John Hancock Usa Annuities Request For 1035 Exchange Form

John Hancock USA Annuities

Request for 1035 Exchange Form

INSTRUCTIONS

Use this form to accomplish a FULL or PARTIAL exchange of a life insurance policy or annuity contract (pursuant to IRC section 1035)

to a Venture Annuity.

Please note the following:

This form is not to be used for qualified retirement plan or IRA transfers, or other taxable exchanges.

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The application for the new annuity contract must have the same contractual designation (i.e. owner

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and annuitant

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) as the current contract.

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

New Annuity Contract Applicants:

Check this box if proceeds from this 1035 exchange will be used to open a new non-qualified annuity.

Complete this form and 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 contracts or certificates.

Existing Annuity Contract Owners:

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

existing annuity for this transfer. It is not necessary to complete a new annuity application. 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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Co-owner’s name (if any):_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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

Annuitant’s/Insured’s name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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

Co-annuitant’s/Insured’s name (if any): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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

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

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

State: _ _ _ _ _ _ _ _ _

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

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

2. POLICY EXCHANGE INFORMATION

A) Information about the policy to be surrendered/exchanged:

Surrendering financial institution: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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

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

State: _ _ _ _ _ _ _ _ _

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

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

Current contract/Policy number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Annuity contract

Life insurance policy

Other

B) Type of exchange (Check one):

Full liquidation/exchange

My original contract/policy is:

Enclosed

Destroyed

Partial liquidation/exchange

I request a partial exchange from the aforementioned annuity in the amount of: $_____________________ or _____________________%

of my current contract value.

C) Instructions:

Please liquidate:

Immediately

When indicated: ________ /________ /___________

3. COST BASIS INFORMATION (For insurer use only):

Please provide John Hancock USA with the following tax cost basis information:

Pre-TEFRA: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(DEPOSITS MADE PRIOR TO AUGUST 14, 1982, LESS APPLICABLE WITHDRAWALS)

Post-TEFRA: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(DEPOSITS MADE AFTER AUGUST 14, 1982, LESS APPLICABLE WITHDRAWALS)

0505: 130703

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