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                                                                              Automatic Payout Option
                                                                              (APO) Instructions
Important Notes:
· If this form is incomplete or not legible when returned, your request may be delayed.
· Once a payout has occurred it cannot be reversed.
· Only one contract per form.
· Questions on completing this form may be directed to the Thrivent Financial Customer Interaction Center at
   800-847-4836, Monday ­ Friday 7am­9pm CST, or Saturday 9am­1pm CST.
· Send completed forms to: PO Box 8075, Appleton WI, 54912-9722 or fax them to 800-225-2264. For your own
   security, do not e-mail the completed forms to Thrivent, as e-mailed forms will not be accepted.
General Information
·   Enter the name of the Annuitant.
·   Enter the Social Security number of the Annuitant.
·   Enter the contract number.
    · If your annuity contract is a Tax Sheltered Annuity (TSA/403(b)), Money Purchase, or Profit Share Plan, please
      contact the Customer Interaction Center because additional forms are required.
·   Enter the address and phone number of the owner.
Automatic Payout Option Selection Information
· Check the box for New, Cancel, or Change Existing Automatic Payout Option.
· Check the box to designate the APO Frequency.
· Enter the distribution date (1-28). If no date is indicated, the 15th of the current/next month will be used.
· Designate the Option Desired: Interest Only, Fixed Amount, or Percentage (percentage is only available for pre-merger
  AAL annuities).
· Check the box to add or subtract withdrawal charges and tax withholding. (Add charges/withholding results in a net
  distribution, subtracting charges/withholding results in a gross distribution).
· Enter subaccount designations for variable annuity withdrawals only. If nothing is indicated, the withdrawal will process
  proportionately from each subaccount.
Taxable Gain
· IRA = all taxable
· ROTH = undetermined
· Non-Pension = all or a portion of your distribution may be taxable. Note: Two or more non-pension contracts issued in the
  same calendar year may increase your taxable gain. Contact the Customer Interaction Center for assistance.
Penalty Tax
· If you are under age 59 ½, the IRS may assess a 10% premature distribution penalty on the taxable portion of your
  withdrawal.
Withdrawal Charges
· Withdrawal charges may apply based on the issue date of your contract and/or the amount of your payout(s).
  Note: A withdrawal of 10% of your cash value can be withdrawn each contract year without a charge. Contact the
  Customer Interaction Center for assistance.
Request for Waiver of Surrender Charges
· If confinement to a nursing home or assisted living facility applies and is not already on file at Thrivent, form 14804
  (available at Thrivent.com) is also required.
Triggering Event
· Enter the triggering event for TSA/403(b) annuities only.
· If your annuity contract is a Tax Sheltered Annuity (TSA/403(b)), Money Purchase, or Profit Share Plan, please
  contact the Customer Interaction Center because additional forms are required.
Distribution Option Desired
· Check the box to designate the distribution method: Check or Direct Deposit.
· If you are requesting Direct Deposit:

14642INS    R1-07                                                   1
   · Fill in your bank account number, indicate checking or savings, or include a copy of a voided check.
   · For checking, the Transit number is the 9 digit routing number located on the bottom of left corner of your check. This
     number begins with a 0, 1, 2 or 3.




Note:
· If funds are being sent to a bank account other than the contract owner, if a check is made payable to someone other than
  the contact owner, or a check is sent to an address other than the address of record, a Medallion Signature Guarantee for
  variable annuities or a Notary Public for fixed annuities is required. See below for additional information.
· If your intent is to complete an IRA transfer or Rollover to an IRA, other Company Paperwork is required. This option can
  not be completed as an APO.
Notification for Federal and State Income Tax Withholdings
· If there is a taxable event, your request will be subject to Federal and State Income Tax Withholding. If no box is checked,
  Thrivent will automatically withhold 10% federal and any required state income tax withholding.
· Note: A ROTH IRA distribution does not allow for any withholding.
· Certain states require that your federal withholding election must follow what your state tax election is. (e.g. if you want a
  percent/dollar for state tax, then you must also elect federal tax. If you do not want state tax, you must also say no to
  federal tax withholding). Contact the Customer Interaction Center for assistance.
· North Carolina requires NC-4P form for no withholding, available at Thrivent.com or www.state.nc.us.
Medallion Signature Guarantee or Notary Public Stamp
· A Medallion Signature Guarantee is required for Variable Annuities, and a Notary Public is required for Fixed Annuities in
  these situations:
  · Withdrawal amount exceeds $100,000 (net).
  · Send proceeds by check to an address other than the address on file at Thrivent Financial.
  · Make the proceeds payable to someone other than the current owner(s).
Signatures
· Signature from the owner(s) is required to process each withdrawal.
· Types of required signatures:
  · Absolutely assigned to a corporation, church, or partnership
    · Signatures of two officers and their titles
  · Collaterally assigned
    · Signature of one officer and his/her title, and the signature of the contract owner
  · Owned by a trust
    · Signatures of all trustees with the titles of their legal capacities (trustee)
    · Copy of the pages of the Trust that indicate the name of the Trust, date of the Trust, and the names of the Trustees
      and Successor Trustees
    · The Certification of Trust, form 24143, available at Thrivent.com
  · POA, guardian or conservator
    · Signature of the POA, guardian, or conservator along with the title of legal capacity in which they are acting
    · Copy of the legal documents supporting this capacity
  · Contract has an irrevocable beneficiary
    · Signature of the irrevocable beneficiary (and title if applicable)
    · If funeral establishment is the beneficiary, authorization on their letterhead is required, and a copy of the pre-needs
      agreement
    · Signature of the owner(s)
  · Joint Owners
    · Signatures of all owners


14642INS     R1-07                                                  2