your income
subject to federal income tax. You may revoke this withholding election at any time by contacting Athene Annuity & Life Assurance Company of
New York in writing unless the distribution is from a tax sheltered annuity or qualified plan that is eligible to be rolled over to an IRA or qualified
plan. In these cases, the distribution will be subject to a 20% mandatory withholding therefore you may not elect to waive the federal income tax
withheld. Electing not to withhold at this time does not release the liability for payment of federal and, if applicable, state income tax on the
taxable portion of your payment. You may incur tax penalties if your withholding and tax payments are not adequate.
Athene Annuity & Life Assurance Company of New York is unable to render tax advice, and therefore, we suggest that you consult your tax advisor
regarding your financial situation.
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TSA/403(b) Loan Repayment Distribution
Athene Annuity & Life Assurance Company of New York
3. Certification of Taxpayer Identification Number
Under Penalty of Perjury, I certify that:
The number shown on this form is my correct Taxpayer Identification Number.
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS
that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I
am no longer subject to backup withholding.
I am a U. S Citizen, or other U.S. Person
Certification Instructions: You must cross out item (2) above, if you have been notified by the IRS that you are subject to backup
withholding because of underreporting interest or dividends on your tax return. However, if after being notified by the IRS you were subject
to backup withholding you received another notification from the IRS that you are no longer subject to backup beholding, do not cross out item (2).
*If you are not a U.S. person, you must complete IRS Form W-8 Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding
and/or IRS Form W7 Application for IRS Taxpayer Identification Number. You can locate these forms at
4. Signature of Owner
Contract Owner
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