Beneficiary Change Request

Athene.com

Submit completed form to: Athene Annuity and Life Company

P.O. Box 1555, Des Moines, IA 50306-1555 Fax: 866-709-3922 7700 Mills Civic Parkway, West Des Moines, IA 50266-3862
Email: [email protected] Athene Annuity & Life Assurance Company of New York
Contact us: Pearl River, NY 10965
Annuity Customer Contact Center: 888-266-8489
Email: [email protected]

INSTRUCTIONS
• Use this form to make changes to your beneficiary designation.
• To expedite the processing of your request, all pages must be completed and returned.
• Use percentages in your designation. All proceeds must total 100%. If the percentages do not equal 100%, the
request will not be accepted. If no percentages are listed, proceeds will be divided equally.
• If you designate a class of beneficiaries (such as Children), list the full names and relationships of the known beneficiaries
of that class. Notify us of any changes to that class of beneficiaries.
• If the owner is a Pension Plan, submit a Pension Plan Verification (Form 17982), if you have not already done so.
• If the owner is a company, submit a Company, Partnership or Limited Liability Corporation (LLC) Verification (Form
19861) and provide a Corporate Resolution or similar document that lists all of the officers and/or individuals authorized
to sign on behalf of the company, if you have not already done so. If you are designating a Company, Partnership or
Limited Liability Corporation (LLC) as your beneficiary, please submit an updated Company, Partnership or Limited
Liability Corporation (LLC) Verification Form (19861) and provide a Corporate Resolution or similar document that lists
all of the officers and/or individuals authorized to sign on behalf of the company.
• If the owner is a Trust, submit a Trust Verification Request (Form 16541), if you have not already done so. If you are
designating a Trust as your beneficiary, signing as a Trustee, or if there have been changes to the Trust, please submit
an updated Trust Verification (Form 16541).
• If a Trust is designated as beneficiary please use the following format:
The John J. Smith Trust under agreement dated January 1, 2017.
• “Last Will and Testament” will not be accepted as a beneficiary designation
• The effective date of the change will be the date the form is received in the Home Office.
• If this form is for the designation to a charity, address is required.

1. OWNER INFORMATION

Individual, Trustee or Company Name

If Trust, list Trust Name and Trust Date Email Address

Policy Number(s) Address Change Requested

Mailing Address City State Zip Country

Street Address (REQUIRED if mailing address is a PO Box) City State Zip Country

Social Security / Tax Identification Number Date of Birth (mm/dd/yyyy) Personal Phone
/ / ( ) -

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 Beneficiary Change Request

2. BENEFICIARY(IES) Required Information - If this section is blank we will be unable to process your request.

If additional space is needed, you may copy this page, mark the checkbox at the bottom of the page and return. You may
also use additional blank pages labeled “Additional Beneficiaries”. Each blank page must be signed by the Owner and
dated, labeled with the word “Attachment” and include beneficiary information and policy/contract numbers. Indicate if
each named designation is Primary or Contingent.

Individual, Trust or Company Name Percentage

%
Date of Birth (mm/dd/yyyy) Telephone Number Relationship to Owner, or Insured/Annuitant if Non-Natural Owner
/ /
Street Address City State Zip

Social Security / Tax Identification Number

Primary Contingent

Individual, Trust or Company Name Percentage

%
Date of Birth (mm/dd/yyyy) Telephone Number Relationship to Owner, or Insured/Annuitant if Non-Natural Owner
/ /
Street Address City State Zip

Social Security / Tax Identification Number

Primary Contingent

Individual, Trust or Company Name Percentage

%
Date of Birth (mm/dd/yyyy) Telephone Number Relationship to Owner, or Insured/Annuitant if Non-Natural Owner
/ /
Street Address City State Zip

Social Security / Tax Identification Number

Primary Contingent

Individual, Trust or Company Name Percentage

%
Date of Birth (mm/dd/yyyy) Telephone Number Relationship to Owner, or Insured/Annuitant if Non-Natural Owner
/ /
Street Address City State Zip

Social Security / Tax Identification Number

Primary Contingent

If you need more space and have attached additional sheets to your form, check this box

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 Beneficiary Change Request

3. BENEFICIARY(IES)

If additional space is needed, you may copy this page, mark the checkbox at the bottom of the page and return. You may
also use additional blank pages labeled “Additional Beneficiaries”. Each blank page must be signed by the Owner and
dated, labeled with the word “Attachment” and include beneficiary information and policy/contract numbers. Indicate if
each named designation is Primary or Contingent.
Individual, Trust or Company Name Percentage
%
Date of Birth (mm/dd/yyyy) Telephone Number Relationship to Owner, or Insured/Annuitant if Non-Natural Owner
/ /
Street Address City State Zip

Social Security / Tax Identification Number

Primary Contingent

Individual, Trust or Company Name Percentage

%
Date of Birth (mm/dd/yyyy) Telephone Number Relationship to Owner, or Insured/Annuitant if Non-Natural Owner
/ /
Street Address City State Zip

Social Security / Tax Identification Number

Primary Contingent

Individual, Trust or Company Name Percentage

%
Date of Birth (mm/dd/yyyy) Telephone Number Relationship to Owner, or Insured/Annuitant if Non-Natural Owner
/ /
Street Address City State Zip

Social Security / Tax Identification Number

Primary Contingent

Individual, Trust or Company Name Percentage

%
Date of Birth (mm/dd/yyyy) Telephone Number Relationship to Owner, or Insured/Annuitant if Non-Natural Owner
/ /
Street Address City State Zip

Social Security / Tax Identification Number

Primary Contingent

If you need more space and have attached additional sheets to your form, check this box

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 Beneficiary Change Request

4. YOUR CONFIRMATION AND SIGNATURE

By signing below:
• I acknowledge this request is subject to the provisions and conditions of my policy/contract(s) and Athene may
request additional information in order for my request to be processed.
• I understand by submitting this document, I revoke any existing beneficiary designations and settlement agreement
and request Athene change the beneficiary for the listed policy/contract(s).

Spousal Consent May Be Required

You as the contract owner should determine whether to obtain your spouse’s signature to change the beneficiary of this
contract if you live in a Community Property state. The following states are subject to Community Property laws at the time
of this printing: Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington and Wisconsin. These are
subject to change and should be verified.

It is your sole responsibility to determine whether a spousal signature should be obtained and/or if your state is subject to
community property rules and laws. Questions regarding the legal and/or tax effects of this Beneficiary Change Request
should be referred to a legal professional.

Athene assumes no responsibility and has no obligation to inquire and/or investigate whether such interest exists. In
consideration of accepting this Beneficiary Change Request form, you agree to indemnify and hold Athene harmless from
any and all consequences and effects of accepting and complying with the election made.
Owner/Trustee Signature Date (mm/dd/yyyy)
X / /
Owner Title (if Trust or Corporation)

Joint Owner Signature (if applicable) Date (mm/dd/yyyy)

X / /
Other Required Signatures (Irrevocable Beneficiaries, if any) Date (mm/dd/yyyy)
X / /

If you are signing on behalf of the owner, print your name and provide your signature below. Check the box that
applies to the capacity in which you are signing. If you have not already done so, provide your Power of Attorney,
Conservatorship, or Guardianship documents to verify you are authorized to act on behalf of the owner.

Conservator Guardian Power of Attorney

Printed Name

Signature Date (mm/dd/yyyy)

X / /
Witness Signature (Required Only in Massachusetts) Date (mm/dd/yyyy)
X / /

5. SPOUSAL CONSENT
By signing this form, I consent to the designation of the beneficiary(ies) listed above. I understand and agree:
• The effect of this designation is to cause some or all of my spouse’s death benefit to be paid to a beneficiary other
than me;
• Each beneficiary designation is valid; and
• My consent is irrevocable unless my spouse revokes the beneficiary designation(s).
Spouse Signature Date (mm/dd/yyyy)
X / /

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