2) One copy of Form DR-23 is completed by each individual. 3) All signatures on the form match the signatures on the original request. 4) All information is accurate. If any information on the forms that you provide is incorrect or incomplete, it will be considered an abuse of the system. You agree to submit to a background check, including a fingerprinting, on your request for a dividend or similar distribution to be withheld. This background check is to confirm that information on Forms DR-23 and DR-24 have been received, verified, and approved by the Department of the Treasury. A background check is not to be employed to harass, harass, or intimidate you. The Department of the Treasury will send you a notice in writing if your request is approved. You must have the approval of the Department of the Treasury before the Form DR-23 or Form DR-24 is filed on your file. This notice is provided for your information only. If you have additional questions or concerns, please contact your nearest Customs and Border Protection office. We appreciate your cooperation in assisting us in fulfilling our duty to safeguard the currency and other property, including your requests to withdraw your funds to protect citizens and residents abroad from international terrorism. If you have any further questions, please contact your local office of the Customs and Border Protection Office of Field Operations at or Customs and Border Protection is required to retain your information until the date that your form is processed. The Government of the United States retains a royalty fee for each Form DR-23 sent to the Department of the Treasury as proof of receipt of each Form DR-24. It is important to note that while the information on file with the Department of the Treasury may be used for criminal law purposes, the Department of the Treasury is unable to identify terrorists, terrorists organizations, or any other entities involved in financial crimes. Therefore, it is important to note that the information on file is for law enforcement purposes only, and the Department of the Treasury does not keep a record of terrorist activity, or otherwise collect information that may be used to identify criminals. Please consult your local office of the Customs and Border Protection Office of Field Operations for assistance if you have further questions regarding the Form DR-23 process and this request.
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Instructions on completing Request for Dividend Withdrawal Mail your request to: For Individual Life Products, Customer Service Center R-02 John Hancock 1 John Hancock Way Suite 1350 Boston MA 02217-1099
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