403B Request Form – Fill Out and Use This PDF

Contract/Certiicate Number:

3. AMOUNT AND SOURCE OF WITHDRAWAL

A.฀I wish to withdraw my entire Account Balance.

•If you currently contribute to your contract through payroll deductions, you must contact your payroll department to stop contributions to your contract. If contributions are received after a full surrender is taken, they will be sent back to the employer.

•If you have an oustanding loan, it will automatically be closed upon request of a full surrender.

Check here if this is a “systematic termination” request (EPPA or FFA only). B.  I wish to withdraw a NET amount of $_______________.

•Only complete items below if you have variable funding option allocations in a variable annuity.

•Distributions will be automatically prorated against all funding and money type options unless you specify otherwise in the section below.

I wish to withdraw the requested amount using the following allocation or money types. (Indicate from which funding options and/or money types we should take this withdrawal. Write percentages in whole number, e.g., 33% not 331/3%.)

	Percentage or
Investment Options/Money Type	Dollar Amount
_____________________________________________________________________________________	______________________
_____________________________________________________________________________________	______________________
_____________________________________________________________________________________	______________________
_____________________________________________________________________________________	______________________
_____________________________________________________________________________________	______________________
_____________________________________________________________________________________	______________________
TOTAL (100% or $)	______________________

4. REQUIRED MINIMUM DISTRIBUTION INSTRUCTIONS FOR ROLLOVERS/TRANSFERS

If you checked withdrawal reason F, G, H or I in section 2 on page 1, and you have been taking minimum distributions from this account, you must take one for this tax year before the account is rolled over.

A. Check here if you are enrolled in MetLife’s Minimum Distribution Service (a check will be automatically sent to you for the required amount).

B.฀฀฀฀Check here if you are NOT enrolled in MetLife’s Minimum Distribution Service. Please indicate the required minimum distribution amount $________________

(See sections 8 and 9 for important income tax withholding instructions and election options).

5. OUTSTANDING LOAN PAYOFF INFORMATION AND INSTRUCTIONS

A.฀฀฀฀Attached is a certiied check to pay off my outstanding loan balance. (Use eService or call our customer service number for loan payoff amount.)

B.฀ Treat my outstanding loan (principal and interest) as a distribution. (This option only available after you reach age 591/2 have a severance from employment, or become disabled.) I understand that if my loan is not currently in default, this offset will be reported as a taxable distribution for the year of offset.

C.฀ For partial withdrawals: I have not separated from service and the partial withdrawal amount I have requested does not exceed the amount permitted as a partial withdrawal while I have a loan outstanding. Do not treat my outstanding loan as a taxable distribution. I understand that my loan will remain in force and I must continue to repay it; my account will remain open for crediting of future loan repayments.

Note: If you have an outstanding loan, it will automatically be closed upon request of a full surrender.

6. PAYMENT INSTRUCTIONS

A. Send check to the address listed in Section 1 above.

B.฀  Send check to the following address:

Address: _______________________________________ City:________________________ State:_____ ZIP:_______________

Special Mailing Instructions: _________________________________________________________________________________

C.฀฀฀To the extent permitted under the Internal Revenue Code, I wish to have the entire amount requested in section 3 (net of any applicable charges) directly transferred or rolled over as indicated in item F, G, H, or I of section 2 to the plan or provider below. (Conirmation from accepting plan or provider must be attached to this form.)

Plan or Provider Name: ___________________________________________________________ Phone Number: _________________________

Address: _____________________________________________________________________________________________________________

Name on Account: _______________________________________________________________ Account Number: _______________________

403B-WITHDRAWAL (09/09)

Page 2 of 12

eF

7. FEDERAL INCOME TAX WITHHOLDING NOTICE – Eligible Rollover Distribution Amounts Paid to You

If you withdraw eligible rollover distribution amounts and have such amounts paid to you (rather than transferring or rolling over such amounts to another plan or an IRA), the taxable portion of such amounts will be subject to mandatory 20% Federal income tax withholding. You may have more than 20% withheld by checking the box below and writing in a dollar amount. If you are under 591/2, you may owe a 10% IRS premature distribution penalty.

In addition to the mandatory 20% Federal income tax withholding applicable to eligible rollover distribution amounts not rolled over, I want an ฀additional

_________% or $___________ withheld on such amounts.

8.FEDERAL INCOME TAX WITHHOLDING INSTRUCTIONS – Amounts Not Eligible for Rollover Paid to You (Complete only if applicable)

If you withdraw amounts that cannot be rolled over (for example, a required minimum distribution after you reach age 701/2 or a payment to an alternate payee who is not the participant’s former spouse), the taxable part of such amounts will be subject to 10% Federal income tax withholding unless you elect to have no withholding apply. If you elect no withholding, or if you elect withholding and have insuficient Federal income tax withheld, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are insuficient. Even if you elect no Federal income tax withholding, you are responsible for Federal income tax on the taxable part of this withdrawal. You may owe a 10% IRS premature distribution penalty if you are under 591/2.

A. Do not withhold Federal income tax on payment to me of amounts not eligible for rollover. (Note: Checking this box does not waive the mandatory 20% Federal income tax withholding on eligible rollover distribution amounts paid to you.)

B. Withhold __________% (greater than 10%) for Federal income tax on payment to me of amounts not eligible for rollover.

9. STATE INCOME TAX WITHHOLDING INSTRUCTIONS (Complete only if applicable.)

Some states require MetLife to withhold state income tax if we withhold for Federal income tax. MetLife will calculate the amount of withholding for you. In some of these states, you may ask for no state income tax withholding (even though you requested or we are required to withhold for Federal income tax) or you may specify the amount you want withheld. In other states, no state income tax withholding will apply unless you indicate the amount you want withheld for state income tax.

10. PARTICIPANT/ALTERNATE PAYEE STATEMENT & SIGNATURE

As a participant or a former spouse alternate payee, I understand I have the right to consider whether to make or not make a direct rollover election with respect to eligible rollover distribution amounts and to consent to a distribution from my annuity account or contract without regard to the 30-day waiting period. By submitting this completed form within 30 days of receiving the Special Tax Notice Regarding TSA Payments, I hereby authorize the processing of this election without regard to the 30-day waiting period. I acknowledge that I have received and read the Special Tax Notice Regarding TSA Payments.

I certify all of the information I have provided is true, accurate and complete to the best of my knowledge.

Participant/Alternate Payee Signature: ________________________________________________ Date: _________________________________

Participant/Alternate Payee Name (please print): _______________________________________________________________________________

Contract/Certiicate Number: _________________________________

11. PLAN ADMINISTRATOR/AUTHORIZED REPRESENTATIVE SIGNATURE (Complete for all ERISA Plans or Direct Transfer/Rollover Requests)

Participant is __________% vested. (only required for ERISA Plans)

I certify this withdrawal is permissible under the terms of the Plan, that all ERISA and Plan requirements have been satisied, and hereby approve this withdrawal request.

____________________________________________________________________________________________________________________

Plan Administrator/Authorized Representative Name (please print)

__________________________________________________________________________________	_______________________________
Plan Administrator/Authorized Representative Signature	Date

FOR EMPLOYER-SPONSORED PLANS, SEE NEXT PAGE FOR QJSA WAIVER AND SPOUSAL CONSENT.

403B-WITHDRAWAL (09/09)

Page 3 of 12

eF

12. ANNUITY INFORMATION, QJSA AND NOTICE WAIVER, AND SPOUSAL CONSENT

Note: This section does not apply if your Employer’s plan does not include a qualiied joint and survivor annuity (“QJSA”) provision.

Qualiied Joint and Survivor Annuity. ERISA and/or your Employer’s plan requires that your vested Plan Account Balance be paid in the form of a qualiied joint and survivor annuity (“QJSA”) unless you and (if you are married) your spouse elect a different payment alternative. The QJSA is an annuity payable to you for your lifetime and, upon your death, an annuity payable to your spouse for his or her lifetime. The amount of each annuity payment to your spouse will equal at least 50% of the annuity payment made to you. If you are not married or your spouse does not survive you, the payments under the QJSA will stop at your death. For more information concerning the amount of each payment and other terms of the QJSA, see the Plan Administrator or your Employer.

You may waive your right to have your vested Plan Account Balance paid in the form of a QJSA. If you are married and the contract value exceeds $5,000, your spouse must consent to this waiver in order for it to be valid. You (and your spouse) may do this by completing items A. and B. below. If you make such a waiver, all or part of your vested Plan Account Balance will be paid in accordance with your withdrawal election above.

A.Waiver of Annuity and Minimum Notice Period. I waive any right to claim that the part of my vested Plan Account Balance payable as a result of this withdrawal request be paid in the form of a QJSA. I request that my vested Plan Account Balance instead be paid to me in accordance with my election above. This waiver does not affect the payment of the remainder of my vested Plan Account Balance as a QJSA. I consent to an immediate distribution of the elected part of my vested Plan Account Balance. I afirmatively waive any unexpired part of the minimum 30-day notice period during which I may consent to a distribution from the Plan.

Participant Signature: ______________________________________________________ Date: ________________________

B.Spousal Consent*. (This section must be completed if the Participant is married and the contract value amount exceeds $5,000.) I, the Participant’s spouse, have received and understand the information provided above. I voluntarily consent to the payment election and above Waiver of Annuity completed by my spouse, the Participant. I understand the law requires my spouse’s Plan Account Balance be paid as an annuity (called a qualiied joint and survivor annuity) that will pay lifetime beneits to me if I survive my spouse. I may, but am not required to, waive my rights to this annuity. My spouse’s election to not receive his or her Plan Account Balance in the form of the qualiied joint and survivor annuity is not valid unless I consent to such election. By signing this Consent, I forever waive my rights to the annuity for this part of my spouse’s Plan Account Balance.

Spouse Signature: _________________________________________________________ Date: __________________________

Notarization of Spouse’s Signature

STATE OF ___________________________________________

COUNTY OF _________________________________________

The undersigned Notary Public certiies that ______________________________________ , personally known to me to be the same person whose name is subscribed to the foregoing document, appeared before me in person, and acknowledged the signature and delivery of this instrument as his or her free and voluntary act, for the uses and purposes therein set forth.

Notary Public Signature: ___________________________________________	Date: ___________________________________
Print Name of Notary: _____________________________________________	My Commission Expires: ____________________

OR

Plan Administrator/Authorized Representative Witness

The undersigned, with authority to act on behalf of the Plan, certiies that ________________________________ , the Participant’s spouse, appeared

before me in person, and executed the foregoing document freely and voluntarily.

Plan Administrator/Authorized Representative Signature: ____________________________ Date: __________________________

*If spousal consent is required but cannot be obtained, this form must be accompanied by an afidavit completed by the participant and approved by the Plan Administrator. The afidavit must state that spousal consent is not needed or cannot be obtained because: (1) the participant’s spouse cannot be found; or (2) the participant is legally separated from or has been abandoned by the spouse (within the meaning of local law) and has a court order to such effect and no qualiied domestic relations order exists that requires spousal consent to this withdrawal.

403B-WITHDRAWAL (09/09)

Page 4 of 12

eF

INSTRUCTIONS

WHO MAY USE THIS FORM

If you are a participant, use this form to request a withdrawal from your 403(b) annuity (also known as a tax-sheltered annuity or “TSA”), other than for hardship or as a systematic withdrawal. If you are receiving disability payments from the Federal Social Security Administration, terminally ill, conined to a nursing home, or requesting a withdrawal for disability, please call our customer service number indicated on the last page of these instructions for additional requirements.

If you are an alternate payee, use this form to request a distribution from a segregated TSA account set up on your behalf. Do not use this form if you are a beneiciary.

Be sure to read the attached Special Tax Notice Regarding TSA Payments information about rollovers, when they are allowed and not allowed, and the Federal income tax consequences of rollovers, direct rollovers, and payments not rolled over. Please note that a withdrawal may incur withdrawal charges. If your certiicate is for a two-tiered annuity, a withdrawal will cause a loss of upper-tier interest.

These instructions summarize MetLife’s understanding of tax rules that may apply to your withdrawal. Tax rules are complex and contain conditions and exceptions not included in these Instructions. MetLife does not offer these Instructions as tax advice, and you may not rely upon any statement therein as such. Consult your tax advisor and/or retirement planner before you request a withdrawal. For more speciic information on the tax treatment of payments from tax-qualiied retirement plans, see Internal Revenue Service (“IRS”) Publication 571, Tax-Sheltered Annuity Plans, Publication 575, Pension and Annuity Income, and Publication 590, Individual Retirement Arrangements. These publications are available from your local IRS ofice or by calling 1-800-TAX-FORM (1-800-829-3676).

TSA WITHDRAWAL INFORMATION

IRS rules restrict when you may make withdrawals from your TSA or 403(b)(7) custodial account. Your employer’s plan may include provisions in addition to the IRS restrictions below that further limit your ability to make withdrawals before you have a severance from employment.

			IRS 403(b) Withdrawal Restrictions
		Restricted	Restricted But Available for Hardship	Unrestricted
	Other than for hardship, amounts below are		Subject to certain conditions, amounts below are	Amounts below are generally eligible for
	eligible for withdrawal only after participant’s		available for hardship before participant’s age	withdrawal at any time:
	age 591⁄2, severance from employment, death,		591⁄2 or severance from employment:
	or disability:
403(b) Annuity	•	Post-1988 earnings on your voluntary	• Your post-1988 voluntary pre-tax contributions,	• Your voluntary pre-tax contributions from
(“TSA”)		pre-tax contributions from before 1989;	but not their earnings.	before 1989 and their pre-1989 earnings;
	• Your post-1988 voluntary pre-tax contributions		• You and your employer’s pre-1989 contributions	• Your pre-tax contributions made as a
		and their earnings; and	and their pre-1989 earnings that you directly	result of an	irrevocable election	or as
	•	Amounts you or your employer contributed	transferred to the TSA under Revenue Ruling	a condition	of employment and	their
			90-24 from a 403(b)(7) custodial account.	earnings;
		to a 403(b)(7) custodial account and that
		you later directly transferred under Revenue		• Your after-tax contributions plus their
		Ruling 90-24 to your TSA.		earnings;
				• Your employer’s contributions and their
				earnings.
				• Above amounts that were directly
				transferred to your TSA from another TSA
				(other than a section 403(b)(7) custodial
				account); and
				• Eligible rollover distribution amounts
				you rolled to your TSA from another
				TSA, a 403(b)(7) custodial account, an
				IRA, a Section 401(a) or 403(a) plan, a
				governmental Section 457(b) plan, and
				their earnings.
403(b)(7)	•	All amounts.	• Your post-1988 voluntary pre-tax contributions,	No amounts.
Custodial			but not their earnings; and
Account			• You and your employer’s pre-1989 contributions
			and their pre-1989 earnings.

403B-WITHDRAWAL (09/09)

Page 5 of 12

eF