RiverSource Life Insurance Company 70100 Ameriprise Financial Center Minneapolis, MN 55474
TSA Loan Note, Agreement and Pledge
for Salary Reduction Plans:
Retirement Advisor Variable Annuity (RAVASM)
and RiverSource Group Annuity (RGA)
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Select the Product Type for this request: (Required):
RAVA 5SM Account Number
The loan options available to you may be restricted by your
employer's 403(b) plan provisions. See your Plan Administrator or
Summary Plan Description for further information.
This form is used to request a loan from a RAVASM Tax-Sheltered
Annuity (TSA) only.
Loan requests for other Non-RAVA products (Flexible Annuity,
Flexible Portfolio Annuity, etc.) should use Form 30023.
Part 1
9925
Other RAVASM Account Number
004
9310
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Failure to select a Product Type could result in
processing delays.
Contract Owner Information
Contract Owner Name
Street Address
City
!
State
This TSA Loan Note, Agreement and Pledge allows the contract owner to borrow a portion of the account value of the above-referenced
TSA, according to the terms of the contract and in accordance with applicable tax law.
Part 2
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ZIP code
Loan Request and Certification
Failure to complete this section or to provide accurate information may result in the denial of this request.
Date of separation (MMDDYYYY)
Yes, severed employment from employer.
I hereby request a loan in the amount of:
$
I hereby request a loan for the maximum amount available
If no amount is indicated or if the amount I have requested is greater than the maximum amount available, I authorize RiverSource Life
Insurance Company (RiverSource Life) to process a loan for the maximum amount available.
In support of this loan request, I certify that:
I have not had any outstanding loans from any of this employer's qualified plan(s) (including 401(k) and 403(b) plans) during the previous
12 months
I have had one or more outstanding loans from qualified plans of this employer during the last 12 months (complete all statements
below):
1. The highest aggregate loan balance(s) (including any unpaid Deemed Distributed Loans) from any plan with this employer in the most
recent 12 month period was $
.
2. I currently have a Deemed Distributed Loan that has not been repaid.
Sign on Page 4, 5, 6 and 8
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Yes
.
No
© 2009-2013 RiverSource Life Insurance Company.
All rights reserved.
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Part 3
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Promise to Pay
A monthly payment option is only available if payment is set up on a bank authorization and must be selected at the time of submission
(See page 6).
In consideration of receipt of a loan, I promise to pay RiverSource Life the full amount I borrow plus interest of 6% in substantially level installments,
due at least quarterly as required by Section 72(p) of the Code. Once my loan is approved and processed, you will give me payment information
showing the minimum quarterly loan payment amount. You will apply the payments to my then-current allocation.
For TSA plans that are subject to the Employee Retirement Income Security Act, (ERISA) (9925 accounts)
I promise to pay RiverSource Life the full amount I borrow plus interest of Prime + 2%, not to exceed 8% in substantially level installments,
due at least quarterly as required by Section 72(p) of the Code. Once my loan is approved and processed, you will give me payment information
showing the minimum quarterly loan payment amount. You will apply the payments to my then-current allocation.
In the event the interest rate of Prime + 2% does exceed 8%, I understand that I may not be able to take a loan from my employer's 403(b) plan.
I intend to use the loan proceeds to buy a principal residence (Select one):
Yes (loan payment period is 10 years)
No (loan payment period is 5 years) (If no election is made, we will default to a 5 year payment period)
Part 4
Payment and Delivery Information (Required)
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Provide both payment and delivery instructions in this section. You must specify where you would like your loan amount delivered. If no
instructions are provided, we will send the distribution to your address of record via regular mail. To have your distribution wired directly to
your bank or credit union account, you will need to select and complete the "Wire to bank account" section and/or provide a voided check.
!
Direct deposit is only available for RAVA 5SM and RiverSource Group Annuity contracts. If this option is selected for an ineligible
product, we will send the distribution to your address of record via regular mail.
Send to my address of record
Regular Mail
Express Mail (Fee instructions in Part 5 required. If Part 5 is not completed, delivery will
default to address of record via regular mail.)
Deposit into my existing non-qualified account(s) at Ameriprise Financial Services, Inc.
Account Number
Amount
% of Distribution
$
%
$
%
Wire to bank account (Fee instructions in Part 5 required. If Part 5 is not completed, delivery will default to address of record via regular mail.)
Direct Deposit to bank account (For RAVA 5SM and RiverSource Group Annuity contracts only (9925))
Bank Account Type:
Checking (attach voided or canceled check below)
Savings or non-draft account at a credit union (complete all information below)
Do you want this bank information to be used in connection with other RiverSource Life products?
Yes
No
Important
Attach a voided check or bank letter
providing the bank transit number and your bank account number.
Do not use a Deposit Slip
Name of Financial Institution
Financial Institution Routing Transit
Number/ABA Number(9 digits)
Bank Account Owner(s)
Bank Account Number
Send to alternate payee (Provide name and address in space below)
Name
Billing Address
City
35033
State
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ZIP code
Part 5
Charge Fee Options
Select one
Deduct fee from loan amount (Loan check amount will be reduced by the fee amount)
(annuity products excluded)
Deduct fee from other Ameriprise® account
Deduct fee from Credit Card (Complete Credit Card information below)
!
If this section is incomplete or the fee is declined, a check will be sent via U.S. First Class Mail
Wire/Express fees may not be paid for by anyone other than the policy/contract owner.
Credit Card Type:
American Express
Visa
Mastercard
Discover
Credit Card Number
Expiration Date (MMYY)
Name
Billing Address
City
Part 6
State
ZIP code
Definitions, Loan Requirements and Signatures
Definitions
I, me, my - The borrowing contract owner
You, your, RiverSource Life - RiverSource Life Insurance Company
TSA - The tax-sheltered annuity contract identified above, which is issued under Section 403(b) of the Internal Revenue Code of
1986, as amended (the "Code").
IRC 72(p)/Applicable Tax Law - The portion(s) of the Code related regulations and other guidance that govern loans from TSAs,
as they now exist or are later amended or supplemented.
Loan Balance - The amount of principal outstanding on your loan from the TSA identified above, plus interest.
Loan Offset - The event that occurs if a TSA loan fails to meet the requirements of IRC 72(p), at a time when the contract owner is
eligible to receive a distribution from the TSA. The value of the TSA is reduced to pay off the outstanding debt, and a taxable
distribution in the amount of the Offset Loan is re ported to the IRS as a taxable distribution (See Part 6, number 7 in the Loan
Requirements section).
Deemed Distribution - The event that occurs if a TSA loan fails to meet the requirements of IRC 72(p), at a time when the contract
owner is not eligible to receive a distribution from the TSA. Any such loan is reported as taxable and continues to be held in the
acount as a Deemed Distributed Loan (See Part 6, number 7 in the Loan Requirements section).
Surrender Value - Value of account after surrender charges have been deducted.
Pre-TAMRA Value - Value accumulated prior to December 31, 1988.
Policy Anniversary - The same day and month each year as the contract issue date.
Loan Requirements
I agree that my loan will be subject to the following requirements:
1. Only one loan may be outstanding at any one time from this TSA.
2. There is a 10 business day waiting period between loans.
3. As I pay back the loan according to the payment schedule, the loan balance will be reduced. The loan account earns interest at
a rate of 3% instead of the current interest rate under the TSA.
4. For RAVASM, RAVA Advantage®, RAVA Select®, RAVA Plus, and RAVA 4SM annuities contracts: The maximum loan
amount available to me is limited by loans I have from other qualified retirement plans offered by my employer. My new loan
amount, plus the outstanding balance of all other loans I have taken from my employer's qualified plans, cannot exceed the
lesser of: (a) $50,000 reduced by the excess (if any) of the highest outstanding balance of loans from my employer's qualified
retirement plans during the one year period ending on the day before the date on which such loan was made, over the
outstanding balance of loans from such plans on the date the new loan is made; or (b) the greater of 50% of my vested accrued
balance or $10,000. The loan balance cannot exceed 94% of the contract's surrender value. The minimum loan amount is $500.
5. For RAVA 5SM contracts and RiverSource Group Annuities: The maximum loan amount available to me is limited by loans I
have from other qualified retirement plans offered by my employer. My new loan amount, plus the outstanding balance of all
other loans I have taken from my employer's qualified plans, cannot exceed the lesser of: (a) $50,000 reduced by the excess (if
any) of the highest outstanding balance of loans from my employer's qualified retirement plans during the one year period
ending on the day before the date on which such loan was made, over the outstanding balance of loans from such plans on
Definitions, Loan Requirements and Signatures continued on next page...
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Definitions, Loan Requirements and Signatures continued
the date the new loan is made; or (b) 50% of my vested accrued balance. The minimum loan amount is $500.
6. The maximum loan payment period is 5 years unless my loan is to purchase my principle residence, then payment may be
made over 10 years.
7. If I fail to make any payment when it is due, or my loan fails to meet the requirements of applicable tax law for any other reason,
RiverSource Life may treat all or part of my Loan Balance as a taxable Offset Loan or Deemed Distributed Loan, as appropriate.
However, before taking such action, RiverSource Life may choose to extend me a grace period or "cure period" during which I
may bring my payments current or pay off my loan. If my loan is treated as an Offset Loan, RiverSource Life will deduct all or an
appropriate portion of my Loan Balance from the contract value of my TSA, first by reducing the value of the loan account and
then, if necessary, by reducing the value of my accounts on a pro rata basis. If my loan cannot be treated as an Offset Loan,
because I am not currently eligible for a distribution, the loan will continue to be held in my account as a Deemed Distributed
Loan. Interest will be charged and credited on any Deemed Distributed Loan until it is paid in full. I am responsible to
notify RiverSource Life of the occurrence of any distribution triggering event other than attaining age 59½ . After I attain age
59½ , or after I notify RiverSource Life that I have otherwise become eligible for a distribution, RiverSource Life will deduct all or
an appropriate portion of my Loan Balance from the accrued cash value of my TSA in the manner described above for an Offset
Loan. I understand that any Offset Loan or Deemed Distributed Loan will be reported to the IRS, and that in addition to the taxes
I owe on the amount treated as taxable income to me, I may be subject to early withdrawal excise taxes, other adverse tax
consequences and/or contract surrender charges. I also acknowledge and agree that RiverSource Life will not accept
partial payments on a Deemed Distributed Loan, so that a lump sum payoff payment is required in order to repay my loan
following a deemed distribution.
To ensure timely loan payments that will keep your loan in good standing, we encourage you to make systematic payments
through bank authorization.
8. My loan is not transferable, and while it is outstanding, no scheduled distributions will be allowed. If my loan is not fully paid
before my TSA is distributed or rolled over to another qualified account, RiverSource Life may reduce the amount that is
distributed and/or rolled over by an amount not to exceed the amount of my Loan Balance, plus applicable surrender charges. If
this occurs, all or an appropriate portion of my Loan Balance may be taxable to me or to my beneficiary, and IRS penalties may
also apply.
9. This Loan Note, Agreement and Pledge will be governed by the laws of the State of Minnesota to the extent not governed by
applicable federal law.
If you are currently retired, unemployed or working for an employer who does not sponsor a 403(b) program, your 403(b) account is
deemed associated with your most recent employer who sponsored the 403(b) arrangement.
Irrevocable Pledge and Assignment
As security for the payment of the above loan, I hereby irrevocably pledge and assign to you a security interest in my TSA identified
above that will at all times be equal to 100% of the Loan Balance. I further waive receipt of any portion of my TSA to the extent it is
so pledged, and must be applied in accordance with this Loan Note, Agreement and Pledge to ensure payment of my loan. This
Irrevocable Pledge and Assignment will bind my heirs, personal representatives or other legal representatives.
Signature(s)
I have read and understand this Loan Note, Agreement and Pledge. I specifically understand that if my loan does not meet all of the
requirements of applicable law and this Loan Note, Agreement and Pledge, all or a portion of the amount outstanding may become
immediately taxable, and I may also be subject to IRS penalties and other adverse tax consequences. I accept full responsibility for
complying with all of these requirements, and agree that RiverSource Life is not responsible for any tax consequences to me
resulting from this loan. I certify that I have truthfully completed this document to the best of my knowledge, and that this loan will
not be used to purchase securities.
I am returning the original and making a copy for my records, as this Loan Note, Agreement and Pledge together with the
Loan Initiation Letter (mailed to me after the loan is processed) compromises the Loan Agreement.
Signature of Contract Owner
Date (MMDDYYYY)
X
Signature of Contract Owner's Spouse
Date (MMDDYYYY)
X
Consent of spouse is required for distributions from a 403(b) plans that are subject to the Employee Retirement Income Security Act (ERISA).
If you are unsure if your plan is subject to ERISA (and consequently spousal consent requirements) check with your plan sponsor. (Usually your
employer).
Generally:
403(b) plans sponsored by a governmental entity such as a public school or university are not subject to ERISA
403(b) plans sponsored by a church or qualified church controlled organization are generally not subject to ERISA, however some exceptions
may apply
403(b) plans sponsored by a 501(c)(3) (non-profit) organization may be subject to ERISA depending on the design and operation of the plan.
!
The spouse's signature must be witnessed by either the Plan Sponsor/Administrator or a Notary Public.
Definitions, Loan Requirements and Signatures continued on next page..
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Definitions, Loan Requirements and Signatures continued
For governmental and ERISA plans, the requested transaction has been approved and acknowledged by; OR for 501(c) (3) non-ERISA plans, the
Plan Sponsor represents that the participant had a termination of employment.
I acknowledge and approve the requested transaction.
For ERISA Plans, with the authority to act on behalf of the Plan, I certify that the participant's spouse
personally
appeared before me with evidence to be the person whose name is named below and executed the foregoing document voluntarily.
Name of Plan Sponsor (Required)
Phone Number
Employer ID Number (EIN)
Mailing Address (Required)
State
City
ZIP Code
Third Party Administrator Entity Name (if applicable)
Plan Sponsor/Third Party Administrator Authorized Signor Name (if applicable)
Plan Sponsor/Third Party Administrator Signature (if applicable)
Date (MMDDYYYY)
X
Plan Sponsor/Designated Plan Administrator Notes Section
Amount approved if different than requested
$
Spousal consent for 403(b) plans that are subject to ERISA
!
The spouse's signature must be witnessed by either the Plan Sponsor/Administrator or a Notary Public.
Owner's marital status:
Single
Married
Widowed
Divorced
I understand that, as the owner's spouse, I have certain rights concerning his or her benefits, including the right to receive any death benefits
unless I consent to another disposition. I hereby consent to the above requested withdrawal and I acknowledge that this consent will have the
effect of waiving any and all rights concerning this withdrawal.
Spouse Name
Spouse Security Number
Spouse Signature
Date (MMDDYYYY)
X
Is this transaction based on a recommendation by an Ameriprise financial advisor?
i
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Yes
No
If yes, provide the Recommending Advisor Name and ID# below.
Name
Advisor ID
It is assumed the Recommending Advisor and Servicing Advisor are the same if the Recommending Advisor is not identified.
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Part 7
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Notarization
Spousal consent is required for 403(b) plans subject to ERISA and the signature must be witnessed by either the plan sponsor/
administrator or a notary.
I certify that
personally
appeared before me with satisfactory evidence to be the person whose name is subscribed within the instrument and acknowledged to me that
he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument executed the instrument.
I certify under PENALTY OF PERJURY under laws of the State of
is true and correct.
, Country of
that the foregoing paragraph
WITNESS my hand and official Seal:
Print Notary Name
Signature of Notary
Date (MMDDYYYY)
X
Notary Commission Number
Notary Commission Expiration Date (MMDDYYYY)
Notary Seal:
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RiverSource Life Insurance Company 70100 Ameriprise Financial Center Minneapolis, MN 55474
TSA Loan Note Bank Authorization
This form is used only for TSA loan payments
Select the Product Type for this request: (Required):
RAVA 5SM Account Number
9925
Other RAVASM Account Number
004
9310
!
Part 8
Failure to select a Product Type could result in
processing delays.
Account Owner Information
Contract Owner Name
Social Security Number
Current Bank Authorization
None
Existing: List one RiverSource Life account number that currently is on BA
Part 9
Loan Payment Information
Annuity BA Loan Payment Setup: Frequency (Select one):
!
If no election is made, we will default to a 5 year monthly payment period.
Monthly - payments will begin 30 days after loan date
Quarterly - payments will begin 90 days after loan date
Loan Payment Amount (Select one)
A.
To RiverSource Life: Calculate the amount needed to
pay the loan requested over the period indicated on the Loan
Request. You will receive confirmation of the amount prior to the
first payment due date.
Part 10
B.
Other Amount
$
(Must be equal to or greater than A amount)
Bank Account Information and Type (select one, either Checking or Savings)
Checking (attach voided or canceled check below)
Savings or non-draft account at a credit union (complete all information below)
Important
Attach a voided check or bank letter
providing the bank transit number and your bank account number.
Do not use a Deposit Slip
Name of Financial Institution
Financial Institution Routing Transit
Number/ABA Number(9 digits)
Bank Account Owner(s)
Bank Account Number
Sign on page 8
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© 2009-2013 RiverSource Life Insurance Company.
All rights reserved.
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Part 11
Authorization and Signatures
Authorization
By signing below:
For the purpose of repaying the TSA loan you have requested, over a period of no greater than five years (10 if for purchase of principal
residence), you authorize RiverSource Life Insurance Company to charge your account at the financial institution named above to pay the
amount necessary to amortize your TSA loan over the period indicated in the TSA Loan Note, Agreement and Pledge, or if greater, the amount
listed above. The payments will be used to reduce the loan balance of the account(s) listed above; and
You authorize the financial institution named above to honor these charges for payment, as if they were signed by you; and
You certify this agreement will remain in effect until the loan balance is paid or you notify us or your financial institution in writing to cancel it,
allowing reasonable time to act on your cancellation.
You may stop any payment by notifying the financial institution or us at least three banking days before the charge is to be made. You will receive
notice from us of any payment that differs in amount from the previous payment.
I am returning the original and making a copy for my records, as this Loan Note, Agreement and Pledge together with the Loan Initiation
Letter (mailed to me after the loan is processed) compromises the Loan Agreement.
Date (MMDDYYYY)
Signature of Bank Account Owner(s)
X
X
Advisor Information
Is this transaction based on a recommendation by an Ameriprise financial advisor?
i
Yes
No
If yes, provide the Recommending Advisor Name and ID# below.
Name
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Advisor ID
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