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NON-ERISA - 403(b) withdrawal request

AnnuitiesNE403 BWITHDRAWAL (10/20)Page 1 of 11 Fs/fNON-ERISA - 403(b) withdrawal request Metropolitan Life Insurance Company Things to know before you begin Because 403(b) withdrawal rules are complex, please read Instructions and Special Tax Notice Regarding TSA Payments before completing this form. If you are under 59 , your withdrawal may be subject to a 10% federal income tax penalty. Your withdrawal may also incur withdrawal or surrender requests in which the money has already been received in your bank account cannot be 1: General informationAnnuity contract/Certificate numberOwner/Participant or Alternate payeeFirst nameMiddle nameLast nameAddressCityStateZIPS ocial Security numberSexMaleFemalePreferred method of contact (choose one)PhoneMailDaytime phone numberMarital citizen Resident AlienNonresident AlienEmployer nameEmployer group numberSECTION 2: Reason for withdrawal (Check all applicable boxes)AParticipant s age 59 or s date of birth (mm/dd/yyyy) :(If you are an alternatepayee, please see Instructions.)

• Because 403(b) withdrawal rules are complex, please read Instructions and Special Tax Notice Regarding TSA Payments before completing this form. If you are under 59½, your withdrawal may be subject to a 10% federal income tax penalty. Your withdrawal may also incur withdrawal charges. Withdrawal or surrender requests in which the money

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