variable annuity election of systematic withdrawals · variable annuity election of systematic...

Annuities

8300-B (02/18) of 5

Fs-B/f

Variable annuity election of systematic withdrawals This form is used to start or change a systematic withdrawal program from your annuity contract.

Brighthouse Life Insurance Company Brighthouse Life Insurance Company of NY (Collectively and singly, "Brighthouse Financial")

Things to know before you begin • Fund units will be liquidated pro-rata, based on fund allocations at the

time of processing. Fund specific withdrawals are not available if the rider increasing amount is selected.(

• Systematic withdrawals cannot be coded as transfers. • The Owner's signature is required in Section 5 of this form. If there is

more than one Owner, all Owners must sign. Please use black ink. (If the contract owner is a trust, additional paperwork may be required.)

• You must complete each section of this form (with the exception of Section 4, Alternate payment instructions, which is optional). Missing information can lead to delays in processing your request.

• Please read the Income tax withholding election section carefully and indicate a withholding percentage.

Please note: Withdrawal or surrender requests in which the money has already been received in your bank account cannot be returned.

SECTION 1: Contract informationAnnuity contract number

AnnuitantFirst name Middle name Last name

OwnerFirst name Middle name Last name

Social Security number or TIN Phone number

Please choose one: Start a new systematic withdrawal

Modify an existing systematic withdrawal

SECTION 2: Payment informationPlease be aware that withdrawing more than your guaranteed withdrawal amount, called “excess withdrawals”, may permanently reduce your future guaranteed withdrawal amounts. If you are considering making an excess withdrawal but are uncertain as to how it will affect your future guaranteed withdrawal amounts, we encourage you to contact us prior to requesting the withdrawal to obtain a personalized, transaction-specific calculation showing the effect of the excess withdrawal.

Payment frequency - the date you indicate below is the date the distribution will be processed on your contract.• This form must be received at least 10 days prior to your requested first payment date. • Upon our receipt of this form, if the beginning date requested below has passed, your payments will begin on

the next available frequency date requested.

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• Please allow additional time to receive your payment once processed.

Monthly payments beginning on / / (date must be 1st through 28th of month)

Quarterly payments beginning on / / (date must be 1st through 28th of month)

The additional frequency options below may not be available with certain riders, and are not available during the first year of the contract.

Semi-annual payments beginning on / / (date must be 1st through 28th of month)

Annual payments beginning on / / (date must be 1st through 28th of month)

Payment amount options (for all options, each payment must be a minimum of $100):Important: Please review your contract and/or prospectus for detailed information regarding early withdrawal penalties and other withdrawal provisions. If you have elected Guaranteed Withdrawal Benefit (GWB) or LifetimeWithdrawal Guarantee (LWG), cumulative withdrawals that exceed the Annual Benefit Payment in any contract year may significantly reduce the value of the GWB or LWG benefit. If you elect the LWG and you make any withdrawals prior to age 59½, we will not make payments to you over your lifetime. If you elect a Guaranteed Minimum Income Benefit (GMIB) and/or Enhanced Death Benefit (EDB) rider, cumulative withdrawals in a contract year that exceed the dollar-for-dollar withdrawal limit may significantly reduce the value of the GMIB and/or EDB. If you elected the GMIB Max IV, or GMIB Max IV with EDB Max IV and you take your first withdrawal prior to the 5th contract anniversary, your dollar-for-dollar withdrawal rate will be 4.5% of the Annual Increase Amount (AIA) each year. If you take your first withdrawal on or after the 5th contract anniversary, your dollar-for-dollar withdrawal rate will be 5% of the AIA each year. If you elected the GWB v1 rider and wish to withdraw an amount that is equal to your Annual Benefit Payment (ABP) and take a withdrawal prior to the 5th contract anniversary, your ABP will be 5% of your Total Guaranteed Withdrawal Amount (TGWA) each year. If you take a withdrawal on or after the 5th contract anniversary, but prior to your 10th contract anniversary, your ABP payment will be 6% of your TGWA each year. If you take a withdrawal on or after your 10th contract anniversary, your ABP payment will be 7% of your TGWA each year. Cumulative withdrawals in a contract year that exceed your ABP will reduce your TGWA and Remaining Guaranteed Withdrawal Amount (RGWA) on a proportional basis, which may significantly reduce your future benefits. If you elected the GWB v1 Rider and wish to take a withdrawal for a specific dollar amount, that withdrawal amount may not exceed the Annual Benefit Payment amount allowed under the rider. If you elected a FlexChoice living benefit rider and take a withdrawal prior to the Lifetime Withdrawal Age (59 1/2), your Benefit Base and Death Benefit Base will be reduced in the same proportion as the amount of the withdrawal (including Withdrawal Charges, if any) divided by the account value prior to the withdrawal (a Proportional Adjustment). This can cause a substantial reduction in your benefits. Prior to the Lifetime Withdrawal Age there is no Annual Benefit Payment (ABP). Any withdrawal that occurs after 59 1/2 is considered either a Non-Excess or an Excess Withdrawal. Your ABP is the maximum amount that may be withdrawn in a contract year without triggering a Proportional Adjustment to the Benefit Base. Your first withdrawal after the Lifetime Withdrawal Age determines your Withdrawal Rate. Once determined, the Withdrawal Rate will not change for the remainder of the contract. A "Non-Excess Withdrawal" is a withdrawal that does not exceed the ABP for the current contract year. Non-Excess Withdrawals do not reduce the Benefit Base but will reduce the Death Benefit Base. An "Excess Withdrawal" is a withdrawal that causes the cumulative withdrawals for the current contract year to exceed the ABP. An Excess Withdrawal, and any subsequent withdrawals that occur in that Contract Year, trigger a Proportional Adjustment to the Benefit Base and Death Benefit Base and can cause a substantial reduction in your benefits.

10% of total purchase payments not subject to withdrawal charge.

$ per withdrawal. ( The annual total of all withdrawals must be 10% or less of purchase payments. For Series/Class C Contracts and Brighthouse Investment Portfolio Architect C Share Contracts, must be 20% or less of purchase payments.)

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For contracts with Guaranteed Withdrawal Benefit (GWB) or Lifetime Withdrawal Guarantee (LWG) - withdrawal amount that increases upon GWB or LWG Optional or Automatic step-up* to equal 100% of the annual benefit payment upon step-up (the withdrawal amount will not increase as a result of increases due to added purchase payments or interest adjustments). Initial withdrawal amount prior to a step-up will equal the remaining unpaid annual benefit payment for the current contract year and will continue unchanged until the next contract anniversary on which a step-up occurs, provided that if you are currently enrolled in the systematic withdrawal program,the initial withdrawal amount prior to a step-up will equal the current systematic withdrawal amount and will continue unchanged until the next contract anniversary on which a step-up occurs.For contracts with Guaranteed Minimum Income Benefit (GMIB)** and/or Enhanced Death Benefit (EDB) - withdrawal amount that increases upon an optional or automatic step-up* to equal 100% of the withdrawal rate applied to the annual increase amount (“compounding income base”) upon step-up (withdrawal amount will not increase as a result of increases due to added purchase payments*** or interest adjustments*.) Initial withdrawal amounts prior to a step-up will equal the selected percentage applied to the annual increase amount as of the beginning of the current contract year (less any non-systematic withdrawals made in the current contract year), and will continue unchanged until the next contract anniversary on which a step-up occurs, provided that if you are currently enrolled in a systematic withdrawal program, the initial withdrawal amount prior to step-up will equal the current systematic withdrawal program amount and will continue unchanged until the next contract anniversary on which a step-up occurs.

For contracts with Guaranteed Minimum Income Benefit (GMIB)** - level amount equal to 100% of the withdrawal rate applied to the annual increase amount (“compounding income base”) as of the prior contract anniversary under the GMIB rider. This withdrawal amount will not be recalculated by the company after the next contract anniversary regardless of any changes to the annual increase amount. The withdrawal amount will remain unchanged unless a new request for a different amount is submitted.

100% of the current Withdrawal Rate under the FlexChoice living benefit rider. (This option only applies to contracts where the FlexChoice living benefit rider has been elected.)

*GWB, LWG, GMIB, LIS, and EDB must be elected at issue and electing optional/automatic step-ups may be elected by separate election forms. **including versions of the Lifetime Income Solution (LIS) rider. ***except will increase upon purchase payments made in the first 120 days of the contract issuance.

SECTION 3: Income tax withholding electionGenerally, the withdrawals you take from this contract are non-periodic payments and the taxable amount will be subject to 10% federal income tax withholding unless you elect not to have withholdingapply. You may elect not to have withholding apply to your withdrawals from this contract by checking the appropriate box below. If you elect not to have withholding apply to your systematic withdrawals, or if you do and you do not have enough federal income tax withheld from your payments, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. Even if you elect not to have federal income tax withheld from your systematic withdrawals, you are liable for payments of federal income tax on the taxable portion of each payment sent to you. In some states, your distribution may also be subject to state income tax withholding requirements. In certain states, we may be required to withhold state income tax if we withhold federal income tax from your distribution. Certain states may also require you to make estimated tax payments. Your withholding election will remain in effect for future payments under this Systematic Withdrawal Program until you change or revoke it by filing a new election with us. You may change your withholding election at any time and as often as you wish. Remember, part or all of your withdrawal is subject to income tax and a 10% IRS penalty may also apply to withdrawals made before age 59½.

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Choose one:I elect to have federal and state, if applicable, income tax withheld from these distributions(s).(This must be listed as a percentage only, NOT as a dollar amount.)

Federal % State % Owner’s state of residence

I elect NOT to have federal, or state if applicable, income tax withheld from these distribution(s).

SECTION 4: Alternate payment instructions (Optional)

Choose One:

A check will be sent to the address on record if Electronic Funds Transfer or Alternate Payee is not selected below.

1. Electronic Funds Transfer (EFT)Note: You must attach a copy of a voided check when requesting EFT. If a voided check is not provided, a paper check will be mailed to the address of record.

Bank name Account holder name (must match the contract ownership)

Bank address Bank city State ZIP

Bank account number Bank ABA routing number

Type of Account:Checking ((A photocopy of a voided check is required, unless Electronic Payments are being sent to a previously established EFT account. If the contract has joint owners, both names must appear on the voided check.)

Savings (A bank statement or pre-printed deposit slip, containing EFT information and account registration, is required. If the contract has joint owners, both names must appear on the documents.)

2. Check for the benefit of (FBO) the contract ownerAlternate payee name (Bank, Brokerage Firm, etc.)

Alternate payee address City State ZIP

Account number (if applicable)

SECTION 5: Acknowledgement and authorizationUnder 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 U.S. person and the account is located within the

United States.

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(If you are not a U.S. Citizen or other U.S. person for tax purposes, please cross out the last two certifications and complete appropriate IRS documentation.)

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Signature of Contract Owner Title (if applicable) Date (mm/dd/yyyy)

Printed name of individual signing aboveFirst name Middle name Last name

Signature of Joint Owner (if any) Title (if applicable) Date (mm/dd/yyyy)

Printed name of individual signing aboveFirst name Middle name Last name

Note: If you are signing on behalf of another individual or entity, please indicate your title, position or status (e.g., Trustee, Attorney-in-Fact, Guardian, Conservator, Executor, Administrator) following your signature and call our Policy Service Office for additional document requirements.

SECTION 6: How to submit this formRegular mail: Brighthouse Financial P.O. Box 10366 Des Moines, IA 50306-0366

Overnight mail only: Brighthouse Financial 4700 Westown Parkway, Ste 200 West Des Moines, IA 50266

Fax: 877-547-9666

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