402310 Annuitization Start Date Postponement Request form

RiverSource Life Insurance Company, 70100 Ameriprise Financial Center, Minneapolis, MN 55474

Annuitization Start Date Postponement Request Form

i Complete all parts below.

DOC0101402310

Account Number

Part 1 Account Information

Contract Owner Name:

For RiverSource? annuities held inside a brokerage account, enter 141 for the administration code. For all other products, enter 004.

Part 2 Postponement Information

For fixed index and structured annuities, the annuitization start date must be a contract anniversary date. If the date entered is not a contract anniversary, we'll move it to the contract anniversary date following the date entered.

(MM/DD/YYYY) I would like to postpone my Annuitization Start Date to:

Part 3 Authorization and Acknowledgements

I understand that I may choose to annuitize my annuity contract any time prior to my Annuitization Start Date. I also understand that if my contract is still active, I will receive another communication when my Annuitization Start Date approaches.

Owner Signature

X

Date (MM/DD/YYYY)

Sign on Page 1

402310

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