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18000104684A (11/10) eF CONTRACT RECORDS CHANGE FORM • Change your address. • Update name on contract records. • Name a new Owner or new Joint Owner (NQ). Please return completed forms to: Metropolitan Life Insurance Company P.O. Box 10342 Des Moines IA 50306-0342 OR Fax Number: 877-547-9669 Please allow 24-48 hours to confirm receipt of faxed paperwork. A1 Entry required for address, name or owner. (If any information needs to be updated on MetLife’s records, please check ( 3 or X ) the box(es) next to the correct data.) r Owner’s Name (Print First, Middle, Last) r Social Security/Tax ID# r Telephone Number r Street Address (Include Apt/Floor/PO Box) r City or Town r State r Zip Code Contract/Certificate Number(s) Annuitant(s) if not the Owner(s) A2 Entry required to update NAME. (To name a new Owner - Section A3 must be completed.) Please update records to change or correct the name of the: r Owner/Joint Owner r Annuitant r Beneficiary r Contingent Beneficiary From________GEORGE JEFFERIES______________________________________________________ To_ ____________________________________________________________ Printed Name Printed Name The reason for this change is (Note: If reason is other than correction of spelling, attach a copy of the driver’s license, marriage certificate, divorce decree or similar court issued document reflecting the correction or change of name.): r Marriage r Divorce r Assumption of new name r Correction r Other (please specify)____________________________________________ If reason is other than correction of spelling and the name of the Owner or Annuitant of the contract has changed, please also provide both the previous and new signatures. From______________________________________________________________ To_ ____________________________________________________________ Previous Signature of Owner/Annuitant New Signature of Owner/Annuitant A3 Entry required for owner. (Not available for Traditional IRA or Roth IRA.) Please change the ownership of the contract/certificate as shown below. In making this request, I understand that this assignment may result in a taxable event for me to the extent the value at the time of transfer exceeds my cost basis in the contract/certificate unless the transfer qualifies as a nontaxable transfer of property between spouses or incident to a divorce. Please Note: If the beneficiary is not changed using a signed, written request, the beneficiary designation from the previous owner will remain in place on the annuity contract unless and until the new owner changes the beneficiary. Owner – Name (Print First, Middle, Last) Relationship to Annuitant(s) Date of Birth Social Security/Tax ID# Street Address (Include Apt/Floor/PO Box) City or Town State Zip Code Joint Owner – Name (Print First, Middle, Last) (in addition to the person named as Owner above) Relationship to Annuitant(s) Date of Birth Social Security/Tax ID# Street Address (Include Apt/Floor/PO Box) City or Town State Zip Code A4 Entry required for address, name or owner. Current Owner’s Signature Date Signed Current Joint Owner’s Signature (if needed) Date Signed New Owner’s Signature Date Signed New Joint Owner’s Signature (if applicable) Date Signed For M etLife’s Internal Use Submitting Sales Office Servicing Account Representative Office Agency Index