Qualified transfer request
This qualified transfer request form is provided for your convenience in
handling all transfer and rollovers into qualified accounts.
Things to know before you begin:
• Do not use this form for 1035 exchanges. Instead, use form
Use this form only for transfers and rollovers into qualified accounts.
• Call the current Account Custodian/Trustee, Contract Issuer, or Plan
Administrator to confirm the following information: overnight mailing
address, surrender charges, form requirements, Medallion Signature
Guarantee requirements, and replacement requirements.
• For all transfers and rollovers, mail this form and any paperwork required to
set up a new annuity account to the appropriate address indicated in
Section 8. (Attach a copy of original contract to transfer form.)
• MetLife will not send a TOA out if the maturity date is more than 30 days
into the future.
• For a Qualifying Longevity Annuity Contract (QLAC), please confirm that
the transfer amount does not exceed or cause you to exceed the QLAC
purchase payment limit. For details about the QLAC purchase payment
limit please refer to form QLAC-DISC.
Please complete the entire
form as applicable to avoid
delays in processing
your request.
SECTION 1: New account information
Indicate how you want your transferred or rolled over amount invested under a MetLife annuity:
Deposit into my existing account number:
Open a new MetLife annuity. (An annuity application must accompany this form.)
Your transferred or rolled over amount will be applied to your annuity according to the future contribution
allocation instructions in effect for your annuity when MetLife receives the transferred or rolled over amount,
unless you include a completed payment allocation form.
SECTION 2: Information for contract or account to be liquidated and transferred
I hereby direct the institution indicated below to LIQUIDATE and transfer funds from my current contract
or account to the Company as follows:
Financial Institution name Company phone number
Metropolitan Life Insurance Company
Street address (Overnight mailing address – No P.O. Boxes)
City State ZIP
Account or Contract number
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u OPTION 1: Owner information
Contract Owner - First name Middle name Last name
Owner's Social Security number / Tax ID (Required)
Owner and Annuitant are the same
u OPTION 2: Annuitant/Insured information (Required when the source of funds is Annuity or Life Insurance)
Annuitant/Insured - First name Middle name Last name
Annuitant/Insured Social Security number (Required when Annuitant/Insured information is completed)
u OPTION 3: Joint Annuitant/Insured information (Only available for Individual Flexible Premium
Deferred Paid-Up and Single Premium Immediate Annuity products)
Joint Annuitant/Insured First name Middle name
Last name
Joint Annuitant/Insured Social Security number (Required when Joint Annuitant/Insured information is completed)
Source of funds:
Fixed Annuity
Indexed Annuity
Variable Annuity
Life Insurance
Money Market
Mutual Funds
Pension Assets
SECTION 3: Type of transaction (Complete Option 1 or Option 2)
OPTION 1: Request for qualified transfer (Complete 1A or 1B)
1A: Transfer from a: (Choose one)
Traditional IRA
Transfer to a: (Choose one)
Traditional IRA
Roth IRA
Decedent IRA
1B: Transfer from a: (Choose one)
Decedent IRA to Decedent IRA
Roth IRA to Roth IRA
Issue Date of Original IRA
Issue Date of Original IRA
Issue Date of Original IRA
Issue Date of Original IRA
**For transfers from SIMPLE IRA to IRA, SEP, or SAR-SEP IRA, you may only initiate the transaction after
the end of the two-year period that started on the first day contributions were made to your SIMPLE IRA.
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OPTION 2: Request for qualified rollover (Complete 2A or 2B)
2A: Direct rollover from a: (Choose one)
To a: (Choose one)
Traditional IRA
Roth IRA
Decedent IRA
2B: Direct rollover from a: (Choose one)
TSA 403(b) Direct rollover to an IRA
Contract value as of December 31, 1986
Authorization to transfer funds (Required)
Proceeds should be transferred immediately unless otherwise indicated.
When indicated, transfer as of
This will serve as authorization to liquidate and transfer:
All (Estimated Amount) $
A partial amount of $
Maximum free amount (Estimated Amount) $
Liquidate $ from specific funds of my account, as listed below, to the annuity I have
established or am establishing through MetLife. (If more than five funds are to be liquidated, please
complete an additional QUALTRAN form.)
Fund Name
OR %
Fund Name
OR %
Fund Name
OR %
Fund Name
OR %
Fund Name
OR %
SECTION 4: Transfer and rollover restrictions (Not required, however if completed, must be
completed in full)
Required minimum distributions (RMD) from IRAs, TSAs or Qualified Retirement Plans are not eligible for
transfer or rollover. An IRA owner must take their first required minimum distribution by April 1st of the year
following your required beginning age (except for Roth IRAs). A Qualified Retirement Plan or TSA participant
must take their first RMD from the plan or TSA by April 1st of the year following the later of your required
beginning age or retirement.
I authorize my present Financial Institution named above to:
My RMD has already been taken for the transfer year.
Distribute my RMD to me prior to transfer.
Amount of required minimum distribution for the year of transfer:
How is your life expectancy being calculated? (Please check appropriate boxes in both a and b below)
Single Life Expectancy OR
Recalculation OR
Joint Life Expectancy: AND
Non-Recalculated (reduced by one)
“I understand that I must complete and submit new IRA Minimum Distribution Service paperwork to establish a
new Required Minimum Distribution Program with MetLife once my new annuity contract has been issued.”
With respect to rollovers from IRAs, Federal tax rules permit an individual to make only one IRA to IRA tax-free
indirect rollover in any 1-year period. This limitation does not apply when an IRA owner transfers funds from
one IRA directly to another, because such a transfer is not a rollover and, therefore, is not subject to the one
rollover per-year limitation.
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SECTION 5: Authorization and signatures
Please select one:
Original contract has been lost or destroyed: I certify that the policy/contract is lost or destroyed. In addition,
I certify that the policy/contract has not been assigned or pledged as collateral.
I hereby authorize my current Account Custodian/Trustee, Contract Issuer or Plan Administrator to liquidate and
transfer funds from my current account to my new annuity.
Account Owner: Current tax laws are subject to change. I understand I should consult with my tax advisor if I
have questions about the tax treatment of my transfer or rollover or my annuity contracts. I understand the
Company is not responsible for the tax consequences of this transaction. I understand that only certain
withdrawals are eligible for transfer/rollover to my MetLife annuity and it is my sole responsibility to ensure any
amounts transferred/rolled over are eligible for such treatment. I understand that tax treatment of this
transaction under my state’s law may vary from federal tax law treatment. By signing below, I affirm the amounts
I am transferring/rolling over to my MetLife annuity are eligible for transfer/rollover treatment. If I am making a
rollover from a qualified plan, TSA, or governmental 457(b) plan, I irrevocably elect to treat the distribution from
my prior plan as a rollover contribution. I understand MetLife will rely upon my representations to accept my
transfer or rollover to my MetLife annuity. I am aware that I am not required to transfer or roll over these
previously accumulated amounts. I have determined the dollar amount of the early withdrawal penalties (if
applicable) and understand my prior provider may assess a penalty before transferring this money to MetLife. I
hereby authorize my current Account Custodian/Trustee, Contract Issuer, or Plan Administrator to provide
MetLife, at its request, information regarding the status of my request for a direct transfer or direct rollover.
If my contract requires a single premium payment, I understand that MetLife may refuse funds not received
within 90 days of the contract's effective date. Funds that are refused will be returned to the source.
MetLife, its agents, and representatives may not give legal, tax or accounting advice and this document should
not be construed as such. Clients should confer with their qualified legal, tax and accounting advisors as
Original contract attached
By checking this box I acknowledge that this is an exchange from a MetLife or affiliate annuity contract to a
MetLife annuity contract and that I have received the “Enterprise Annuity Transfer Disclosure Form” and
understand the implications of this exchange.
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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
Signature Guarantee.)
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)
Date (mm/dd/yyyy)
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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
SECTION 8: How to submit this form Please send us the entire form and check by mail.
Regular mail:
P.O. Box 10342
Des Moines, IA 50306-0342
Overnight mail only:
4700 Westown Parkway, Suite 200
West Des Moines, IA 50266
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SECTION 7: Letter of Acceptance (For Home Office use only)
MetLife has established an annuity for this account owner and accepts the liquidation and transfer of the
assets and will apply it to a MetLife annuity contract.
Date (mm/dd/yyyy)Title
Authorized Signature from MetLife