Document:

exv4wxayxvy

Exhibit 4(a)(v)

SPECIFICATIONS PAGE

	 	 	 	 	 	 	 

	TYPE OF CONTRACT/CERTIFICATE:

	 	[QUALIFIED]
	 	MATURITY DATE
	 	[8/1/2032]
	CONTRACT/CERTIFICATE DATE:

	 	[8/1/2009]
	 	MAXIMUM MATURITY DATE
	 	[8/1/2052]
	PAYMENT:

	 	[$250,000]
	 	CONTRACT/CERTIFICATE NUMBER
	 	[000111]
	OWNER:

	 	[DOROTHY HANCOCK]
	 	ISSUE STATE:
	 	[MA]
	CO-OWNER:

	 	[JAMES DOE]
	 	OWNER’S AGE
	 	[52]
	ANNUITANT

	 	[JOHN HANCOCK]
	 	ANNUITANT’S AGE
	 	[52]
	CO-ANNUITANT

	 	[NON APPLICABLE]	 	 	 	 

	 	 	 	 	 

	Initial Term
	 	Declared Interest Rate
	 	Initial Term
	 
	 	(Applicable to the first Contract/Certificate Year)
	 	Expiration Date
	     [3 Years]
	 	                [3.95%]
	 	     [8/1/2012]

	 	 	 

	GUARANTEED MARGIN (Applicable to the Initial Term)

	 	[   ]
	 
	 	 
	CPI-U Value on Contract/Certificate Date

	 	[   ]
	 
	 	 
	RATE CAP (Applicable to the Initial Term)

	 	[8%]
	 
	 	 
	FLOOR RATE (Applicable to the Initial Term)

	 	[0%]
	 
	 	 
	ANNUAL FEE

	 	[$50]
	 
	 	 
	PARTIAL WITHDRAWAL LIMITATIONS:
	 	 
	 
	 	 
	MINIMUM PARTIAL WITHDRAWAL AMOUNT

	 	[$1000]
	MINIMUM ACCOUNT VALUE AFTER PARTIAL WITHDRAWAL

	 	[$5000]
	 
	 	 
	PAYMENT LIMITATIONS:
	 	 
	 
	 	 
	MINIMUM PAYMENT

	 	[$10,000]
	 
	 	 
	MAXIMUM PAYMENT

	 	[$1,000,000]

[THIS CONTRACT/CERTIFICATE IS INTENDED FOR ISSUES AS TO A TAX-QUALIFIED RETIREMENT PLAN UNDER
THE INTERNAL REVENUE CODE FOR TAX-FAVORED STATUS. UNLESS OTHERWISE REQUIRED TO QUALIFY FOR SUCH
STATUS, LANGUAGE IN THIS CONTRACT/CERTIFICATE REFERRING TO FEDERAL TAX STATUS OR RULES IS
INFORMATIONAL AND INSTRUCTIONAL. SUCH LANGUAGE IS NOT SUBJECT TO APPROVAL OR DISAPPROVAL BY THE
STATE IN WHICH THE CONTRACT/CERTIFICATE IS ISSUED FOR DELIVERY. PLEASE SEEK THE ADVICE OF YOUR
OWN TAX ADVISOR REGARDING YOUR INDIVIDUAL TAX TREATMENT.]

SPEC-CPI10-1.2

S.1

 

MVA FORMULA

The Market Value Adjustment factor is determined by the following formula:

Where k, Missue, Mwithdrawal and n are defined as follows:

Missue
 = the Guaranteed Margin in effect for the current Term for this
Contract/Certificate.

Mwithdrawal = the Guaranteed Margin (expressed as a decimal) offered on a Term equal to
the number of months remaining in the current Term, as of the date the withdrawal or annuitization
request is processed. For purposes of this calculation, months remaining will be rounded up to the
next nearest whole month. If a Guaranteed Margin for this duration is not available for new
purchases, we will declare a Guaranteed Margin solely for this purpose that is consistent with the
Guaranteed Margin for durations that are currently available.

k = Adjustment Factor is [0.25%]. This Adjustment Factor effectively reduces the amount paid and
functions as an additional withdrawal charge.

n = number of months from the date that any amounts withdrawn or converted to Annuity Payments are
processed to the end of your current Term. In the case of partial months, n is rounded up to the
next month.

The Market Value Adjustment is equal to A x (B-1) where A is the amount subject to adjustment, and
B is the Market Value Adjustment factor above. The Market Value Adjustment may be positive or
negative.

INDEXED CREDITING RATE FORMULA

The following formula represents that at the beginning of each Contract Anniversary within any
selected Term, the Indexed Crediting Rate (Rt) for each year of the Term (t)
would be the greater of the Indexed Crediting Rate as determined using the CPI-U plus the
Guaranteed Margin (M), or the Floor Rate, and the lesser of the Indexed Credit Rate or the Rate
Cap.

Where:

Rt = Indexed Crediting Rate at time t applicable for
the following year.

CPIt = the CPI-U value from 3 months prior to the rate
determination date.

CPIt-1 = the CPI-U value 1 year prior to CPIt.

M = the Guaranteed Margin which is set at the beginning of the Contract/Certificate and remains
constant throughout the Term. M may be a negative value.

The Indexed Crediting Rate will never be less than a Floor Rate of [0%]nor greater than a Rate Cap
of [10%].

SPEC-CPI10-1.2

S.2

 

TABLES OF WITHDRAWAL CHARGE PERCENTAGES:

[APPLICABLE TO ACCOUNT VALUE DURING THE INITIAL TERM:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	CONTRACT/CERTIFICATE YEAR AT
TIME OF WITHDRAWAL
	TERM
	 	1
	 	2
	 	3
	 	4
	 	5
	 	6
	 	7
	 	8
	 	9
	 	   10   
	1 Year
	 	0%	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2 Year
	 	0%
	 	0%	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3 Year
	 	8%
	 	7%
	 	6%	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4 Year
	 	8%
	 	7%
	 	6%
	 	6%	 	 	 	 	 	 	 	 	 	 	 	 
	5 Year
	 	8%
	 	7%
	 	6%
	 	6%
	 	5%	 	 	 	 	 	 	 	 	 	 
	6 Year
	 	8%
	 	7%
	 	6%
	 	6%
	 	5%
	 	5%	 	 	 	 	 	 	 	 
	7 Year
	 	8%
	 	7%
	 	6%
	 	6%
	 	5%
	 	5%
	 	4%	 	 	 	 	 	 
	8 Year
	 	8%
	 	7%
	 	6%
	 	6%
	 	5%
	 	5%
	 	4%
	 	3%	 	 	 	 
	9 Year
	 	8%
	 	7%
	 	6%
	 	6%
	 	5%
	 	5%
	 	4%
	 	3%
	 	2%	 	 
	10 Year
	 	8%
	 	7%
	 	6%
	 	6%
	 	5%
	 	5%
	 	4%
	 	3%
	 	2%
	 	1%

 ]

APPLICABLE TO ACCOUNT VALUE DURING ANY SUBSEQUENT TERM:

[

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	NUMBER OF COMPLETE CONTRACT/CERTIFICATE YEARS SINCE THE COMMENCEMENT

OF ANY SUBSEQUENT TERM AT THE TIME OF WITHDRAWAL 
	 
	TERM
	 	0
	 	1
	 	2
	 	3
	 	4
	 	 5
	 	6
	 	7
	 	8
	 	 9
	1 Year
	 	0%	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2 Year
	 	0%
	 	0%	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3 Year
	 	6%
	 	5%
	 	4%	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4 Year
	 	6%
	 	5%
	 	4%
	 	4%	 	 	 	 	 	 	 	 	 	 	 	 
	5 Year
	 	6%
	 	5%
	 	4%
	 	4%
	 	3%	 	 	 	 	 	 	 	 	 	 
	6 Year
	 	6%
	 	5%
	 	4%
	 	4%
	 	3%
	 	3%	 	 	 	 	 	 	 	 
	7 Year
	 	6%
	 	5%
	 	4%
	 	4%
	 	3%
	 	3%
	 	2%	 	 	 	 	 	 
	8 Year
	 	6%
	 	5%
	 	4%
	 	4%
	 	3%
	 	3%
	 	2%
	 	1%	 	 	 	 
	9 Year
	 	6%
	 	5%
	 	4%
	 	4%
	 	3%
	 	3%
	 	2%
	 	1%
	 	0%	 	 
	10 Year
	 	6%
	 	5%
	 	4%
	 	4%
	 	3%
	 	3%
	 	2%
	 	1%
	 	0%
	 	0%

 ]

SPEC-CPI10-1.2

S.3

 

BENEFICIARY INFORMATION

Beneficiary(ies) is as designated by you as of the Contract/Certificate Date, unless otherwise
changed per the provisions of the Contract/Certificate.

	 	 	 

	Beneficiary(s)

	 	[John Doe]
	 
	 	 
	Contingent Beneficiary(s)

	 	[Jane Doe.]

SPEC-CPI10-1.2

S.4exv4wxbyxiiyxay

Exhibit 4(b)(ii)(A)

ROTH INDIVIDUAL RETIREMENT ANNUITY ENDORSEMENT

The Contract to which this Endorsement is attached is amended as specified below to qualify as
a Roth IRA under Section 408A of the Internal Revenue Code of 1986, as amended (the “IRC”). Where
the provisions of this Endorsement are inconsistent with the provisions of the Contract, including
the provisions of any other endorsements or riders issued with the Contract, the provisions of this
Endorsement will control.

Owner and Annuitant

	 	1.	 	The Owner must be one natural person who is the sole Owner of the Contract and the
Annuitant. A Joint Owner cannot be named. Except as otherwise permitted under Section 6
of this Endorsement, and otherwise permitted under applicable federal tax law, neither the
Owner nor the Annuitant may be changed. Also, all payments made from the Contract while
the Owner is alive must be made to the Owner. All distributions under an Annuity Option or
Annuity Income Payment Plan (referred to herein as an “Annuity Option”) for a Joint and
Survivor Life Annuity that are made after the Owner’s death and while the Co-Annuitant is
alive must be made to the Co-Annuitant.

Nontransferable and Nonforfeitable

	 	2.	 	The Contract is established for the exclusive benefit of the Owner or his or her
Beneficiaries. If this is an inherited IRA (within the meaning of IRC Section 408(d)(3)(C)
maintained for the benefit of a designated beneficiary of a deceased Owner, references in
this endorsement to “Owner” mean the deceased Owner. The Owner’s interest under the
Contract is nontransferable, and except as provided by applicable federal tax law, is
nonforfeitable.

Maximum Payments

	3.	(a)	 	Except in the case of a “qualified rollover contribution,” a “recharacterization”
(defined in (g) below), or a nontaxable transfer from another Roth IRA, no premium or
Payment otherwise permitted under the Contract (referred to herein as a “Payment”) will be
accepted unless it is in cash and the total of such payments to all the Owner’s Roth IRAs
for a taxable year does not exceed the lesser of the Applicable Amount (as defined in
paragraph (b) below) or the Owner’s compensation for that taxable year. The Payment
described in the preceding sentence is hereinafter referred to as a “regular Payment”.
However, notwithstanding the dollar limits on contributions, an individual may make
additional contributions specifically authorized by statute, such as repayments of
qualified reservist distributions, repayments of certain plan distributions made on account
of a federally declared disaster and certain amounts received in connection with the Exxon
Valdez litigation. A “qualified rollover contribution” is a rollover contribution of a
distribution from an IRA that meets the requirements of IRC Section 408(d)(3), except the
one-rollover-per-year rule of IRC section 408(d)(3)(B) does not apply if the rollover
contribution is from an IRA other than a Roth IRA (a “nonRoth IRA”). For taxable years
beginning after 2007, a qualified rollover contribution includes a rollover from a
designated Roth account described in Code section 402A and a rollover from an eligible
retirement plan described in Code section 402(c)(8)(B). Payments may be limited under
paragraphs (c) through (f) below.

	 	(b)	 	Unless otherwise provided under applicable federal tax law, the
Applicable Amount is determined under (i) or (ii) below:

	 	(i)	 	If the Owner is under age 50, the Applicable Amount is $5,000
for any taxable year beginning in 2008 and years thereafter. After 2008, the
$5,000 amount will be adjusted by the Secretary of the Treasury for
cost-of-living increases under Code section 219(b)(5)(D). Such adjustments
will be in multiples of $500.
	 
	 	(ii)	 	If the Owner is 50 or older, the Applicable Amount under
paragraph (i) above is increased by $1,000 for any taxable year beginning in
2006 and years thereafter.

ICC11-ENDROTH.11

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	 	(c)	 	If (i) and/or (ii) below apply, the maximum regular Payment that can be
made to all of the Owner’s Roth IRAs for a taxable year is the smaller amount
determined under (i) or (ii).

	 	(i)	 	The maximum regular Payment limit is gradually reduced to $0
between certain levels of modified adjusted gross income (“modified AGI,” as
defined in (g) below). For an Owner who is single or is a head of household,
the maximum annual regular Payment is phased out between modified AGI of
$95,000 and $110,000; for an Owner who is married filing a joint return or is
a qualifying widow(er), between modified AGI of $150,000 and $160,000; and for
an Owner who is married filing a separate return, between modified AGI of $0
and $10,000. If the Owner’s modified AGI for a taxable year is in the
phase-out range, the maximum regular Payment determined for that taxable year
is rounded up to the next multiple of $10 and is not reduced below $200.
After 2006, the dollar amounts above will be adjusted by the Secretary of the
Treasury for cost-of-living increases under Code section 408A(c)(3). Such
adjustments will be in multiples of $1,000.
	 
	 	(ii)	 	If the Owner makes regular Payments to both Roth and nonRoth
IRAs for a taxable year, the maximum regular Payment that can be made to all
the Owner’s Roth IRAs for that taxable year is reduced by the regular Payments
made to the Owner’s nonRoth IRAs for the taxable year.

	 	(d)	 	If this is an inherited IRA within the meaning of IRC Section
408(d)(3)(C), no Payments will be accepted.
	 
	 	(e)	 	No Payment will be accepted under a SIMPLE IRA plan established by any
employer pursuant to IRC Section 408(p). Also, no transfer or rollover of funds
attributable to Payments made by a particular employer under its SIMPLE IRA plan
will be accepted from a SIMPLE IRA, that is, an IRA used in conjunction with a
SIMPLE IRA plan, prior to the expiration of the two-year period beginning on the
date the Owner first participated in that employer’s SIMPLE IRA plan
	 
	 	(f)	 	A regular Payment to a nonRoth IRA may be recharacterized pursuant to the
rules in Section 1.408A-5 of the federal income tax regulations as a regular Payment
to this IRA, subject to the limits in (c) above.
	 
	 	(g)	 	For purposes of (c) above, an individual’s modified AGI for a taxable
year is defined in IRC Section 408A(c)(3)(C)(i) and does not include any amount
included in adjusted gross income as a result of a rollover from an eligible
retirement plan other than a Roth IRA (a “conversion”).
	 
	 	(h)	 	For purposes of (a) above, compensation is defined as wages, salaries,
professional fees, or other amounts derived from or received for personal services
actually rendered (including, but not limited to commissions paid salesmen,
compensation for services on the basis of a percentage of profits, commissions on
insurance premiums, tips, and bonuses) and includes earned income, as defined in IRC
Section 401(c)(2) (reduced by the deduction the self-employed individual takes for
contributions made to a self-employed retirement plan). For purposes of this
definition, IRC Section 401(c)(2) shall be applied as if the term trade or business
for purposes of IRC Section 1402 included service described in subsection (c)(6).
Compensation does not include amounts derived from or received as earnings or
profits from property (including but not limited to interest and dividends) or
amounts not includible in gross income. Compensation also does not include any
amount received as a pension or annuity or as deferred compensation. The term
“compensation” shall include any amount includible in the individual’s gross income
under IRC Section 71 with respect to a divorce or separation instrument described in
subparagraph (A) of IRC Section 71(b)(2). In the case of a married individual
filing a joint return, the greater compensation of his or her spouse is treated as
his or her own compensation, but only to the extent that such spouse’s compensation
is not being used for purposes of the spouse making a contribution to a Roth IRA or
a deductible contribution to a nonRoth IRA. The term “compensation” also includes
any differential wage payments as defined in IRC Section 3401(h)(2).

Required Distributions Generally

	 	4.	 	Notwithstanding any provision of the Contract to the contrary, the distribution of the
Owner’s interest in this Roth IRA shall be made in accordance with the requirements of IRC
Sections 401(a)(9) and 408(b)(3), as modified by IRC Section 408A(c)(5), and the
regulations thereunder, the provisions of which are herein incorporated by reference. If
distributions are not made in the form of an annuity on an irrevocable basis (except for
acceleration), then distribution of the interest in the Contract (as determined under
paragraph (b)

ICC11-ENDROTH.11

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	 	 	 	of Section 6 of this Endorsement) must satisfy the requirements of IRC Section 408(a)(6),
as modified by IRC Section 408A(c)(5), and the regulations thereunder, rather than the
distribution rules in paragraphs (a) through (f) of Section 6 below.

Distributions During Owner’s Life

	 	5.	 	No amount is required to be distributed prior to the death of the Owner. If this is an
inherited IRA within the meaning of IRC Section 408(d)(3)(C), this paragraph does not apply.

Distributions After Owner’s Death

	 	6.	 	(a) Upon the death of the Owner, his or her entire interest will be distributed at least
as rapidly as follows:

	 	(1)	 	If the designated beneficiary is someone other than the Owner’s
surviving spouse, the entire interest will be distributed, starting by the end of
the calendar year following the calendar year of the Owner’s death, over the
designated beneficiary’s life, or over the remaining life expectancy of the
designated beneficiary, with such life expectancy determined using the age of the
beneficiary as of his or her birthday in the year following the year of the
Owner’s death or, if elected, in accordance with paragraph (a)(3) below. If this
is an inherited IRA (within the meaning of IRC Section 408(d)(3)(C)) established
for the benefit of a non-spouse designated beneficiary by a direct
trustee-to-trustee transfer from a retirement plan of a deceased Owner under IRC
Section 402(c)(11), then, notwithstanding any election made by the deceased Owner
pursuant to the preceding sentence, the non-spouse designated beneficiary may
elect to have distributions made under this paragraph (a)(1) if the transfer is
made no later than the end of the year following the year of death.
	 
	 	(2)	 	If the Owner’s sole designated beneficiary is the Owner’s surviving
spouse, the entire interest will be distributed, starting by the end of the
calendar year following the calendar year of the Owner’s death (or by the end of
the calendar year in which the Owner would have attained age 701/2, if later) over
such spouse’s life, or over the remaining life expectancy of the surviving
spouse, or, if elected, in accordance with paragraph (a)(3) below. If the
surviving spouse dies before required distributions commence to him or her, the
remaining interest will be distributed, starting by the end of the calendar year
following the calendar year of the spouse’s death, over the spouse’s designated
beneficiary’s remaining life expectancy determined using such beneficiary’s age
as of his or her birthday in the year following the death of the surviving spouse
or, if elected, will be distributed in accordance with paragraph (a)(3) below. If
the surviving spouse dies after required distributions commence to him or her,
any remaining interest will continue to be distributed under the Annuity Option
chosen.
	 
	 	(3)	 	If there is no designated beneficiary or, if applicable, by
operation of paragraph (a)(1) or (a)(2) above, the entire interest shall be
distributed by the end of the calendar year containing the fifth anniversary of
the Owner’s death (or of the spouse’s death in the case of the surviving spouse’s
death before distributions are required to begin under paragraph (a)(2) above).
	 
	 	(4)	 	Life expectancy is determined by using the Single Life Table in
Q&A-1 of Section 1.401(a)(9)-9 of the Income Tax Regulations. If distributions
are being made to a surviving spouse as the sole designated beneficiary, such
spouse’s remaining life expectancy for a year is the number in the Single Life
Table corresponding to such spouse’s age in the year. In all other cases,
remaining life expectancy for a year is the number in the Single Life Table
corresponding to the beneficiary’s age in the year specified in paragraphs (a)(1)
or (2) above and reduced by 1 for such subsequent year.
	 
	 	 	 	If benefits under the Contract are payable in accordance with an Annuity Option
provided under the Contract, life expectancy shall not be recalculated.

	 	(b)	 	Unless otherwise provided under applicable federal tax law, the
“interest” in the Contract includes the amount of any outstanding rollover,
transfer, and recharacterization under Q&As-7 and —8 of Section 1.408-8 of the
Income Tax Regulations. Also, prior to the date that annuity payments commence on
an irrevocable bases (except for acceleration), the “interest” in the Contract
includes the actuarial value of any other benefits provided under the Roth IRA, such
as guaranteed death benefits.

ICC11-ENDROTH.11

3

 

	 	(c)	 	For purposes of paragraphs (a)(2) above, required distributions are
considered to commence on the date distributions are required to begin to the
surviving spouse under such paragraph. However, if distributions start prior to the
applicable date in the preceding sentence, on an irrevocable basis (except for
acceleration) under an annuity contract meeting the requirements of Section
1.401(a)(9)-6 of the Income Tax Regulations, then required distributions are
considered to commence on the annuity starting date.
	 
	 	(d)	 	Except as otherwise provided in paragraphs (h) and (i), and
notwithstanding any other paragraph of this Section 6, if the Owner dies and the
sole designated beneficiary is the Owner’s surviving spouse, the spouse may elect to
treat the Contract as his or her Roth IRA. This election will be deemed to have
been made if such surviving spouse makes a rollover from the Contract or fails to
take required distributions as a beneficiary.
	 
	 	(e)	 	Except as provided in paragraphs (d), (h), and (i), an irrevocable
election of the method of distribution by a designated beneficiary who is the
surviving spouse must be made no later than the earlier of the date distributions
are required to begin pursuant to paragraph (a) or December 31 of the calendar year
containing the fifth anniversary of the Owner’s death. If no election is made, the
entire interest will be distributed by December 31 of the calendar year containing
the fifth anniversary of the Owner’s death.
	 
	 	(f)	 	Except as provided in paragraphs (h) and (i), an irrevocable election of
the method of distribution by a designated beneficiary who is not the surviving
spouse must be made no later than the end of the calendar year immediately following
the calendar year in which the Owner died. If no election is made, the entire
interest will be distributed by December 31 of the calendar year containing the
fifth anniversary of the Owner’s death.
	 
	 	(g)	 	If the Contract contains a section entitled “Death Benefit Before Annuity
Commencement Date”, (1) the provision entitled “Death of Annuitant” under such
section is deleted; and (2) in the “Death of Owner” provision, the distribution
requirements of provisions “(a)”, “(d)”, and “(e)” are deleted. If, after the
Owner’s death, the designated beneficiary dies, no additional Death Benefit is
payable.
	 
	 	(h)	 	Notwithstanding the preceding paragraphs of this Section 6, if the terms
of the Contract so provide, the Owner may elect the method by which distributions
are to be made after his or her death, provided that any such distributions must
satisfy the applicable requirements of IRC Sections 401(a)(9) and 408(b)(3), as
modified by IRC Section 408A(c)(5), and the regulations thereunder. The method of
distribution elected by the Owner shall be binding on the designated beneficiary or
beneficiaries (including a spouse designated beneficiary).
	 
	 	(i)	 	Notwithstanding the preceding paragraphs of this Section 6, if the
Contract is an immediate annuity contract and the Owner dies prior to the First
Payment Date, that date may not be changed, and any remaining interest will be
distributed under the Annuity Option chosen, as amended, if necessary, to meet the
requirements of IRC Sections 401(a)(9) and 408(b)(3).

Annuity Options

	 	7.	 	All Annuity Options under the Contract must meet the requirements applicable to Roth
IRAs under the IRC and applicable federal income tax regulations. The provisions of this
Endorsement reflecting the requirements of these IRC Sections override any Annuity Option
that is inconsistent with such requirements.

IRC Section 72(s)

	 	8.	 	All references in the Contract to IRC Section 72(s) are deleted.

ICC11-ENDROTH.11

4

 

Annual Reports

	 	9.	 	We will furnish annual calendar year reports concerning the status of the Contract and
such information concerned required minimum distribution as is prescribed by the
Commissioner of Internal Revenue.

Amendment of this Endorsement

	 	10.	 	We reserve the right to make any amendments to this Endorsement as may be necessary
to comply with the applicable provisions of the IRC and regulations thereunder as in
effect from time to time. Any such amendment will be subject to any necessary regulatory
approvals and, where required, approval of the Owner. We will send you a copy of the
amended Endorsement. We will not be responsible for any adverse tax consequences
resulting from the Owner’s rejection of any such amendment.

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.)

[]

Secretary

ICC11-ENDROTH.11

5

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