Withdrawal – One-Time
Brighthouse Growth and Income
Annuity and MetLife Growth and Income
Use this form to make a one-time withdrawal from or to surrender your annuity contract. Type on screen or print out and fill in using
CAPITAL letters and black ink. If you need more room for information or signatures, use a copy of the relevant page.
Helpful to Know
To make one-time withdrawals from more than one
annuity, use a separate form for each contract.
Review your contract for conditions and policies
that apply to withdrawals from your annuity, including
frequent trading policies.
A one-time withdrawal from your contract will suspend
systematic withdrawals for the remainder of the con-
tract year. You can reestablish them on or after your
next contract anniversary.
Excess withdrawals any withdrawal greater than your
contract’s guaranteed withdrawal benefit (GWB) will
result in a reduction of future guaranteed withdrawal
amounts. To discuss how an excess withdrawal could
affect your future withdrawals, call Fidelity.
The first withdrawal taken after the youngest annuitant
turns 59½ determines the withdrawal percentage for
the remainder of the contract’s duration.
It is your responsibility to ensure that your withdrawals
comply with IRS rules. All transactions made using this
form are reported to the IRS. You may want to consult a
tax advisor.
1. Contract Owner(s)
Contract Owner Name
Annuity Contract Number
Joint Contract Owner Name if applicable
Trust or Entity Name if applicable
Evening Phone Daytime Phone Extension
2. Withdraw Part of Your Contract Value
Skip to Section 3 on next page if you are surrendering your contract.
The amount you receive will be the amount you request MINUS any taxes and fees triggered by your withdrawal. Withdrawals taken during
the first five contract years may be subject to a 2% surrender fee.
ONLY the following amount:
Dollar Amount $50 minimum
Maximum annual GWB amount Amount for this contract year that does not trigger surrender charges or reduce GWB value.
ONLY the following annuity fund and amount:
Annuity Fund Name or Symbol
ALL units ONLY this
ONLY this
dollar amount:
Dollar Amount
% $
1.900842.110 Page 1 of 3 022470201
Check ONLY one
request option and
provide any required
Form continues on next page.
Phone numbers will be
used if we have ques-
tions, but will not be
used to update your
account information.
Questions on your annuity? Call 1-800-634-9361.
3. Surrender Your Contract
The amount you receive will be the amount you request MINUS any taxes and fees triggered by your withdrawal.
Withdraw ENTIRE contract amount (surrender).
Amount will be the cash value of your contract on the day we process your request.
Original contract has been lost or destroyed. Original contract attached.
4. Withdrawal Method
Be sure to note whether the withdrawal method you choose requires that you obtain a Medallion signature guarantee in Section 6.
Directly deposited to a Fidelity nonretirement account. Withdrawals to a brokerage account will be deposited to the core
position only. Requires Medallion signature guarantee if going to an account of which you are not an owner.
Fidelity Nonretirement Account Number Fidelity Fund Name or Symbol Mutual fund accounts ONLY.
Electronic funds transfer (EFT) to bank or credit union account using EFT instructions ALREADY IN PLACE on the
contract. To add EFT to a contract, go to Fidelity.com/eft.
Bank Account Number Bank Name
Check paid to an alternate payee or mailed to an alternate address:
Requires Medallion signature guarantee.
Alternate Payee Name
City State/Province ZIP/Postal Code Country
Check mailed to the address of record.
Default if no choice indicated or if we are unable to process your choice.
Requires Medallion signature guarantee if the contract’s address of record has been changed within the past 10 days AND
the withdrawal amount is over $10,000.
5. Tax Withholding
Withdrawals from your annuity are subject to federal and, where applicable, state income tax withholding, unless you choose not to have with-
holding apply, below (and if you provided a U.S. address). If you do not elect out of withholding, federal income tax will be withheld at the rate of
10% from the taxable portion of your annuity withdrawal amount, unless you indicate a higher percentage below.
If you choose not to have withholding apply, or if you do not have enough 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 not sufficient.
Withholding instructions provided will remain effective for all withdrawals until you either revoke them or give us new instructions.
Do NOT withhold federal taxes.
Withhold federal taxes at the rate of:
No dollar amounts. Note that if there is
federal withholding, certain states require
that there also be state withholding.
Do NOT withhold state taxes unless required by law.
Withhold state taxes at the applicable rate.
Withhold state taxes at the rate, or in the amount, of:
Dollar Amount
% $
Check one and
provide any required
Check one in
each column.
Contract owner’s legal /
residential address
determines which
state’s tax rules apply.
Form continues on next page.
1.900842.110 Page 2 of 3 022470202
Provide bank informa-
tion ONLY if there are
multiple EFT instruc-
tions on the contract
identified in Section 1.
6. Signature and Date ALL contract owners must sign and date.
By signing below, you:
Authorize and request Brighthouse Life
Insurance Company and, in New York only,
Metropolitan Life Insurance Company, to
make the withdrawals indicated on this
form from the contract listed in Section 1.
Acknowledge that withdrawals will be taxed
as ordinary income, and may be subject
to a 10% early withdrawal penalty if taken
before age 59½.
Indemnify Brighthouse Life Insurance
Company, Metropolitan Life Insurance
Company, and its agents, affiliates, successors,
and employees from any liability in the event
that you fail to meet the IRS requirements.
Acknowledge, if any portion of this con-
tract was funded via a partial exchange of
an existing annuity contract within the last
180 days, that any withdrawals from the
existing or new contract that are not part
of an annuity income program could nullify
the partial 1035 protection or result in an
adverse tax consequence.
Certify under penalties of perjury that
you are a U.S. citizen or other U.S. per-
son (including a resident alien individual).
Customers surrendering contracts
Understand that Fidelity will be released
from any other contractual obligation and
that the contract listed in Section 1 will
be canceled.
Certify that there are no existing assign-
ments and that no bankruptcy petition has
been filed by or against you.
Customers requesting EFTs
Authorize and request Fidelity to make
EFT withdrawals from the contract listed
in Section 1 by initiating debit entries to
that contract.
A Medallion signature guarantee is required next to each signature below if:
Your withdrawal amount is over
Withdrawals are sent to someone other
than the account owner.
Contract’s address of record has been
changed within the past 10 days AND
the withdrawal amount is over $10,000.
You can get a Medallion signature guarantee from most banks, credit unions, and other financial institutions. A notary seal/stamp is NOT a
signature guarantee.
Print Owner Name
Owner Signature
Print Joint Owner Name
Joint Owner Signature
Individual providing signature guarantee Providing this information will avoid delay or rejection of your request.
Guarantor Name Phone Extension
1.900842.110 Page 3 of 3 022470203
Did you sign the form? Send the ENTIRE
form to Fidelity.
Questions? Call 1-800-634-9361.
Regular Mail
Except NY Regular Mail NY only Overnight Mail
Annuity Service Center
PO Box 770001
Cincinnati, OH 45277-0050
Annuity Service Center
PO Box 770001
Cincinnati, OH 45277-0051
Fidelity Investments
100 Crosby Parkway, KC2Q
Covington, KY 41015
This annuity is issued by Brighthouse Life Insurance Company, Charlotte, NC 28277 and, in New York,
only by Metropolitan Life Insurance Company, New York, NY 10166. The contract’s financial guarantees
are solely the responsibility of the issuing insurance company. Fidelity Brokerage Services, member
NYSE, SIPC, and Fidelity Insurance Agency, Inc., are the distributors; they are not affiliated with any
MetLife or Brighthouse Financial company.
528050.11.0 (12/17)