INVE-RET (02 /1 9 ) Page 1 Income Verification Request - Fs Income Verification Form Metropolitan Life Insurance Company Request for Income Verification Requests must be submitted in writing, please submit your request by returning this signed and completed form to MetLife Retiree Service Center, PO Box 25754, Salt Lake City, UT 84125-0754 1. PROVIDE INFORMATION ABOUT YOURSELF Requester Name: _____________________________________________________________________________________________ Annuitant Name: Annt. Social Sec Number: Date of Birth: * Annuitant ID #: Check here if this is a new Address Apt/Unit: State: Zip: Street: City: Daytime Telephone Number: * OPTIONAL 2. PLEASE READ Please allow up to 30 days from the receipt of this signed and completed form to process your request. Must complete entire form and sign Section 4 to be processed properly. 3. REQUESTER PLEASE CHECK BOX THAT APPLIES If payable is other than annuitant or payee please indicate below: Annuitant Attorney Guardian Beneficiary Trustee Joint Survivor* Conservator Other * Note: Joint Survivor must also sign in signature line provided below 4. PLEASE PRINT NAME & SIGN AUTHORIZATION BELOW I hereby affirm that all information reported on this form and any attachments are true, complete and accurate to the best of my knowledge. I understand that any false statements or misrepresentation is unlawful and may result in a denial in request. Print Name Print Name Authorized Signature (Required) * If Joint Annuitant (Signature is Required) Date Date
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INVE-RET (02 /1 9) Page 1 Income Verification Request - Fs
Income Verification Form
Metropolitan Life Insurance Company
Request for Income VerificationRequests must be submitted in writing, please submit your request by returning this signed and completed form to MetLife Retiree Service Center, PO Box 25754, Salt Lake City, UT 84125-0754
1. PROVIDE INFORMATION ABOUT YOURSELF
Requester Name: _____________________________________________________________________________________________
Annuitant Name: Annt. Social Sec Number:
Date of Birth: * Annuitant ID #:
Check here if this is a new Address
Apt/Unit:
State: Zip:
Street:
City:
Daytime Telephone Number: * OPTIONAL
2. PLEASE READ
Please allow up to 30 days from the receipt of this signed and completed form to process your request. Must complete entire form and sign Section 4 to be processed properly.
3. REQUESTER PLEASE CHECK BOX THAT APPLIES
If payable is other than annuitant or payee please indicate below: Annuitant Attorney Guardian Beneficiary Trustee Joint Survivor* Conservator Other* Note: Joint Survivor must also sign in signature line provided below
4. PLEASE PRINT NAME & SIGN AUTHORIZATION BELOW
I hereby affirm that all information reported on this form and any attachments are true, complete and accurate to the best of my knowledge. I understand that any false statements or misrepresentation is unlawful and may result in a denial in request.
Print Name Print Name
Authorized Signature (Required) * If Joint Annuitant (Signature is Required)
Date Date
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