Fillable Form 40922

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Form 40922

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7255-B (05/20) Page 1 of 4
Contract number
Social Security number or Tax ID number
Annuities
Required Minimum Distribution (RMD)
This form is provided for your convenience in setting up Required Minimum
Distribution payments.
Brighthouse Life Insurance Company
Brighthouse Life Insurance Company of NY
("Brighthouse Financial")
Things to know before you begin:
• IMPORTANT INFORMATION: In 2020, under the CARES Act, you do not need to take any Required
Minimum Distributions (RMDs). This applies to IRA owners and their respective beneficiaries.
• For years after 2020, as a result of the passage of the SECURE Act, if you attained age 70½ on or after
January 1, 2020, then your required beginning date for RMDs is extended to age 72. See below.
o If you were born on or after July 1, 1949, RMDs must start by April 1 of the year following attainment of
age 72.
o If you were born before July 1, 1949, RMDs must start by April 1 of the year following the attainment of
age 70½.
• The RMD program is based on information relating to this contract only. If you are referencing multiple
contracts, please complete a separate RMD form for each request.
• This form is applicable to IRAs. It also is available to certain eligible beneficiaries of an inherited IRA who are
allowed to take RMDs over life expectancy.
• The owner must sign the form.
• You must complete all sections of the form except for Section 4 (Payment Instructions, which is optional).
• Please read the Income Tax Withholding Election information carefully and indicate an election.
• Your payments will not be processed unless this form is filled out completely and accurately.
• Withdrawal or surrender requests in which the money has already been received in your bank account
cannot be returned.
• Fund units must be liquidated pro-rata, based on fund allocations at the time of processing.
o For distributions during the IRA owner’s life, if your spouse is named as the sole beneficiary AND
he/she is more than 10 years younger than you, your RMD will be based on a joint life expectancy.
o Withdrawal or surrender requests in which the money has already been received in your bank
account cannot be returned.
SECTION 1: Contract Information
Annuitant
First name
Middle name
Last name
Contract Owner (if different than Annuitant)
First name
Middle name
Last name
Previous year-end policy/contract value (only needed if Brighthouse Financial did not hold the policy/contract
on December 31 of the previous year)
Daytime telephone number
Owner's date of birth
Spouse's date of birth
7255-B (05/20) Page 2 of 4
SECTION 2: Required Minimum Distribution (RMD) Payment Options
For Contracts with GWB or LWG ONLY: The Required Minimum Distribution (RMD) for contracts with the
Guaranteed Withdrawal Benefit (GWB) or the Lifetime Withdrawal Guarantee (LWG) rider may be larger than
your annual Benefit Payment. In order to qualify for the increased RMD payment without the increase being
considered an excess withdrawal, after the first contract year, you must enroll in our Automated RMD program
only and elect annual payment frequency. You may not be enrolled in any other systematic withdrawal program
(SWP). In such case we will increase your Annual Benefit Payment to equal your most recently calculated
RMD amount, if such amount is greater than your Annual Benefit Payment. Any cumulative withdrawals you
make to satisfy your required minimum distribution amount outside of the Automated RMD program will be
treated as excess withdrawals if they exceed your Annual Benefit Payment, and this can have an adverse
impact on the value of the benefit (see the prospectus for details). If you have taken or are considering taking a
partial withdrawal from your contract, electing our Automated RMD program may significantly reduce the value
of the GWB or LWG benefit. Prior to requesting our Automated RMD program for your contract you should
consult with your representative and discontinue any active SWP program.
A. Automated RMD Options – Brighthouse Financial will calculate your RMD amount and distribute the
payments based on the frequency selected below. You will continue to receive a reminder letter each year in
January as required by the IRS, regardless of your instructions for future years.
The date you indicate below is the date the distribution will be processed on your contract. Pleas
e allow
addit
ional time to receive your payment once processed. This form must be received at least 10 days prior
to your requested first payment date. Upon our receipt of this form, if the beginning date request
ed below
has
passed, your payments will begin on the next available frequency date requested.
Restrictions:
• If you currently have a Systematic Withdrawal Program (SWP) in effect on your contract, you may only
elect an annual payment frequency for your Automated RMD option. Your RMD will be withdr
awn
annually
in December after all SWP payments for the year have been processed. The Annual payment
option is available on all products; however, Quarterly and Monthly payment options are only available
on
c
ertain products. If you elect a Quarterly or Monthly option, but it is unavailable for your product,
we will
process your request as an Annual payment scheduled in December.
• If you have a GWB or LWG rider, please see above for important information.
Automated Annual payments to be processed on the following date each year*:
*I
f this date has passed for the current year, the RMD will be processed upon receipt of the request, and
then scheduled for the selected date in future years.
Automated Semi-Annual payments to begin on
(date must be 1st through 28th of month)
(mm/dd/yyyy)
Automated Quarterly payments to begin on
(date must be 1st through 28th of month)
(mm/dd/yyyy)
Automated Monthly payments to begin on
(date must be 1st through 28th of month)
(mm/dd/yyyy)
B. One-time RMD Options – Brighthouse Financial will process your RMD as of the date that the request is received.
A one-time RMD payment for the current tax year (for IRAs, the RMD must be taken on or before
December 31st)
:
Please calculate my RMD amount or
Withdraw $
A one-time first RMD payment for the previous tax year (only available for the first RMD taken by the
IRA owner after turning age 72 and must be taken on or before April 1
st of the following year):
Please calculate my RMD amount or
Withdraw $
Month
Day
Year
7255-B (05/20) Page 3 of 4
Bank name
Account holder name (must match the contract ownership)
SECTION 3: Income Tax Withholding Election
Choose one:
I elect to have Federal and (if applicable) State, if applicable, Income Tax withheld from my RMD(s).
Federal
%
State
%
I elect NOT to have Federal and (if applicable), State, Income Tax withheld from my RMD(s).
Note: If neither of the above withholding elections is chosen, 10 percent of the taxable portion will
automatically be withheld for Federal Income Tax. State Income Tax may be withheld, if applicable.
Even if you elect not to have income tax withheld from a distribution, you are liable for payment of income tax
on the taxable portion of your withdrawal. You may also be subject to tax penalties under the estimated tax
payment rules, if your payments of estimated tax and withholding, if any, are not adequate. You should consult
your tax advisor regarding your personal situation.
SECTION 4: Payment Instructions
It is the Contract Owner's responsibility to inform Brighthouse Financial of any changes to banking information.
Choose One (Optional):
Note: A check will be sent to the address on record if Electronic Funds Transfer or Alternate Payee is not selected
below. For one-time RMD payments, you may only select option 1 or 3 below.
1. Electronic Funds Transfer (EFT) to a pre-authorized account already on file.
2. New EFT instructions for Automated RMD payments only.
Note: You must attach a copy of a voided check when requesting EFT. The first payment will be
sent by check to your address of record. Future payments will be sent EFT. If a voided check is not
provided, a paper check will be mailed to the address of record.
Type of Account:
Checking (A photocopy of a voided check is required, unless Electronic Payments are being sent to a
previously established EFT account. If the contract has joint owners, both names must appear on the
voided check.)
Savings (A bank statement or pre-printed deposit slip, containing EFT information and account
registration, is required. If the contract has joint owners, both names must appear on the documents.)
3. Check for the benefit of (FBO) the contract owner
Alternate payee name (Bank, Brokerage Firm, etc.)
Account number (if applicable)
Alternate payee address
City
State
ZIP
Bank account number
Bank ABA routing number
Bank address
Bank city
State
ZIP
7255-B (05/20) Page 4 of 4
Signature of Policy/Contract Owner
Title (if applicable) Date (mm/dd/yyyy)
SECTION 5: Signature
U.S Tax Certification
Under penalties of perjury, I certify that:
1. The number shown on this form 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 no
longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person; and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting
is correct.
Certification Instructions: You must cross out item 2 above if you have been notified by the IRS that you
are currently subject to backup withholding because you have failed to report all interest and dividends on
your tax return. "U.S. citizen" and "U.S. person" are as defined in IRS Form W-9. If you are not a U.S. citizen
or a U.S. person for tax purposes, please cross out item 3 above and complete appropriate IRS
documentation such as IRS Form W-8BEN. Item number 4, FATCA Code: N/A (No FATCA Code
Applicable).
The Internal Revenue Service does not require your consent to any provision of this document other
than the certifications required to avoid backup withholding.
Note: If you are signing on behalf of another individual or entity, please indicate your title, position or
status (e.g., Trustee, Attorney-in-Fact, Guardian, Conservator, Executor, Administrator) following your
above signature and include the proper documentation.
SECTION 6 - How to submit this form
Please submit this entire form by mail or fax
Regular mail:
Brighthouse Financial
P. O. Box 10366
Des Moines, IA 50306-0366
Overnight mail only:
Brighthouse Financial
4700 Westown Pkwy, Ste 200
West Des Moines, IA 50266
Fax:
877-547-9666
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Form 40922

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Completed 20 July 2020

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