TIAA-CREF Investment Horizon Annuity IRA Application

EX-4.(F) 5 dex4f.htm TIAA-CREF INVESTMENT HORIZON ANNUITY IRA APPLICATION TIAA-CREF Investment Horizon Annuity IRA Application


		Exhibit 4(F)

		IRA APPLICATION FOR A TIAA-CREF INVESTMENT HORIZON ANNUITY CONTRACT

Page 1 of 9

Please print in capital

SECTION A: PRODUCT/REGISTRATION INFORMATION

letters and only use

black or dark blue ink.

Please select an IRA registration type:

Mail To:

Traditional

Roth

SEP*

TIAA-CREF Life

For SEP, please provide the Employee Tax ID #

Insurance Company

Attn: New Business Dept.

P.O. Box 1291

Charlotte, NC

28201-1291

Please indicate your initial investment amount if you are submitting a check with your application

Home Office

New York, New York

* For SEP enrollments, form 5305-SEP is required. Go to www.irs.gov to download the form.

Please indicate your approximate initial investment amount if you are transferring funds from another company

SECTION B: OWNER/ANNUITANT INFORMATION

Name (Title, First Name, Middle Name, Last Name)

Gender

Social Security Number

Birth Date (mm/dd/yyyy)

Male

Female

Daytime Phone

Evening Phone

E-mail Address

A residential address

must be provided. No

P.O. Boxes please.

Residential Address

Address

City

State

Zip Code


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IRA APPLICATION FOR A TIAA-CREF

INVESTMENT HORIZON ANNUITY CONTRACT

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SECTION B: OWNER/ANNUITANT INFORMATION (CONTINUED)

A mailing address is optional. Please provide if different from your residential address.

Mailing Address

Address

City

State

Zip Code

Are you currently or formerly employed by:

College, university or other nonprofit

education or research institution

K-12

Other

SECTION C: REPLACEMENT

Regulations require that we ask if you are replacing an existing annuity contract or life insurance policy with this contract.

Do you presently own any existing individual life insurance policies or annuity contracts?

Yes

Will any existing life insurance or annuity be replaced, changed, or used to fund the contract applied for in this application? If you answered “Yes”, please complete the information below:

Yes

Company Name

Indicate Insurance
or Annuity

Policy/Contract

Approximate
Amount of
Policy/Contract

Is this a Direct
Transfer or 60 Day

Rollover? Yes/No


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IRA APPLICATION FOR A TIAA-CREF

INVESTMENT HORIZON ANNUITY CONTRACT

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NOTE: SEP IRA contributions are reported on Form 5498 in the calendar year in which they are received. Your tax form may reflect both current and prior year contributions if both were received in the same calendar year. Please consult your tax advisor with any questions.

SECTION D: PREMIUM AMOUNT AND METHOD OF PAYMENT

Indicate your premium amount and the tax year allocation:

For tax year

Select an option to indicate how your premium will be paid:

Check(s) submitted with this application. (You must also complete the 60-day
Rollover form included in this package for funds received from a distribution
from your employer’s plan or another IRA within the past 60 days.)

Payment drafted from my bank account. Please note funds drafted from your
bank account will always be applied to the current tax year. (Complete the
Electronic Funds Transfer information in Section E.)

Direct transfer or rollover from another financial institution. (You must also
complete the Transfer or Rollover Authorization form included in this package.)

Transfer funds from my TIAA-CREF Brokerage Account

Account Number


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IRA APPLICATION FOR A TIAA-CREF

INVESTMENT HORIZON ANNUITY CONTRACT

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Please note there is a minimum deposit of $5,000 per Fixed Term Deposit allocation.

SECTION E: ELECTRONIC FUNDS TRANSFER INFORMATION

Provide the following information if you selected the option to have your premium electronically drafted from your bank account. Please note funds drafted from your bank account will always be applied to the current tax year. If you did not select to have your premium electronically drafted from your bank account, please proceed to Section F.

Deduct premium from my:

Checking

Savings

* Refer to the bottom of your check or savings deposit slip for the 9 digit bank routing number.

Account Number

Bank Routing Number*

Name(s) on Account

Name of Bank

Bank Telephone Number

See example below to identify your bank routing number and account of record

LOGO

The minimum allocation to each fixed term deposit that you select is $5,000. Allocations are subject to current Fixed Term Deposit availability.

SECTION F: FIXED TERM DEPOSIT ALLOCATIONS

Allocations to Fixed Term Deposits and the Flexible Lifetime Income Option, if elected, must total your initial contribution amount.

Term

Deposit

Term

Deposit

1 Year

6 Year

2 Year

7 Year

3 Year

8 Year

4 Year

9 Year

5 Year

10 Year


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IRA APPLICATION FOR A TIAA-CREF

INVESTMENT HORIZON ANNUITY CONTRACT

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SECTION G: SYSTEMATIC INTEREST WITHDRAWAL ELECTION

You may elect to have the full amount of interest from all of your fixed term deposits periodically withdrawn and paid to you. These withdrawals are not subject to market value adjustments. This election is only available at application and is irrevocable. Your initial minimum premium must be at least $25,000 to elect this option. Consult your tax advisor before electing this option.

Payment frequencies

Do not withdraw my interest

other than “Monthly” will be based upon your contract issue date.

Withdraw Interest

Annually

Semiannually

Quarterly

Monthly on Day:

(1-28)

Provide the following information if you would like to have your Systematic Interest Withdrawal payment electronically deposited into your bank account.

Deposit payment into my:

Checking

Savings

Check here if you would like to use the same bank account information already provided in Section E.

*Refer to the bottom of your check or savings deposit slip for the 9 digit bank routing number. See Section E for a sample image indicating the location of bank routing and account numbers.

Account Number

Bank Routing Number*

Name(s) on Account

Name of Bank

Bank Telephone Number


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IRA APPLICATION FOR A TIAA-CREF

INVESTMENT HORIZON ANNUITY CONTRACT

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SECTION H: FLEXIBLE LIFETIME INCOME OPTION

You may elect to invest some, or all, of your initial premium in the Flexible Lifetime Income Option (FLIO). The guaranteed lifetime payments will begin immediately, and your FLIO election cannot be revoked. The initial premium used for this option is applied to a cash value that decreases as payments are made. You, and your spouse as joint annuitant if elected, must be 59¹/2 or older to elect this option now.

I do not wish to invest in the Flexible Lifetime Income Option at this time.

(Proceed to Section I)

I would like to invest in the Flexible Lifetime Income Option.

Investment Amount

($25,000 minimum)

Flexible Lifetime Income Option (FLIO) Payment Frequency (select one):

Annually

Semiannually

Quarterly

Monthly

Provide the following information if you would like to have your Flexible Lifetime Income Option (FLIO) payment electronically deposited into your bank account.

Deposit payment into my:

Checking

Savings

Check here if you would like to use the same bank account information already provided in Section E.

* Refer to the bottom of your check or savings deposit slip for the 9 digit bank routing number. See Section E for a sample image indicating the location of bank routing and account numbers.

Account Number

Bank Routing Number*

Name(s) on Account

Name of Bank

Bank Telephone Number

You may elect to have your Flexible Lifetime Income Option payment based on a one-life annuity or a two-life annuity. The periodic amount paid depends on which of these options you choose. The one-life option will use you, the contract owner, as the annuitant. The two-life option will use you, the contract owner, as the first annuitant. The second annuitant must be your spouse. You, and your spouse as joint annuitant if elected, must be 59¹/2 or older to elect this option now.

FLIO One-Life Annuity

FLIO Two-Life Annuity

Spouse’s Name (Title, First Name, Middle Name, Last Name)

Spouse’s Date of Birth (mm/dd/yyyy)

Spouse’s Social Security Number


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IRA APPLICATION FOR A TIAA-CREF

INVESTMENT HORIZON ANNUITY CONTRACT

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* If unanswered, beneficiary will be considered primary.

SECTION I: BENEFICIARY INFORMATION

If you need more space to name your beneficiaries, please continue on a separate sheet of paper. Make sure
to sign the additional page of instructions.

Primary or Contingent*

Benefit Percentage Allocated

(Whole Percentages - Must Total 100%)

Relationship to Owner

Primary

Contingent

Full Legal Name of Beneficiary

(Title, First Name, Middle Name, Last
Name)

Age or Date of Birth

Social Security Number

Primary or Contingent*

Benefit Percentage Allocated

(Whole Percentages - Must Total 100%)

Relationship to Owner

Primary

Contingent

Full Legal Name of Beneficiary

(Title, First Name, Middle Name, Last
Name)

Age or Date of Birth

Social Security Number

Primary or Contingent*

Benefit Percentage Allocated

(Whole Percentages - Must Total 100%)

Relationship to Owner

Primary

Contingent

Full Legal Name of Beneficiary

(Title, First Name, Middle Name, Last
Name)

Age or Date of Birth

Social Security Number

SPOUSAL/CALIFORNIA REGISTERED DOMESTIC PARTNER CONSENT-FOR COMMUNITY
PROPERTY STATES ONLY

(Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, Wisconsin)

I am aware that my spouse or California registered domestic partner has designated someone other than me
to be the primary beneficiary of this contract. I hereby consent to such designation and waive any rights I
may have to the proceeds of such contract under applicable community property laws.

Signature of Spouse

Date (mm/dd/yyyy)

California Registered Domestic Partner

Date (mm/dd/yyyy)

Signature of Witness

(Signature must be witnessed by someone other than a designated or potential beneficiary.)

Date (mm/dd/yyyy)


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IRA APPLICATION FOR A TIAA-CREF

INVESTMENT HORIZON ANNUITY CONTRACT

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SECTION J: APPLICATION AUTHORIZATION

IMPORTANT INFORMATION

The annuity applied for will not take effect unless and until, during the lifetime of the owner/annuitant, TIAA-CREF Life has received the initial premium and has approved this application. The owner controls the contract and may exercise every right given by the contract without the consent of any other person. The contract has no provision for loans and cannot be assigned.

For your protection, some states require a warning against fraud substantially similar to the following, to appear on this form.

People who file applications for insurance or statements of claim commit a fraudulent insurance act if they:

knowingly do so with intent to injure, defraud, or deceive any insurance company or another person; and/or

knowingly include in their application or statement of claim any materially false or misleading information; and/or

knowingly conceal information for the purpose of misleading concerning any fact material to the application or claim.

A fraudulent insurance act is a crime, and penalties may include imprisonment, fines, denial of insurance, and civil damages.

The owner acknowledges the following: I have read a current prospectus for the TIAA-CREF Investment Horizon Annuity contract, and have read and understand all provisions of this application. I understand the eligibility requirements for the type of IRA deposit I am making and state that I do qualify to make the deposit. I also understand it is my responsibility for understanding contribution limits for IRAs. Over-contributions may result in IRS penalties.

The statements made in this application are to the best of my knowledge and belief.

PROSPECTUS AND OTHER DOCUMENTS ACKNOWLEDGMENT

Please check the box below acknowledging your receipt of the following documents:


¡TIAA-CREF Investment Horizon Annuity^® product prospectus		¡ TIAA-CREF Business Continuity Policy
¡TIAA-CREF Privacy Policy		¡ IRA Disclosure Statement and Custodial Agreement

Please check the box below to acknowledge electronic receipt of prospectuses and other required documents.


¨		I acknowledge that I consent to receiving and have received the above-referenced documents by means of either the TIAA-CREF website (tiaa-cref.org) or a CD accompanying my application.
		¡I further acknowledge that I am able to access these documents via one of these sources. I understand that this acknowledgment applies only to this initial application.
		¡To select this acknowledgment and consent, you must either have access to the websites noted above or a computer with a CD drive and Internet access. In either case, you must also be able to download, view and print the documents. You will need Adobe Reader to view and print electronic PDF documents. If you don’t have Adobe Reader, go to www.adobe.com to download a free copy. To request assistance with accessing these documents electronically, please contact us toll-free at 800 842-2273.
		¡You understand and acknowledge that accessing documents electronically may involve additional costs, including but not limited to, subscription access fees from an Internet service provider and printing costs.
		¡Paper versions of the above documents can be ordered free of charge, both now and in the future, by calling toll-free 877 694-0305 or go to tiaa-cref.org.
		¡If you are unable to acknowledge that you have received and accessed these documents on the website or CD, please call 877 694-0305 for paper prospectuses at no charge.

Note: Unless indicated above, I acknowledge that I have received paper copies of the above-referenced documents.

Under penalties of perjury, you certify that the taxpayer identification number shown on this form is your correct Social Security
number. The Internal Revenue Service does not require your consent to any provision of this document.

The Internal Revenue Service does not require your consent to any provision of this document other than certifications required to
avoid backup withholding.

Amounts withdrawn or payable as income benefits from fixed term deposits prior to dates specified in the contract are subject to a market value adjustment. Flexible Lifetime Income Option account withdrawals are subject to a market value adjustment and surrender charge.


Please sign in only black or dark blue ink.	Signature of Owner	Date (mm/dd/yyyy)


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IRA APPLICATION FOR A TIAA-CREF

INVESTMENT HORIZON ANNUITY CONTRACT

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FOR OFFICIAL USE ONLY – AGENT CERTIFICATION AND SIGNATURE

I hereby certify that I have reviewed with the owner the (1) answers to the replacement questions, and (2) all the information in the application. I further certify that to the best of my knowledge and belief, the owner


		Does				Does Not

Intend to replace coverage under an existing life insurance policy or annuity contract.

If this sale involves a replacement transaction, please provide the requested information below:

Did you recommend replacement to the applicant?


		Yes – Reason for recommending replacement


		No – Owner’s reason for replacement


Agent’s Name (Print)				Agent’s NPN Number

Agent’s Signature				Date (mm/dd/yyyy)


HOME OFFICE USE ONLY

AG				RF1

RF2				RF3

Marketing Source Code


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