Your current financial institution MAY require a Medallion
Signature Guarantee. Please contact your current account
holder for their requirements.
A Medallion Signature Guarantee must be provided by a bank,
member of a national securities exchange, savings and loan
association, credit union, broker or other acceptable financial
institution. (A notary public cannot provide a Medallion
Original transfer paperwork with an original Medallion Signature
Guarantee should be sent by mail to address listed in Section 8.
Medallion Signature Guarantee
Releasing Plan Administrator
(direct rollover of Eligible Rollover Distribution only); I have reviewed the
Transfer Order form and represent that our plan/account, as noted in Section 1, qualifies as such under
federal tax law and that the amount being directly rolled over is eligible for such treatment.
SECTION 6: Payment information (For Home Office use only)
Please make check payable to: Metropolitan Life Insurance Company
(Owner) and reference the following Contract number
on the check.
Title (if applicable) Date (mm/dd/yyyy)
Page 5 of 6
US 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
(If you have been notified by the IRS that you are currently subject to backup withholding because of
under reporting interest or 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 United States person and the account is
located within the United States.
(If you are not a U.S. Citizen or a U.S. resident alien for tax purposes, please cross out the last two
certifications and complete appropriate IRS documentation.)
Signature of Account Owner
Signature of Plan Administrator