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Exhibit 5(j)
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MetLife Insurance Company of Connecticut SYSTEMATIC WITHDRAWAL PROGRAM
MetLife Life and Annuity Company of Connecticut
Xxx Xxxxxxxxx - Xxxxxxxx, XX 00000-0000 METLIFE RETIREMENT ACCOUNT
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PURPOSE OF REQUEST: [ ] Initiate Program [ ] Change Current Instructions [ ] Cancel Program
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OWNER INFORMATION
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Owner Name Owner SS#
_______________________________________________________________ __________________________________________________________________
Account Number (Existing accounts only) _______________________________
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PROGRAM INFORMATION
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- A minimum Contract Value of $15,000 is required to start the program. The minimum withdrawal amount is $100.
- A request to enroll in the Systematic Withdrawal Program (SWP) must be received at Our Home Office at least five business days
prior to the date of the first withdrawal.
- Only one SWP may be active per account.
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PROGRAM INSTRUCTIONS
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- Frequency of Withdrawal [ ] Monthly [ ] Quarterly [ ] Semi-Annual [ ] Annual
- Date of first withdrawal (Do not choose a day later than the 28th): __________/__________/__________
(MM/DD/YYYY)
The date of first withdrawal also determines the "day" on which funds will be withdrawn from your annuity account each month. Please
allow 2 business days for direct deposit and 5-7 days for mailed checks. If the day of withdrawal falls on a weekend or holiday, the
withdrawal will be made on the next business day.
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CHOOSE EITHER OPTION 1 OR 2 BELOW:
[ ] OPTION 1: Withdraw a specific amount over the withdrawal frequency selected above. Total amount of withdrawal: $__________
CHOOSE ONE OF THE FOLLOWING WITHDRAWAL OPTIONS:
[ ] Surrender on a pro rata basis from all active investment options.
[ ] Surrender from each of the investment options noted on page 2, in the amounts indicated.
[ ] OPTION 2: Withdraw only the available Free Withdrawal Amount (FWA) over the frequency selected above. The available FWA is
calculated annually as of the contract anniversary date (refer to your product prospectus/disclosure for details).
This will result in an increase or decrease in the payment amount.
CHOOSE ONE OF THE FOLLOWING WITHDRAWAL OPTIONS:
[ ] Surrender on a pro rata basis from all active investment options.
[ ] Surrender on a pro rata basis from each of the investment options on page 2 marked with an "X" in the "$"
column.
NOTE:
- Option 2 will be canceled if a subsequent request is received to change the withdrawal amount to an amount other than
the FWA.
- If any withdrawal depletes the FWA in the current contract year, the systematic withdrawal program will be suspended
for the balance of the contract year and restarted after the next contract anniversary.
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SEE PAGE 2 FOR INVESTMENT OPTIONS
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X-00000XXX (XXX CODE) ORDER # L-19244 1 of 3; Rev. 11/06
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INVESTMENT OPTIONS
NOTE: Investment options shown below with an asterisk (*) may not be available to all contracts. For more information, call your
representative or our Customer Service Center.
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NAME CODE AMT NAME CODE AMT
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AIM VI Core Equity Fund* AA $__________ Xxxx Xxxxx Partners Variable Total Return
American Funds Global Growth Fund IL $__________ Portfolio* AE $__________
American Funds Growth Fund IG $__________ Lord Xxxxxx Bond Debenture Portfolio AF $__________
American Funds Growth-Income Fund II $__________ Lord Xxxxxx Growth and Income Portfolio HL $__________
Batterymarch Mid-Cap Stock Portfolio 1M $__________ Lord Xxxxxx Growth and Income Series Fund -
BlackRock Aggressive Growth Portfolio DQ $__________ Class VC FK $__________
BlackRock Bond Income Portfolio 4W $__________ Lord Xxxxxx Mid-Cap Value Series Fund -
BlackRock Large-Cap Core Portfolio DR $__________ Class VC FL $__________
BlackRock Money Market Portfolio 1K $__________ Met/AIM Capital Appreciation Portfolio KC $__________
Credit Suisse Emerging Markets Portfolio* AU $__________ Met/AIM Small Cap Growth Portfolio FY $__________
Delaware VIP Small Cap Value Series AP $__________ MetLife Aggressive Allocation Portfolio H9 $__________
Dreman Small-Cap Value Portfolio F0 $__________ MetLife Conservative Allocation Portfolio H5 $__________
Dreyfus VIF Appreciation Portfolio DP $__________ MetLife Conservative to Moderate Allocation
Dreyfus VIF Developing Leaders Portfolio DS $__________ Portfolio H6 $__________
FI Large Cap Portfolio (Fidelity) 4G $__________ MetLife Investment Diversified Bond Fund OB $__________
FI Value Leaders Portfolio (Fidelity) 4F $__________ MetLife Investment International Stock Fund OI $__________
Fidelity VIP Contrafund(R) Portfolio FT $__________ MetLife Investment Large Company Stock Fund OC $__________
Fidelity VIP Dynamic Capital Appreciation MetLife Investment Small Company Stock Fund OE $__________
Portfolio* D2 $__________ MetLife Moderate Allocation Portfolio H7 $__________
Fidelity VIP Mid Cap Portfolio D1 $__________ MetLife Moderate to Aggressive Allocation
Xxxxxx Oakmark International Portfolio 4C $__________ Portfolio H8 $__________
Janus Aspen Series Mid Cap Growth MFS(R) Total Return Portfolio HT $__________
Portfolio JA $__________ MFS(R) Value Portfolio BD $__________
Janus Aspen Series Worldwide Growth Xxxxxxxxx Xxxxxx Real Estate Portfolio I3 $__________
Portfolio* WW $__________ Xxxxxxxxxxx Global Equity Portfolio IK $__________
Janus Capital Appreciation Portfolio US $__________ PIMCO VIT Real Return Portfolio PR $__________
Xxxx Xxxxx Partners Managed Assets PIMCO VIT Total Return Portfolio PM $__________
Portfolio UA $__________ Pioneer Fund Portfolio UP $__________
Xxxx Xxxxx Partners Variable Adjustable Pioneer Mid-Cap Value Portfolio FW $__________
Rate Income Portfolio BI $__________ Pioneer Strategic Income Portfolio HP $__________
Xxxx Xxxxx Partners Variable Aggressive Xxxxxx VT Discovery Growth Fund* OV $__________
Growth Portfolio SG $__________ Xxxxxx VT International Equity Fund* ON $__________
Xxxx Xxxxx Partners Variable All Cap Xxxxxx VT Small Cap Value Fund OP $__________
Portfolio AD $__________ Xxxxxxxxx Developing Markets Securities Fund VQ $__________
Xxxx Xxxxx Partners Variable Appreciation Xxxxxxxxx Foreign Securities Fund VG $__________
Portfolio 1N $__________ Third Avenue Small Cap Value Portfolio IT $__________
Xxxx Xxxxx Partners Variable Dividend Xxx Xxxxxx LIT Xxxxxxxx Portfolio NJ $__________
Strategy Portfolio* G1 $__________ Xxx Xxxxxx LIT Enterprise Portfolio* NP $__________
Xxxx Xxxxx Partners Variable Equity Index Xxx Xxxxxx LIT Strategic Growth Portfolio* NY $__________
Portfolio GF $__________ Xxxxx Fargo VT Advantage Small/Mid Cap Value
Xxxx Xxxxx Partners Variable Fundamental Fund* AT $__________
Value Portfolio* KR $__________ Western Asset Management High Yield Bond
Xxxx Xxxxx Partners Variable High Income Portfolio UB $__________
Portfolio HH $__________ Western Asset Management U.S. Government
Xxxx Xxxxx Partners Variable International Portfolio GV $__________
All Cap Growth Portfolio* HI $__________ Fixed Account (if available) $__________
Xxxx Xxxxx Partners Variable Investors $__________
Portfolio C2 $__________ $__________
Xxxx Xxxxx Partners Variable Large Cap TOTAL: $__________
Growth Portfolio AB $__________
Xxxx Xxxxx Partners Variable Premier
Selections All Cap Growth Portfolio* P1 $__________
Xxxx Xxxxx Partners Variable Small Cap
Growth Opportunities Portfolio C9 $__________
Xxxx Xxxxx Partners Variable Small Cap
Growth Portfolio* SS $__________
Xxxx Xxxxx Partners Variable Social
Awareness Stock Portfolio SA $__________
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PLEASE READ AND SIGN PAGE 3
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X-00000XXX (XXX CODE) ORDER # L-19244 2 of 3; Rev. 11/06
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TAX WITHHOLDING ELECTION
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The distribution you receive is subject to 10% Federal Income Tax withholding and State Income Tax withholding, where applicable,
unless you elect not to have withholding apply. Even if you elect not to have Federal and State Income Tax withheld, you are liable
for payment of Federal Income Tax and State Income Tax, where applicable, on the taxable portion. You may also be subject to tax
penalties under the estimated tax payment rules if your payments of estimated tax and withholding, if any, are not adequate. Please
check one of the following. IF NO BOX IS CHECKED, WE WILL WITHHOLD ANY APPLICABLE TAXES.
[ ] Check this box to have Federal Income Tax and State Income Tax, where applicable, withheld.
[ ] Check this box if you elect NOT to have Federal Income Tax and State Income Tax, where applicable, withheld.
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72(T)/72(Q) DISTRIBUTIONS (complete if you would like to take distributions under IRC sections 72(t)/72(q)
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[ ] NEW 72(T)/72(Q) DISTRIBUTION: I understand that if systematic payments begin prior to age 59 1/2, they cannot be modified for
at least 5 years or until I reach age 59 1/2, whichever is later except under the one-time exception described below. If
modified for any other reason, the IRS premature distribution tax penalty could be charged retroactively against all payments
received.
[ ] FOR 72(T)/72(Q) CHANGES TO CURRENT DISTRIBUTIONS ONLY: I understand that a one-time calculation change to the required minimum
distribution method is allowed for distributions taken under 72(t)/72(q) and that this method must remain in effect for the
remaining duration of 72(t)/72(q) payments. Accordingly, please change my current 72(t)/72(q) distribution method to the
Required Minimum Distribution Method. I UNDERSTAND THAT METLIFE DOES NOT CALCULATE THE ANNUAL DISTRIBUTION AMOUNT UNDER THIS
METHOD. I UNDERSTAND AND AGREE THAT I AM RESPONSIBLE FOR CALCULATING THE AMOUNT TO BE DISTRIBUTED EACH YEAR AND FOR PROVIDING
THAT NUMBER TO METLIFE EACH YEAR.
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UNDER PENALTIES OF PERJURY I CERTIFY: 1) THAT THE NUMBER SHOWN ABOVE IS MY CORRECT SOCIAL SECURITY NUMBER OR TAXPAYER IDENTIFICATION
NUMBER; AND 2) THAT I AM NOT SUBJECT TO BACKUP WITHHOLDING BECAUSE: (A) I HAVE NOT BEEN NOTIFIED BY THE IRS THAT I AM SUBJECT TO
BACKUP WITHHOLDING AS A RESULT OF FAILURE TO REPORT ALL INTEREST OR DIVIDENDS; OR (B) THE IRS HAS NOTIFIED ME THAT I AM NO LONGER
SUBJECT TO BACKUP WITHHOLDING; AND 3) I AM A U.S. CITIZEN OR A U.S. RESIDENT FOR TAX PURPOSES.
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THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATIONS REQUIRED
TO AVOID BACKUP WITHHOLDING.
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OWNER'S SIGNATURE DATE
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DIRECT DEPOSIT AUTHORIZATION (complete if you want your deposits transferred directly to your bank account)
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Bank Name Account Type
_______________________________________________________________ __________________________________________________________________
Bank Address Your Bank Account Number
_______________________________________________________________ __________________________________________________________________
City, State, Zip Code Bank Routing Number
_______________________________________________________________ __________________________________________________________________
Bank Phone Number
_______________________________________________________________ __________________________________________________________________
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- Please include a voided check if a checking account is elected.
- If your account is with a credit union, please check here. [ ]
- If payment is to be deposited into the bank account of an alternate payee, please complete the following:
Name of Alternate Payee: ___________________________________________________________________________
- In the event of any overpayment by Us, the bank will debit your account and refund the overpayment directly to Us.
- Please note that the processing for direct deposits will generally begin with your second systematic withdrawal payment.
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ALTERNATE PAYEE OR ADDRESS
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Please complete this section in full if you are not Alternate Recipient: _____________________________________________
participating in Direct Deposit and withdrawals are to be paid
to other than Owner and/or mailed to an address other than Street Address: __________________________________________________
address of record.
City, State, Zip Code: ___________________________________________
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The Owner(s) agree and certify that the directions and authorizations contained herein will continue until written notice of any
change or revocation is received by Us.
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OWNER'S SIGNATURE DATE
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L-19066SWP (BAR CODE) ORDER # L-19244 3 of 3; Rev. 11/06
