EXHIBIT 5(g)(iv)
Filed with Post-Effective Amendment No. 15
to this Registration Statement on Form N-4
on April 8, 1993.
(Logo of MetLife appears here)
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EGN Pension & Savings Center
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SIMPLIFIED EMPLOYEE PENSION (SEP) PLAN
FUNDING AUTHORIZATION AGREEMENT
Name of Employer:___________________________________________________________________________________________________________________
Contact Person:__________________________________________________________ Title:____________________________________________________
Employer Tax ID Number:__________________________________________________ Phone #:__________________________________________________
Employer Address:___________________________________________________________________________________________________________________
City:____________________________________________________________________ State: ________________________ Zip:______________________
Tax Status: [_] Corporation [_] Unincorporated [_] 501c(3) Non-Profit
[_] Other:__________________________________________________________________________________________________
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Type of Plan: [_] SEP using IRS Form 5305-SEP [_] SAR-SEP using IRS Form 5305A-SEP
(check one) [_] Prototype SEP using plan documents from_________________________________________
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Contact Type(s): [_] Preference Plus(R) Account [_] Growth Plus(R) Account
(check all that apply) [_] VestMet (available in certain states) [_] Max 1/ Max 3
[_] Other_____________________________________________________
Contribution Frequency: [_] Monthly [_] Quarterly [_] Semi-Annual [_] Annual [_] Other________________________
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I, as the Employer, by signing below, certify and agree that:
. The Employer acknowledges that the contract(s) purchased is (are) only a funding vehicle(s), and that such contracts are permitted
as funding vehicle(s) under the plan.
. MetLife is not a fiduciary of the plan nor is MetLife authorized to act as your legal counsel or representative.
. MetLife assumes no responsibility for the plan and is under no obligation to inquire as to the terms of the plan. MetLife will not
provide administrative services to the plan unless agreed to in writing by an officer of MetLife under a separate service
agreement. For a Salary Reduction SEP (SAR-SEP), I understand that compliance testing is required annually and that MetLife will
not provide such testing or the recordkeeping to perform such testing unless agreed to in such writing by an officer of MetLife
under a separate service agreement.
. MetLife shall execute all transactions solely on the signature of the employee as owner of the contract. MetLife is under no
obligation to inquire as to the actions of the employee.
. No one, except an authorized officer of MetLife has the authority to make or change the contract, to waive or alter any rights of
MetLife, or to make any binding promises about the contract or our services.
_________________________________________________________________________ ________________________________________________
SIGNATURE for the EMPLOYER TITLE
_________________________________________________________________________ ________________________________________________
CITY and STATE of SIGNING DATE
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________________________________________________________ _____________________________ ________________________________
REPRESENTATIVE NAME BRANCH NUMBER/BRANCH NAME AGENCY INDEX NUMBER
T22698 SEP (0293) Printed in U.S.A. Metropolitan Life Insurance Company 18000005286 SEP (0293)
Home Office: New York, NY
