Carrier:          
Current Value: $        
Surrender Value: $        
Cost Basis: $        
Penalty Free W/D: $        
Tax Rate:   (Use 0% for IRA to IRA or 1035)    
Net Desired: $        
             
Total Withdrawal:     This document is believed to be up-to-date & accurate.    
             
Surrender Penalty:     You may use it freely, but at your own risk.    
Taxable Gain:          
Taxas Withheld:     Please report any problems, suggestions, or updates to:    
Penalty Paid:     cliff@cliffbassett.com or (817) 235-4133    
             
Remaining in Annuity: