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Symetra Life Insurance Company

Home Office: 777 108th Avenue NE, Suite 1200 | Bellevue, WA 98004-5135
Mail to Administrative Office: PO Box 305154 | Nashville, TN 37230-5154
Phone 1-800-796-3872 | Fax 1-866-532-1357 | TTY/TDD 1-800-833-6388

TRUSTEE CERTIFICATION AND DISCLOSURE


Under section 72(u) of the Internal Revenue Code (the Code), a trust that holds a non qualified deferred annuity contract may be
taxed each year on the increase in the contracts value regardless of whether contract earnings are withdrawn or distributed.
Furthermore, tax treatment otherwise accorded to the holder of an annuity contract may be unavailable. An exception may apply if a
trust holds an annuity contract as an agent for a natural person (i.e., an individual) as provided under the Code and applicable
regulations. If you are unsure about the status of your trust, you should consult your legal advisor before completing this form.
Do not send a copy of the trust document to Symetra Life Insurance Company (Symetra). This document will be used to
certify that the contract is being held by a trust as agent for a natural person and to verify the trustee(s) who is (are) authorized to act
for the trust that owns the Symetra annuity contract.
Trust,
Annuitant
and Contract
Information

Name of Trust

Tax ID Number

Date of Trust

Annuity Contract Number (if issued)

Annuitant Name(s)

Phone Number

Address (number and street, city, state, zip)

Authorized
Trustee(s)

Provide the names of all authorized trustees. This list will supersede any previously provided certifications, if any.
Trustee Name

Trustee Name

If the box is
Address (number and street, city, state, zip)
checked,
trustees
Trustee Name
can act
independently.

Address (number and street, city, state, zip)

Trustee Name

Address (number and street, city, state, zip)

Signatures

Address (number and street, city, state, zip)

By signing below, each and all of the undersigned certify:


(a) They constitute all of the trustees of the trust, that they have read and understand the information on this
form, and that they have all requisite authority to complete this form and to bind the trust and all of its
beneficiaries with respect to all matters relating to the contract; if this form is submitted for a change of
trustee, this form will supersede any previously provided certifications;
(b) The trust holds the contract as agent solely for one or more natural persons within the meaning of section
72(u) of the Internal Revenue Code and none of the beneficiaries of the trust are business organizations
operating for profit such as corporations, partnerships, limited liability companies, associations or business
trusts; they and not Symetra are solely responsible for any consequences of having the contract held by the
trust including, but not limited to, tax consequences;
(c) They have been advised to and have obtained all legal and tax advice (from sources other than Symetra, its
employees, and agents) necessary to complete this form correctly;
(d) They will notify Symetra promptly in writing of any amendments to or revocation of the trust which would
cause the representations in this Trustee certification to be incorrect, or of any change in circumstances which
would cause the trust to no longer hold the contract as the agent for a natural person under 72(u);
(e) They will jointly and severally defend, indemnify and hold Symetra, its affiliates and agents harmless from
and against any and all claims, demands, liabilities, damages, costs or expenses, including, but not limited to,
reasonable attorneys fees, arising from any transactions that they make or authorize as trustees of the trust.
Symetras acceptance of this form does not constitute its conclusion or advice as to the tax or other
consequences arising from the trust owning the contract.

RSNB-0024 6/15

Trustee Signature

Date (mm/dd/yyyy)

Trustee Signature

Date (mm/dd/yyyy)

Trustee Signature

Date (mm/dd/yyyy)

Trustee Signature

Date (mm/dd/yyyy)

Symetra is a registered service mark of Symetra Life Insurance Company.