Metlife Withdrawal Form – Fill Out and Use This PDF

Metropolitan Life Insurance Company

MetLife Investors USA Insurance Company

MetLife Insurance Company of Connecticut

403(b) Hardship Withdrawal Request Form

(Including “Safe Harbor” Hardship Rules)

Because 403(b) withdrawal rules are complex, please read Instructions before completing this form.

1.GENERAL INFORMATION (Complete all applicable items.)

Participant Name (First, Middle & Last)	Social Security Number			Contract/Certiicate Number
Street Address	Marital Status ________________			U.S. Citizenship Status
	Sex:	___ Female	___ Male	___	U.S. Citizen
				___	U.S. Resident Alien
City, State & ZIP Code	Daytime Phone Number
				___	Nonresident Alien

2.REASON FOR HARDSHIP WITHDRAWAL (Check all applicable boxes. You must provide documentation showing evidence of hardship to Plan.)

A.q Medical expenses described under Code 23(d) incurred or anticipated to be incurred by the employee, the employee’s spouse or dependent. This is for all deductible medical expenses – not just the amount that actually exceeds 7.5% of adjusted gross income.

B.q Purchase (excluding mortgage payments) a principal residence of the employee.

C.q Tuition and related educational fees for the next 2 months for post-secondary education for the employee, spouse, children or dependents.

D.q Payment to prevent eviction from the employee’s primary residence or foreclosure on the mortgage on the employee’s primary residence.

E.q Funeral expenses of parents, spouse, children or dependent.

F.q Certain expenses relating to the repair of damage to the employee’s principal residence that would qualify for the casualty deduction, such as those resulting from hurricane or lood damage.

G.q Other reason permitted under Plan and Internal Revenue Code __________________________________________________________.

3.NET AMOUNT OF WITHDRAWAL

Indicate the amount you need to satisfy your hardship: $_______________. (The net amount of withdrawal you are requesting must be a speciic dollar

amount. If you write “maximum available amount” or a similar expression without a dollar amount, we cannot process your request. Your contract/certiicate value will be reduced by this amount plus any applicable federal/state tax withholding. A $500 minimum may apply based on contract provisions.)

If you have elected a living beneit rider, please note that the withdrawals could negatively impact the beneits under this rider. Please refer to your prospectus for details.

4. SOURCE OF WITHDRAWAL (Optional)

Distributions will be automatically prorated against all funding and money type options unless you specify otherwise. Do not complete if you own a fixed annuity.

•Complete section below if you wish to have the distribution taken from speciic sources by indicating the fund and/or money type along with the percentage and/or dollar amount.

•Write percentages in whole numbers (e.g., 33%, not 33 /3%).

Funding/Money Type Options	Percentage or	Funding/Money Type Options	Percentage or
	Dollar Amount		Dollar Amount
___________________________________	________________	___________________________________	________________
___________________________________	________________	___________________________________	________________
___________________________________	________________	___________________________________	________________
		TOTAL of both columns	00% and/or $

5. FEDERAL INCOME TAX WITHHOLDING INSTRUCTIONS

The taxable part of your hardship withdrawal will be subject to 0% Federal income tax withholding unless you elect not to have withholding apply, or elect to have more than 0% withheld below. If you elect no withholding, or if you elect withholding and you 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 also owe an additional 0% penalty tax to the IRS if you have not yet reached age 59/2.

6. 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.

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7. PAYMENT INSTRUCTIONS

qSend check to the address listed in Section above.

qSend check to the following address:

Address: ________________________________________________ City:___________________________ State:_______ ZIP:____________

Special Mailing Instructions: ____________________________________________________________________________________________

8. PARTICIPANT STATEMENT & SIGNATURE

I certify the amount of withdrawal requested above is not more than the amount I need to relieve my inancial hardship and, if applicable, to cover the resulting taxes. I understand the law prohibits my withdrawal if my need may be satisied from other resources reasonably available to me. I certify my hardship cannot be satisied:

•through reimbursement or compensation by insurance or otherwise;

•by reasonable liquidation of my assets;

•by other distributions (including distributions of amounts rolled over to my 403(b) annuity) or nontaxable loans available from this and any other plans of my Employer;

•by stopping my voluntary pre-tax and after-tax contributions (if any) to this and any other plans of my Employer for at least 6 months (or for ERISA Plans, the length of time required under the Plan) after receiving this withdrawal;

•by borrowing from commercial sources on reasonable commercial terms; or

•by the assets of my spouse or minor children which are reasonably available to me.

I certify that the amount I have requested does not exceed my elective deferrals to the Plan.

I certify that I have provided documentation showing evidence of the hardship reason(s) indicated in Section 2 to my Plan Administrator/Authorized Representative.

I understand MetLife (and if my plan is an ERISA Plan, my Employer or Plan Administrator) makes no warranty or representation regarding the tax consequences, if any, resulting from my hardship withdrawal. I understand that in determining my eligibility for this withdrawal, MetLife is relying on my Employer or Plan Administrator/Authorized Representative.

I understand and agree that salary reduction contributions to all plans of my employer must be suspended for at least six (6) months after the inancial hardship distribution.

I understand that if I have a variable annuity with an outstanding loan, my contract/certiicate must have an amount in the Fixed Interest Account equal to 5% - 25% of the gross loan amount as applicable to my contract/certiicate. On the day MetLife receives my hardship withdrawal request in good order, funds from the Separate Account investment divisions will be transferred to the Fixed Interest Account to satisfy this requirement if my contract/certiicate does not have 5% - 25%, as applicable, of the gross loan amount requested in the Fixed Interest Account. The funds transferred from the Separate Account investment divisions will be in proportion to the current allocation of funds to the Separate Account investment divisions within my contract/ certiicate on the day MetLife receives my hardship withdrawal request in good order.

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

Participant Signature: ________________________________________________________________________ Date: ______________________

9. PLAN INFORMATION AND PLAN ADMINISTRATOR/AUTHORIZED REPRESENTATIVE OR EMPLOYER STATEMENT & SIGNATURE

A) Complete for ERISA Plans only:

Participant is __________% vested. The Plan makes the following contribution types available for this withdrawal in the priority order listed below:

. __________ Employee Rollovers into the Plan

2.__________ Pre-989 Employee Voluntary Pre-Tax contributions (and their pre-989 earnings) not subject to 403(b)(7) withdrawal restrictions

3.__________ Employee After-Tax Contributions not subject to 403(b)(7) withdrawal restrictions

4.__________ Employer Matching Contributions not subject to 403(b)(7) withdrawal restrictions

5.__________ Employer Basic Contributions not subject to 403(b)(7) withdrawal restrictions

6.__________ Employee Mandatory Contributions (i.e., pre-tax contributions made as a result of an irrevocable election or as a condition of employment) not subject to 403(b)(7) withdrawal restrictions

7.__________ Any of contribution types 3–6 checked above made before 989 and subject to 403(b)(7) withdrawal restrictions (but not their post- 988 earnings)

8.__________ Pre-989 Employee Voluntary Pre-Tax contributions (and their pre-989 earnings) that are subject to 403(b)(7) withdrawal restrictions

9.__________ Post-988 Employee Voluntary Pre-Tax contributions (but not their earnings)

Note: Write “N/A” if a contribution type is already available for in-service distributions without having to meet the hardship withdrawal requirements, is not available for hardship withdrawals, or does not apply. If contribution types 7–9 are available for hardship withdrawals, they must be accessed last.

B) For both Non-ERISA and ERISA Plans:

I certify this withdrawal is permissible under the terms of the Plan and I have been provided documentation showing evidence of the hardship reason(s) indi- cated in Section 2. The participant has already received all loans or other distributions for which he/she qualiies. I also certify contributions will be stopped for at least 6 months (or the length of time required under the Plan) after the hardship withdrawal. I hereby approve this withdrawal request.

Plan Administrator/Authorized Representative Signature:______________________________________________ Date: _______________________

Employer Signature (if applicable):_______________________________________________________________ Date: _______________________

SEE NEXT PAGE FOR QJSA WAIVER AND SPOUSAL CONSENT (SECTION 10).

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

NOTE: This section applies ONLY if your Employer’s plan includes a qualified joint and survivor annuity (“QJSA”) provision.

Qualified Joint and Survivor Annuity. The law 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 distribution 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 hardship 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 hardship 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 in Section 5 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 distribution 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 affidavit completed by the participant and approved by the Plan Administrator. The affidavit 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 qualified domestic relations order exists that requires spousal consent to this withdrawal.

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Instructions

WHO MAY USE THIS FORM

If you are a participant, use this form to request a hardship withdrawal from your 403(b) annuity (also known as a tax-sheltered annuity or “TSA”) if you participate in either a voluntary non-ERISA 403(b) program or in an employer-sponsored 403(b) Plan that follows the 40(k) “deemed” or “safe harbor” hardship withdrawal rules. (An employer-sponsored plan is a 403(b) ERISA plan or a church or governmental 403(b) plan operating under a written plan document and/or providing employer contributions.) If you are 59/2 or older or have separated from service, you may not be eligible for a hardship withdrawal under the Plan’s rules and may instead need to use the 403(b) Withdrawal Request Form. Do not use this form if you are an alternate payee or beneiciary.

Please note that a hardship withdrawal may incur certiicate withdrawal charges. If your certiicate is for a two-tiered annuity, a hardship withdrawal will cause a loss of upper-tier interest.

These instructions summarize MetLife’s understanding of tax rules that may apply to your hardship withdrawal. Tax rules are complex and may 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 57, 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 -800-TAX-FORM (-800-829-3676).

TSA WITHDRAWAL RESTRICTIONS AND PENALTIES

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 restrict 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		Subject to certain conditions, amounts below		Amounts below are generally eligible for
	are eligible for withdrawal only after		are available for hardship before participant’s		withdrawal at any time:
	participant’s age 59/2, severance from		age 59/2, or severance from employment:
	employment, death, or disability:
403(b)	•	Post-988 earnings on your voluntary	•	Your post-988 voluntary pre-tax	•	Your voluntary pre-tax contributions from
Annuity		pre-tax contributions from before 989;		contributions, but not their earnings.		before 989 and their pre-989 earnings;
(“TSA”)	•	Your post-988 voluntary pre-tax	•	You and your employer’s pre-989	•	Your pre-tax contributions made as a result
		contributions and their earnings; and		contributions and their pre-989 earnings		of an irrevocable election or as a condition of
	• Amounts you or your employer			that you directly transferred to the TSA		employment and their earnings;
				under Revenue Ruling 90-24 from a
		contributed to a 403(b)(7) custodial			•	Your after-tax contributions plus their
				403(b)(7) custodial account.
		account and that you later directly				earnings;
		transferred under Revenue Ruling			•	Your employer’s contributions and their
		90-24 to your TSA.
						earnings; and
					•	The above amounts that you 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
						40(a) or 403(a) plan, a governmental 457(b)
						plan, and their earnings.
403(b)(7)	•	All amounts.	•	Your post-988 voluntary pre-tax	No amounts.
Custodial				contributions, but not their earnings; and
Account			•	Your and your employer’s pre-989
				contributions and their pre-989 earnings.
Hardship Withdrawals

IRS “safe harbor” rules require that hardship withdrawals satisfy the following conditions:

•You must have an immediate and heavy inancial need. Withdrawals you make for any of the reasons listed in Section 2 of the form are deemed to satisfy the immediate and heavy inancial need condition.

•The amount you request must not exceed the amount you need to relieve the need (plus reasonably anticipated income taxes or penalties). You must also have exhausted all other resources reasonably available to you. This includes withdrawing from your TSA or 403(b)(7) custodial account IRS unrestricted amounts or requesting a loan.

•Your hardship withdrawal will be subject to 0% Federal income tax withholding unless you elect no withholding. Depending on your state of residence, your hardship withdrawal may be subject to state income tax withholding.

Your employer’s 403(b) plan may also apply the irst two conditions above to withdrawals of IRS unrestricted amounts you make before severance from employment. If you participate in such a plan, a hardship withdrawal of such amounts will be subject to 0% Federal income tax withholding, unless you elect no withholding. State income tax withholding may also apply.

You may not roll over a hardship withdrawal from a TSA or a 403(b)(7) custodial account to any other type of plan or IRA.

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Premature Withdrawal Penalty

A 0% IRS penalty tax applies to withdrawals of any amounts from TSAs and 403(b)(7) custodial accounts unless the withdrawals are made:

•After you reach age 59/2;

•After you die;

•Because of your permanent and total disability;

•As part of a series of substantially equal periodic payments for your life or life expectancy or for the joint lives or joint life expectancies of you and your designated beneiciary, if payments begin after you separate from service;

•After you separate from service in or after the year you reach age 55;

•To an alternate payee under a qualiied domestic relations order;

•In an amount that does not exceed your allowable medical care deduction under Internal Revenue Code (“IRC”) Section 23;

•To remove certain excess amounts; or

•Because of an IRS levy.

HOW TO COMPLETE THE FORM

1General Information

You must complete this section of the form to ensure accurate processing.

2Reason for Hardship Withdrawal

Check the appropriate box(es) to indicate the reason for this hardship withdrawal. For box A, “medical care” and “unreimbursed medical expenses” must meet the deinition provided in IRC Section 23(d). (This is the same deinition that you use in iguring a deduction for medical expenses on Schedule A of IRS Form 040. See IRS Publication 502, Medical and Dental Expenses, for further information.)

For boxes A, C and E, “dependent” is any individual deined in IRC Section 52 and includes any of the following individuals over half of whose support, for the calendar year in which your taxable year begins, was provided by you:

•Your son or daughter, or a descendant of either;

•Your stepson or stepdaughter;

•Your brother, sister, stepbrother, or stepsister;

•Your father or mother, or an ancestor of either;

•Your stepfather or stepmother;

•The son or daughter of your brother or sister;

•The brother or sister of your father or mother;

•Your son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law; or

•An individual who, for your taxable year, has your home as his principal place of residence and is a member of your household.

Included in the deinition of “dependent” is any child you legally adopted, for your taxable year, if the child has your home as his/her principal place of abode and is a member of your household, and you are a citizen or national of the United States. The term “dependent” does not include any individual who is not a citizen or national of the United States unless such individual is a resident of the United States or a country contiguous to the United States.

3Net Amount of Withdrawal

Write in the dollar amount you need to receive to satisfy your hardship and that you cannot obtain from other resources. If the amount you request is unavailable because of the application of IRS or Plan withdrawal restrictions, surrender charges, or income tax withholding, we will send you the maximum amount available from your account/certiicate. The minimum hardship withdrawal amount is $500, except for VestMet contracts ($250 minimum for withdrawals from Separate Account divisions or $,000 minimum for withdrawals from the Fixed Interest Account) and AAA contracts ($,000 minimum). Hardship withdrawals are not available from FPPA and FPPC contracts issued before 974. Review your account/certiicate and/or the prospectus to determine the minimum amount you must leave in your account/certiicate to keep it open after a partial withdrawal is processed.

We will withdraw from your account/certiicate more than the net amount you request if: () administrative and/or surrender charges apply to this withdrawal; (2) we are required to or you ask us to withhold Federal income taxes; or (3) we must withhold state or local income taxes. (See Sections 5 and 6 of the form for additional information on income tax withholding.)

If you have an outstanding loan, 5% – 25% of your outstanding loan balance must remain in your annuity as loan collateral and is not available for hardship withdrawals. Please refer to your contract/certiicate to determine the applicable percentage.

4Source of Withdrawal

This section does not apply if you are making a hardship withdrawal from a ixed annuity.

If you are making a hardship withdrawal from a variable annuity, you may tell us the names of the funding options from which we are to take the withdrawal and the percentage applicable to each. (The distribution will be automatically prorated against all funding options if the percentages are not completed or funds are not available in the funding options you choose.) The percentages must be whole numbers that total 00%. If you have an outstanding loan, 5% – 25% of your outstanding loan balance must remain in the Fixed Interest Account as loan collateral and is not available for hardship withdrawals. Please refer to your contract/certiicate to determine the applicable percentage.

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5Federal Income Tax Withholding Instructions

0% Federal income tax withholding will apply unless you check one of the boxes in this section. If you are a U.S. citizen or resident alien and you provide a delivery address outside the U.S. or its possessions, you may not waive the 0% federal income tax withholding. If you are a nonresident alien, you must provide a completed IRS Form W-8BEN to certify your foreign status. To claim reduced withholding under a tax treaty, you must also provide an IRS Individual Taxpayer Identiication Number (“ITIN”). If there is no applicable tax treaty or you do not provide an ITIN, we will automatically withhold 30% of the taxable amount for federal income tax. If you do not provide an ITIN, you must provide an updated W-8BEN every three years. If you are a nonresident alien requesting payment through a “qualiied intermediary,” the qualiied intermediary must complete IRS Form W-8IMY.

6State Income Tax Withholding Instructions

In the following states, state income tax must be withheld when Federal income tax is withheld: Delaware, Iowa, Kansas, Massachusetts, Maine, North Carolina, Oklahoma, Virginia, and Vermont. In California and Oregon, we will withhold for state income tax unless you tell us not to. MetLife will calculate the amount of withholding for you if you live in one of these states.

We will withhold the amount you tell us to withhold in the following states: Alabama, Arkansas, Colorado, Connecticut, District of Columbia, Georgia, Idaho, Indiana, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Montana, North Dakota, Nebraska, New Jersey, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, Utah, Wisconsin, and West Virginia.

In Mississippi, we will withhold for state income tax unless your payment is made after you reach age 59/2, is made as the result of your death or disability or under a QDRO, if you have separated from service and are at least age 55, or you are receiving payments based on your life expectancy or the joint life expectancies of you and a beneiciary.

7Payment Instructions

Indicate how we should mail the distribution check. Indicate where we should mail the distribution check. If you have selected overnight mail delivery, the address you have chosen for check delivery purposes must be a street address. Please note that Overnight Delivery does not include weekend or holiday delivery service.

8Participant Statement and Signature

Read this section carefully before you sign. If you are signing on behalf of the TSA participant as his or her legal guardian or conservator, provide a copy of your appointment that has been certiied by the Clerk of Court in the last 60 days. If you are signing as the TSA participant’s Attorney-in-Fact, provide a Power of Attorney Document and a Certiication of Attorney in Fact.

9Plan Information and Plan Administrator/Authorized Representative or Employer Statement & Signature

The Plan Administrator/Authorized Representative must indicate the vesting percentage applicable to employer matching and nonelective (basic) contributions, which contribution types are available and the order in which you must use them for hardship withdrawals, and the length of time (6 or 2 months) your contributions to the plan will be suspended after you take a hardship withdrawal. The Plan Administrator (or an authorized representative of your employer if there is no Plan Administrator) must sign this request.

10 Annuity Information, QJSA and Notice Waiver, and Spousal Consent - Required for ERISA Plans only

If your employer’s plan provides a Qualiied Joint and Survivor Annuity beneit, you must sign this section of the form to acknowledge waiver of the Qualiied Joint and Survivor Annuity. If you are married and the withdrawal request exceeds $5,000, your spouse must consent to your waiver of the Qualiied Joint and Survivor Annuity. A notary public must notarize your spouse’s signature. (Some plans allow an authorized representative of the plan to witness the spouse’s signature as an alternative to notarization.)

MAILING AND FACSIMILE INSTRUCTIONS

Mail this form to:	Overnight mail only:	Fax:
MetLife	Metlife	908-552-3403
P.O. Box 0356	4700 Westown Parkway, Ste 200
Des Moines, IA 50306-0356	Des Moines, IA 50266

Note: If you fax the completed form, please do not mail it unless you are requested to do so.

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