Withdrawal Request (continued)

Federal lncome Tax Withholding (Please selec one)

3 lf no amount or percg$aqe are lndiated belor l07o (20% for TSA r03(b) aaount) will be withheld, Stete wi*rholding is requird in certain states if federal
income taxes are wiftheld.

E Please do NOT wisrhold Federal lnome Tax. EI Please wittrhold tl-O"/o--or va.

Delivery Options
4 Unless othenvls€
(Please selec ONE ol dre following options)
lnstucted below, the ploceods wlll be malled to tfte owne/s address of record.
Optlon 1. neCrontc Fund Trunrfrr (EFl) - The quickest and safest way to receive your dBtribution,
ff
mPoqIAiIr: Phase sttad,l a \okhd dn& o $b rquest (&posil dip and sbrhr $6d6 aru not aaeptg. The voided dre* must be in dn
name of fie oryner{s). lf fie annuig ls rugbterd to a tus!, t'te fun& must be sent to a bsnk accdlm in $at f$t's name. Plese allo,rr tlvo busins
drys from the efftrtive date of $e udtrdnwd fur tre payrnem b b€ dditd b your acount
Federal Furd tillre anilabh upon tEuest" A lee will be darged fur dris senrice and addisonal lex may be drarged by your financial ilxdtrtions,

Optlon 2. E Pleare mall my chedt to:

E lddres of record EI Aternte Addrc* (Slgnature Gurrantee b requlred|: Fax request are not an acceptable for this option.

STREET ADDRESS

lnstructions for tl{l3(b) Annuity Withdrawal Requesb

5 The lmernal Revenue Seruice rules governing 403(b) distlb-utlons are omplex. The lntemal Revenue Code $3(b) llmit liquidations for 403(b) plan partici.
pans. Acording to the tode, the only acceptable renons for llquidations are dea$, disability, separation from service, attainment of age 59fi or fihancial
har&hip. You may need to prwide proof to the lRS, Plcare contact your tax adviser,
Generally, distributions cannot be made until one of the follouring uiggering annt ocqrn: (Check one)
tr Death - Additional paperuork ls needed, Please contact Cllent SeMces to request a Death Benefit Package.
tr Age 59?t attained.
E Separation of Serulce - Conflrmatlon from your employer may be required.
tr Oisabitity - Certification of Dlsabillty Form must be on file or must accompany fiis form.
tr Finandal Har*trip - A finanhl har*hlp ls defined as an immedkrte and heavy financial need wiilr no ofia resources reconably anilable. A har*hlp witfidranral
must not s(c€€d te amutfi of $e immdiau need, Pumuant to lnt€mal Revenue Cod€ Sectlon 403$) (11), the eamlngi on 401(b) sahry riductlon
contlbutlons cannot be dbulhiled ln th€ case of hrdshlp (only dre afrial contrlbutlons may be dlstlbute$ drerefore generalty 40iO) cofifacb
not be fully sunendered based on lurdshlp. Effecttue l/1/99, hadshlp dlstslhrtlons are iro longer ellglble to rollovfu to an lnn
-may
fermination - Plan tarminatlon doorm€ntsdon slgned by the plan administrator is requlred.
ftflan
Telephone Withdrawal Agreement
6 Be advlsed $at uking wi$dnwals from some d our product may advenely affect fie undedylng guarantees. Please onsuh your advisor, your product
prospectus, or call 1.80&3tll-1029 wl$ any questlons.

Contract uA,ners who au$orize John Hancotk to accept wlddrawal lnsfuctions b, telephone agree fifi such wilhdralrals are made subject to $e
followlng prwlsions:

A) For varlable annuities, wi$drawals made on lnstructions recefued by John Hancock by telephone before 4:00 PM Eastem Time will be made in
aaordance whh fte unit value for that day. Wfidrawals recefued after 4:00 PM will be made in aaordance with dre unit value for $e nen
valuation period. 0n[ one sa ofwhhdrawal instnrctlons will be accepted per valuation period.

Bl lnstructions for partiel wi$drah,als, up to $50,000 per confract, are permitted (full whhdnwals are not permitted by telephone).

C} lnsrrucions may be given by olling 1-877-543-3676 (JHF.FORM) on regular businss days.

D) ln $e went that proper ldentificatlon is not proridd, John Hancock reservc fre right to refr$€ to act on telephffe witMrawal instrucions.

E) All witrh*awals made in aaordance with instructions received $ telephone must be made in aaordance with dre tenns d fie ontract and/or prcpectrs.
lf wifidrawal instuctions are not in good ot&r, $e wifidrawal will not be made and fie contact orvner will h notified within lE horrs,

F) No telephone withdrarvab will be allcnued on ontracB wherc the addres has been dranged in fre last 30 dap,

Gl The $eck may be payable only to $e 0r ,ner of recod (who must be an indivkluaD and nray be mailed only to t're address of record.

l0 The oume(s) of record and $e agent of recod can rquest a wifrdraral x long as zuch penon prorrides fre infomation requested.

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