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
$100,000.
• 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
Date MM DD YYYY
DATE
Owner Signature
SIGN
Print Joint Owner Name
Date MM DD YYYY
DATE
Joint Owner Signature
SIGN
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
MEDALLION SIGNATURE GUARANTEE
MEDALLION SIGNATURE GUARANTEE
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)
