Fillable Dividend/Rider withdrawal and dividend option request change (MetLife)

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Dividend/Rider withdrawal and dividend option request change (MetLife)

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The Dividend/Rider withdrawal and dividend option request change (MetLife) form is 5 pages long and contains:

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  • 29 check-boxes
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Page 1 of 5
Fs/f
DIVRIDWITHDRAWAL (05/20)
U.S. Retail Life Operations
Dividend/Rider withdrawal and dividend option
change
request
Use this form to request a dividend withdrawal or a withdrawal from a rider on your policy (not
for use with Universal Life or Variable Universal Life policies).
The Company indicated in this section is referred to as "the Company."
Metropolitan Life Insurance Company Metropolitan Tower Life Insurance Company
Things to know before you begin
• Please complete this form in its entirety to avoid any delays
in processing.
• If you need assistance in completing this form, please call
your representative, sales office, or the appropriate number
listed under How to submit this form.
If premiums are being paid through the
use of policy values, this request could
result in the need to make additional
out-of-pocket premium payments.
SECTION 1: About the Owner
Policy number
Type of Owner:
Individual
or
Trust/Business entity
If Individual or Co-Owner:
First name Middle name Last name
Phone number Social Security number E-Mail address
Co - Owner - First name Middle name Last name
Phone number Social Security number E-Mail address
If Trust/Business entity Owner:
Name of Trust Date executed (mm/dd/yyyy)
Name of Business entity Tax ID number of Trust/Business entity
Trust/Business entity contact person
First name Middle name Last name
Contact phone number E-Mail address
Please provide the address where your proceeds should be sent:
Number and street/Post office box City State ZIP
Should we use this address for all future correspondence?
Yes No
Page 2 of 5
Fs/f
DIVRIDWITHDRAWAL (05/20)
SECTION 2: About the Insured
First name Middle name Last name
SECTION 3: About the withdrawal request
Dividend withdrawal request:
Maximum amount available Specific Amount $
*
Rider Withdrawal Request (Insert name of rider)
Maximum amount available
Specific amount $
*
*If there is not sufficient value to meet the specific dollar amount, the largest amount available will be withdrawn.
Payment options: Please select one of the following methods of payment:
A. Pay by check.
B. Apply withdrawal to pay premiums on other policies as detailed below:
Policy 1 Policy 2
Policy number
Number of premiums to pay
Due date of first premium
Additional funds submitted to be applied
If amount withdrawn exceeds amount to be applied, the excess will be sent by check. If available value is
insufficient, this may result in a delay in processing.
C. Apply withdrawal to pay loans as detailed below:
Policy 1 Policy 2
Policy number
Amount to pay loan interest
Amount to pay loan principal
Additional funds submitted to be applied
If amount withdrawn exceeds amount to be applied, the excess will be sent by check. If available value is
insufficient, this may result in delay of processing.
D. Open a new Total Control Account
®
Money Market Option (TCA) or deposit to my existing
TCA #
*
* Please see features and benefits of the Total Control on page 4 for important information to help you
make an informed decision.
Special instructions:
Page 3 of 5
Fs/f
DIVRIDWITHDRAWAL (05/20)
SECTION 4: About change of dividend option
Request for change of dividend option - Social Security number and withholding election is required for all
dividend transactions.
Please check the appropriate box(es)
Use future dividends to reduce my premium. If you select this option, that part of the dividend not needed
to pay the premium will be used to purchase paid-up additional insurance if available, unless another choice
is indicated below:
Dividends with interest
Applied to purchase paid-up additional insurance
Loan principal
Loan interest
Cash
Use future dividends to purchase paid-up additional insurance
Let future dividends accumulate with interest
Use future dividends to pay loan principle
Use future dividends to pay loan interest.
This option is not available on all policies. Please review your
policy or contact your financial professional for more information.
To receive future dividends in cash
Used to purchase term and paid-up insurance under the flexible term rider.
This option is not available on all
policies. Review your policy or contact your financial professional for more information if you wish to change
to this dividend option.
Note: Please note that your Life insurance policy may offer other options not listed above. Enter other option
elections in special instructions.
Request for dividend balance transfer
Transfer existing dividend balance to additional insurance, subject to company approval.
Transfer existing additional insurance to have dividends accumulate with interest.
Special instructions:
Important: Complete this entire form, including your Social Security number certification and signature/title.
SECTION 5: About income tax withholding
Under current federal income tax law, we are required to withhold 10% of the taxable portion of the cash
withdrawal value and pay it to the IRS unless you tell us in writing not to withhold tax. Some states also require
us to withhold state income tax if we withhold federal tax.
You are responsible for paying income tax on the taxable portion of the payment, even if we do not withhold
taxes. In making your decision about withholding taxes, you should consider that penalties under the estimated
income tax rules may apply if your withholding and estimated income tax payments are not sufficient.
Check here if you do not want us to withhold federal and state income tax
(This choice is void if we do not have your social security or Tax ID number or if you reside outside of the U.S.)
Page 4 of 5
Fs/f
DIVRIDWITHDRAWAL (05/20)
SECTION 6: Certification and signature
Under penalties of perjury I certify:
1) The number shown in this document is my correct taxpayer identification number, and
2)
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not
been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a
failure to report all interest or dividends, or (c) the IRS has notified me that I am not subject to backup
withholding.
(if you have been notified by the IRS that you are currently subject to backup withholding because of under
reporting interest of dividends on your tax return, you must cross out and initial this item.)
3) I am a U.S. Citizen or other U.S. person, and;
4)
I am not subject to FATCA reporting because I am a U.S. person and the account is located within the United States.
(If you are not a U.S. citizen or other U.S. person for tax purposes, please cross out the last two
certifications and complete appropriate IRS documentation, e.g. IRS Form w-9BEN for individuals, which
can be found on the IRS website)
The Internal Revenue Service does not require your consent to any provision of this document other
than the above certifications required to avoid backup withholding.
SECTION 7: Signature(s)
Signature requirements
All Owners must sign this form. Any Irrevocable Beneficiary or Collateral Assignee must sign this form.
Please sign as shown below:
A Partnership The full name of the firm should be printed with the signature of all general partners
(not limited partners).
A Sole Proprietorship The full name of the business should be printed with the signature of the owner
followed by the word “owner.”
A Trust Signatures, followed by the word "Trustee," of all required Trustees. Also submit a
Trust Certification, which is available from your financial professional, sales office, or
the appropriate number listed under How to submit this form.
A Corporation The signature and title of one officer (other than the Insured).
An Individual acting The full name of the Owner's fiduciary or agent and the legal documentation of the
on behalf of the Owner authority to act (e.g., power of attorney, guardianship papers, etc.).
Print name of individual signing -
First name Middle name Last name
Signed at city State
Title (If you are acting in a representative capacity)
Signature of Owner
Date (mm/dd/yyyy)
Page 5 of 5
Fs/f
DIVRIDWITHDRAWAL (05/20)
Print name of individual signing -
First name Middle name Last name
Signed at city State
Title (If you are acting in a representative capacity)
Signature of Co-Owner
Date (mm/dd/yyyy)
For sales office use only
Sales office/Agency number - Representative ID Date (mm/dd/yyyy)
Sales representative - First name Middle name Last name
SECTION 8: How to submit this form
Return pages 1 through 5 of the completed form to the address or fax number listed below for the company that
issued the policy. If policies are issued by more than one company, return the completed form to any company
that issued at least one of the policies.
Mail:
P.O. Box 336
Warwick, RI 02887-0336
Phone :
1-800-638-5000
Fax :
1-401-827-2225
Email:
INDLifeRequests@metlife.com
SECTION 9: Additional information and instructions (About the Total Control Account)
Total Control Account (TCA) - Please keep this page for your records. If payment is made by
establishing a new TCA, the signature you provide will be placed on file with that account.
Availability: A TCA may be elected when the amount payable to you is at least $10,000, or you have an
existing TCA Account issued by the same MetLife affiliated insurance company that issued the policy (you must
provide the TCA Account number). The TCA generally is not available to corporate entities, or to residents of
foreign countries. For more information, call our Customer Service Center at 1-800-638-7283.
Features:
• Interest compounded daily. Rates are set weekly and are equal to or higher than one of two nationally
recognized money market rate indexes. Interest is credited monthly and is currently taxable.
• Detailed, easy-to-read statements.
• Free unlimited check writing privileges - Minimum check amount $250.
• No penalties for withdrawing all or part of your money.
• No charge for processing or printing checks. Free check reorders.
• No transaction or monthly fees, although there may be charges for stop orders and special services.
• Additional amounts from other sources may not be added to the TCA, nor can amounts withdrawn be
redeposited. However, proceeds from other life insurance policies and annuity contracts issued by the same
insurer may be added to an existing TCA in some circumstances.
• Information available electronically
through MetLife's eSERVICE web site.
• Principal and interest are guaranteed by the financial strength and claims paying ability of the affiliated
MetLife insurance company which issued the policy/policies above.
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DividendRider withdrawal and dividend option request change (MetLife)

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Completed 26 September 2021

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