Direct Transfer/direct Rollover Request Form - John Hancock Usa

John Hancock USA Annuities

Direct Transfer/Direct Rollover Request Form

INSTRUCTIONS

For use with Venture IRA, Roth IRA, SEP-IRA, SIMPLE IRA, Qualified Retirement Plans and 403(b) Annuity Plans only.

Use this form to:

1. rollover or transfer assets directly from an existing IRA or qualified retirement plan into a John Hancock USA IRA or qualified retirement plan;

2. rollover or transfer assets directly from a 403(b) plan to a John Hancock USA IRA or 403(b) plan; or

3. rollover or transfer assets from a Roth or traditional IRA to a John Hancock USA Roth IRA.

Note: Before completing this form, you should contact the transferring company to determine if they have any special requirements/paperwork for liquidation.

Check this box if proceeds from this transfer/rollover will be used to open a new annuity. Complete this form and

New Annuity Applicants:

forward it to the address listed in the Contact Information section. Be sure to include your completed annuity application, applicable State

Replacement forms and any existing plan contracts or certificates.

Check this box if you have a current qualified annuity with John Hancock USA and wish to use your existing

Existing Annuity Owners:

annuity for this transfer. It is not necessary to complete a new application. John Hancock USA will request funds from the resigning

trustee/custodian/issuer with this form. Be sure to include applicable State Replacement forms and any existing plan contracts or certificates.

Please provide us with your existing Venture Annuity contract number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

1. INFORMATION ABOUT YOU

Owner’s name:______________________________________________________________________

Social security number/TIN: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Annuitant’s name (if different): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Social security number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

State: _ _ _ _ _ _ _ _ _

Zip: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Telephone: (_______) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. REPLACEMENT QUESTIONS

No

Yes

Has Annuitant or applicant(s) any existing annuities or insurance?

No

Yes

Will the purchase of this Annuity replace or change any other insurance or annuity? If “Yes,” please attach state replacement

forms along with this form.

3. TRANSFERRING ACCOUNT INFORMATION

________________________________________________________________________________

A) Existing financial institution/employer plan:

Street address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

State: _ _ _ _ _ _ _ _ _

Zip: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Telephone: (_______) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Policy/Account #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Policy/Account #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

For certificate of deposit: Maturity date: ________ /________ /_________

Value at maturity: $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

B) I authorize you to liquidate and transfer to John Hancock USA:

The entire value

A partial transfer of $______________ or ________% of my account above

C) My current policy (policies) is (are):

Enclosed

Lost/Destroyed

Note: If you are 70

⁄

or older this year, you may not transfer or rollover Required Minimum Distribution amounts.

1

2

0805: 130704

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