Direct Rollover Form printable pdf download

Return to :

John Hancock Life Insurance Company

Fixed Products Operations, S-8

380 Stuart Street

Boston, MA 02117

Toll Free # : 1-800-624-5155

DIRECT ROLLOVER FORM

(For Defined Benefit Plans)

Employer : ___________________________________________________________________________

Group Annuity Contract Number : ____________

Association Number : ____________

PARTICIPANT INFORMATION

(please print clearly)

{ } Check Box if individual making election is an alternate payee eligible for a direct rollover distribution.

Name: ____________________________________________Social Security # : ___________________

Address : ____________________________________________________________________________

____________________________________________________________________________

City : ___________________________________

State : _________

Zip Code : _________

ELECTIONS

Instructions – Complete Section A if you want all or a portion of your distribution made payable to you.

Section A.

I elect to have ____________% or $________________ of the distribution made payable

to me. I understand that 20% of the taxable portion of the distribution will be

withheld.

Signature: _______________________________________________

Date: ____________________

Instructions – If in Section A you elected your entire distribution to be payable to you (i.e. you are not

requesting a “direct rollover” to an “eligible retirement plan”) GO NO FURTHER, your form is complete.

If however, you are requesting a “direct rollover” of any portion of the distribution to an “eligible

retirement plan”, you need to complete Section B and the Recipient Plan Information below.

Section B.

I elect to have ____________% or $________________ of the distribution made payable

to the following “eligible retirement plan”.

{ } Qualified Employer Plan

{ } IRA

RECIPIENT PLAN

Is there a trustee for the Qualified Employer Plan?

{ } Yes

{ } No

Trustee Name

(

) : _____________________________________________________________________

if applicable

Name of IRA Custodian or Qualified Plan

: _______________________________________________________

(whichever is applicable)

Direct Rollover Form

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