Fillable EMPLOYEE TERMINATION/RETIREMENT WITHDRAWAL REQUEST EDUCATION, HEALTHCARE AND GOVERNMENTAL (Town of Brookline)

Fill Online, Printable, Fillable, Blank EMPLOYEE TERMINATION/RETIREMENT WITHDRAWAL REQUEST EDUCATION, HEALTHCARE AND GOVERNMENTAL (Town of Brookline) Form

Use Fill to complete blank online TOWN OF BROOKLINE (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

EMPLOYEE TERMINATION/RETIREMENT WITHDRAWAL REQUEST EDUCATION, HEALTHCARE AND GOVERNMENTAL (Town of Brookline)

On average this form takes 27 minutes to complete

The EMPLOYEE TERMINATION/RETIREMENT WITHDRAWAL REQUEST EDUCATION, HEALTHCARE AND GOVERNMENTAL (Town of Brookline) form is 9 pages long and contains:

  • 0 signatures
  • 27 check-boxes
  • 95 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Brookline

BROWSE TOWN OF BROOKLINE (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Instructions Order #143858 Form #83501 06/10/2011
TM: DISTRIB
KEEP FOR YOUR RECORDS
EMPLOYEE TERMINATION/RETIREMENT WITHDRAWAL REQUEST
EDUCATION, HEALTHCARE AND GOVERNMENTAL MARKETS
ING Life Insurance and Annuity Company (“ILIAC”)
A member of the ING family of companies
PO Box 990063, Hartford, CT 06199-0063
Phone: 800-262-3862 Fax: 800-643-8143
GOOD ORDER
Good order is receipt at our designated location of this form accurately and entirely completed, including all necessary signatures. If
this form is not received in good order, as we determine, it may be returned to you for correction and processed upon resubmission
in good order at our designated location.
INSTRUCTIONS (If you have questions about how to complete the request or to determine if exception handling applies, contact
us at 800-262-3862. The completed request and the State Income Tax Withholding Notification and Spousal Consent, if applicable,
must be mailed to the address above or faxed to ING at 800-643-8143.)
If you choose to fax a request, please DO NOT mail the original to us.
Spousal Consent Required
Account Holder Signature Required
Sponsor Signature Required
Non-ERISA 403(b) NO YES YES - if required by Employer
Non-ERISA 401 NO YES YES
Governmental 457(b) NO YES YES
ERISA 403(b) YES - Rollover or Cash
NO - Transfer/Exchange
YES YES
ERISA 401 YES YES YES
Your future. Made easier.
®
As used on this form, the term “ING,” “Company,” “we,” “us” or “our” refers to your plan’s funding agent and/or
services provider. That entity is ING Life Insurance and Annuity Company. Contact us for more information.
This request may be used to withdraw assets associated with terminating or retiring employees participating in 401, 403 or
Governmental 457(b) Plans. This form cannot be used by Account Holders in corporate non-qualified deferred compensation
plans, 415(m) Plans or 457(f) Plans. This form cannot be used by non-qualified deferred compensation Plans of tax
exempt (non-governmental 457(b) plan) Employers.
It is important that you understand the tax implications and rollover options of a distribution from your account, tax
information may be found in the Special Tax Notice and for ERISA plans Your Right to Defer Distribution. The tax notices
are available at: www.ingretirementplans.com/taxnotice OR to receive a free paper copy, please call us at (800) 262-3862.
You may wish to consult with the Plan administrator or payer, or a professional tax advisor, before taking a payment from the Plan.
The withdrawal effective date will be the date our designated location has received the request and any other required documentation
or forms in good order.
For purposes of calculating the amount to be withdrawn, the value of the individual account will be determined after the final close of
business of the New York Stock Exchange (NYSE) on the date good order is determined. A valuation date is any normal business day,
Monday through Friday, that the NYSE is open.
Payment is generally made 7 calendar days after receipt of the withdrawal request in good order.
All withdrawals may be subject to one or more of the following: ING contractual fees, deferred sales charges or market value adjustments.
There may be withdrawal restrictions on certain funds (please refer to your prospectus)
.
Certain full withdrawal requests will automatically
create the Fixed Plus payout process and the balance in the Fixed Plus account will be paid out over the next four years.
For partial withdrawals where a specific dollar amount of withdrawal has been requested, all charges and adjustments will be
deducted from the remaining balance of the account and the check will be for the amount requested, less any applicable withholding
for federal or state income taxes. For any other full or partial withdrawal, all charges and adjustments will be deducted from the
withdrawal amount requested on this form.
Amounts will be withdrawn from each investment option in the same proportion as its value is to the total value.
TERMS AND CONDITIONS
Page 1 of 5 - Incomplete without all pages. Order #143858 Form #83501 06/10/2011
TM: DISTRIB
KEEP A COPY FOR YOUR RECORDS
EMPLOYEE TERMINATION/RETIREMENT WITHDRAWAL REQUEST
EDUCATION, HEALTHCARE AND GOVERNMENTAL MARKETS
ING Life Insurance and Annuity Company (“ILIAC”)
A member of the ING family of companies
PO Box 990063, Hartford, CT 06199-0063
Phone: 800-262-3862 Fax: 800-643-8143
3. TAX RESIDENCY INFORMATION (Required)
U.S. Citizen
U.S. Resident Alien
Non-Resident Alien. Non-resident aliens must indicate your non-U.S. country of tax residency .
If you do not have a U.S. Social Security Number, you must apply for and receive an Individual Taxpayer Identifi cation Number
from the Internal Revenue Service (IRS) or a U.S. Embassy by using IRS Form W-7 (Application for IRS Individual Taxpayer
Identifi cation Number) which is available on the IRS web site: www.irs.gov or by contacting the IRS at 800-829-1040. Since
you are not a U.S. person, your withdrawal is subject to 30% withholding provisions for non-resident aliens unless tax treaty
provisions can be applied. If you want to invoke a tax treaty, you must complete, sign and date, and return to us the IRS Original
Form W-8BEN, “Certifi cate of Foreign Status of Benefi cial Owner for United States Tax Withholding”.
Check one of the three boxes:
Your future. Made easier.
®
1. PLAN INFORMATION
(Please print.)
Plan Name
Billing Group/Plan Number
Age on Date of Termination/Retirement Under Age 55 Age 55 to 59½ Over Age 59½
2. ACCOUNT HOLDER INFORMATION
City State ZIP
E-mail Address
Work Phone (Include extension.) Home Phone
Name (last, first, middle initial)
Date of Birth (mm/dd/yyyy) SSN (Required)
Resident Street Address or PO Box
RESET FORM
Page 2 of 5 - Incomplete without all pages. Order #143858 Form #83501 06/10/2011
TM: DISTRIB
KEEP A COPY FOR YOUR RECORDS
4. TYPE OF WITHDRAWAL (Check all that apply.)
Letter of Acceptance is required unless (1) distribution is payable to Account Holder, (2) request is signed by
Employer, OR (3) by special contract between the Company and the Employer.
INTERNAL ING PLAN TO ING PLAN TRANSFER/EXCHANGE/ROLLOVER form should be completed for transfers within
ING.
Cash Distribution
Direct Rollover (other than a Designated Roth Account) to a 401(a), 401(k), 403(b), 457(b) governmental plan or a traditional IRA
Direct Rollover (other than a Designated Roth Account) to a Roth IRA (Only applicable to 401(k), 401(a), 403(b) and 457(b)
governmental plans.)
Rollover of a Designated Roth Account to: (Only applicable for Roth 401(k), 403(b) and governmental 457(b) plans.)
Direct to a Designated Roth Account
ING Roth IRA
Non-ING Roth IRA
Service Buy Back Withdrawal and Transfer to Governmental Defi ned Benefi t Plan
Transfer – 401 or 457 only
403 to 403 Exchange to another investment alternative offered under my Employer’s 403(b) Plan
403 to 403 Transfer to another Employer’s 403(b) Plan
Direct Rollover to an ING Account:
If choosing a direct rollover to an ING account, please select destination account(s) below:
ING Choice/SAS/Wealth Management ING express Variable Annuity ING Select Advantage
ING express Fixed Annuity ING IRA/Brokerage Account ING Select Rate
ING express Mutual Fund ING Renuity
Other
Account #
NOTE: For rollovers to an ING account the withdrawal request will not be processed until the new account application is received
and in good order.
I wish to continue making repayments to my loan by maintaining the minimum cash value in my account to keep the loan active.
I no longer will be making repayments to my loan. I understand that if I elect this option my outstanding loan balance will be
considered in default.
If a portion of the account is surrendered and no election is made, it is our understanding that you deemed to have elected the fi rst
option above.
If applicable and 100% of the account is requested, it is our understanding that you deemed to have elected the second option above.
7. OUTSTANDING LOAN INFORMATION (Complete this section only if you have an outstanding loan.)
• In the case of a rollover or transfer, if no amount is indicated, we will process 100% and close the account.
•
If the amount available for withdrawal is less than the dollar amount you are requesting, the transaction will be processed
for the maximum amount available.
5. WITHDRAWAL AMOUNT (If no instructions are indicated, we will withdraw 100% and close your account.)
Withdraw 100% of my account
Do not close my account
Withdraw a portion of my account
Transfer remaining balance to Plan Forfeiture Account
Rollover
($ or %)
Voluntary
($ or %)
Deferred Compensation
($ or %)
Other ______________
($ or %)
Employee Pre-Tax
($ or %)
Employer
($ or %)
Account Type (example: voluntary (VL), mandatory (MN))
After Tax Contributions $
6. COST BASIS
(Non-Roth after tax contributions: For rollovers, unless otherwise indicated, cost basis funds will be rolled over.)
Page 3 of 5 - Incomplete without all pages. Order #143858 Form #83501 06/10/2011
TM: DISTRIB
KEEP A COPY FOR YOUR RECORDS
9. SPECIAL INSTRUCTIONS
(Please indicate special instructions or circumstances unique to your individual request below.)
8. TAX WITHHOLDING
Please indicate whether or not federal/state income taxes should be withheld from payments. Regardless of whether or not you elect to
have federal/state income taxes withheld, you are liable for those taxes on the taxable portion of the benefits. You may also be subject
to tax penalties under the Estimated Tax Payment rules. You are advised to seek the advice of a qualified tax advisor prior to making this
election. If subject to eligible rollover distribution, mandatory 20% withholding will be applied.
Federal Withholding
I want federal income tax of 10% withheld from this payment. (Applicable to non-eligible rollover distribution requests such as
Hardship, Required Minimum Distribution (RMD), IRA or non-qualifi ed annuity distributions.)
I do not want federal income tax withheld from this payment. (You may opt out only if 10% withholding applies. NOT an option
if 20% mandatory withholding applies.)
I have read the withholding notice and elect to have additional income tax withheld of $ .
DEFAULT: If no election is made, standard federal income tax withholding will occur applicable to your type of
distribution.
State Withholding
State income tax withholding may be withheld from your distribution. Certain states base your withholding election on your federal
withholding election. (See attached State Income Tax Withholding Notifi cation.) In the event you live in one of those states, your
distribution will be subject to state income tax withholding.
My residence state for tax purposes is: ___________________________
If these payments are exempt from mandatory state income tax withholding:
I want state income tax withheld from this payment in the amount of $ or %.
I do not want state income tax withheld from this payment. (Please complete the attached State Income Tax Withholding
Notifi cation form, if applicable.)
DEFAULT: If no election is made, state income tax withholding will occur, if applicable.
NOTE: If your residence state for tax purposes is Virginia, you must submit a Form VA-4P to opt out of state withholding. Otherwise,
state tax will be withheld. Requesting North Carolina withholding over mandatory amounts requires a Form NC-4P. If you are a
resident of California, Oregon or Vermont, and you are electing not to have state income tax withheld, your signature is mandatory.
10. PAYMENT AND MAILING INFORMATION (Please allow for standard USPS mailing.)
Mail to Account Holder to address indicated in section 2
Mail to Employer (Check will be made payable to the Account Holder.)
Mail to new Financial Carrier at the address listed below (Check will be made for the benefi t of Account Holder.)
Send check to
New Account #
Address (# & street/PO box)
City
State ZIP
Please mail a separate check to my Roth account. (If this box is not checked, one check will be mailed for all applicable amounts.)
If no selection is made, check will be made payable to and mailed to the Account Holder.
Additional Instructions
Check is to be made payable to
(Custodian of the IRA or Investment Provider of the Plan to receive the benefi t)
Page 4 of 5 - Incomplete without all pages. Order #143858 Form #83501 06/10/2011
TM: DISTRIB
KEEP A COPY FOR YOUR RECORDS
13. TAXPAYER CERTIFICATION
Under penalties of perjury, I certify that:
1. The number on this form is my correct taxpayer identifi cation number; and
2. I am not subject to backup withholding because (a) I am exempt from backup withholding or (b) I have not been notifi ed by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or
(c) the IRS has notifi ed me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (including U.S. resident alien).
I am a non-resident alien and the Taxpayer Certifi cation language included in this form does not apply to me.
14. ACCOUNT HOLDER AUTHORIZED SIGNATURE AND TAX WITHHOLDING CERTIFICATION
Under penalties of perjury, I declare that I have examined the tax withholding for state and federal purposes and to the best of my
knowledge and belief it is true, correct and complete, including state and federal opt out elections, as applicable.
I, the Account Holder, certify that I have read the Terms and Conditions section appearing on the cover page of the request and agree to
its provisions. I also agree with any information that has been pre-fi lled.
I, the Account Holder, certify that I have terminated employment or retired.
I, the Account Holder, certify that there is no pending Qualifi ed Domestic Relations Order (QDRO/DRO), a court judgement, decree or
order relating to the provision of child support, alimony, or marital property rights to a spouse, former spouse, child or other dependant
with respect to the requested withdrawal amount.
I, the Account Holder, certify that the information provided on the Spousal Consent (if applicable) is accurate. I further certify that
if I have indicated that I am legally separated or abandoned on the attached Spousal Consent, I have the necessary court order. I
understand that if I receive a payment as a complete or partial withdrawal of my account (other than a joint and survivor annuity),
the value of benefi ts payable to my spouse either under a Qualifi ed Pre-retirement Survivor Annuity (QPSA) or a Qualifi ed Joint and
Survivor Annuity (QJSA) will be reduced or eliminated. I understand that once payment representing complete or partial withdrawal of
my account has been made, my election to waive QPSA and QJSA is irrevocable with respect to the value of amounts paid pursuant
to my withdrawal request.
I understand that the Company reserves the right to directly or through a third party recover any payments made in excess of
amounts to which I am entitled under the terms of the contract regardless of the method of payment.
11. ELECTRONIC FUND TRANSFER (Choosing this option will result in more timely access to your funds.)
If you decide to have a withdrawal deposited directly into your bank account you need to complete the information below, and by doing
so you authorize ING to initiate an electronic funds transfer (EFT). The electronic deposit is immediately available for use once the transfer
is completed. The Company does not charge you for this service; the payment is typically completed within 3-4 business days.
Please verify the correct ABA routing number with your bank. If the electronic deposit cannot be completed using the information
provided below, we will issue and mail a check to the Account Holder.
The EFT information must be clear and complete. If we are unable to read the instructions, in order to expedite the request,
the payment will be made by check.
• EFT will not deposit to a third party account.
• EFT cannot be made outside of the U.S.
Account Type Checking or Savings Account
ABA Routing # (9 digits, verify with your bank)
Bank Account #
12. IF ING HAS QUESTIONS REGARDING THIS WITHDRAWAL REQUEST
(ING will not contact anyone not affiliated
with this ING Plan.)
Please Contact:
Name Phone
E-mail Address
Page 5 of 5 - Incomplete without all pages. Order #143858 Form #83501 06/10/2011
TM: DISTRIB
KEEP A COPY FOR YOUR RECORDS
This section must be completed if required by the Employer.
I am employed as a Third Party Administrator of the Plan identified above and certify the following:
• I have read and agree to the terms of the requested withdrawal;
• I have verified the Account Holder’s eligibility for such withdrawal and have not relied solely on information provided by the
Account Holders in this form in order to make this determination;
• The requested benefits are permitted in accordance with the terms of the Plan document; and
• The information provided in this document is complete and accurate to the best of my knowledge. If any information provided by
the Account Holder to the Company is in conflict with the information provided by me to the Company, I acknowledge that the
Company will rely conclusively on the information provided by me.
16. THIRD PARTY ADMINISTRATOR AUTHORIZED SIGNATURE AND CERTIFICATION
Authorized Signer Name (Please print.)
Name of TPA Firm
Date (mm/dd/yyyy) Signature
15. THIRD PARTY ADMINISTRATOR (TPA) FEE (To be completed by TPA if applicable. Check will be made payable and
mailed to the TPA.)
From Account Holder Account Account Type (example: deferral, match, etc.)
From Forfeiture Account Account Type (example: deferral, match, etc.)
TPA Fee Amount $
The Third Party Administrator for the Plan identified above has recorded this withdrawal in their records for this plan.
This section must be completed by the Employer or its designee if required by a contract between the Company and the Employer.
I am an Employer, Plan Sponsor, or Named Fiduciary of the Plan identified above and certify the following:
• I have read and agree to the terms of the requested withdrawal;
• I have verified the Account Holder’s eligibility for such withdrawal and have not relied solely on information provided by the
Account Holder in this form in order to make this determination;
• The requested benefits are permitted in accordance with the terms of the Plan document;
• The information provided in this document is complete and accurate to the best of my knowledge. If any information provided by
the Account Holder to the Company is in conflict with the information provided by me to the Company, I acknowledge that the
Company will rely conclusively on the information provided by me; and
• I have amended my Plan document to reflect all applicable federal tax legislation and IRS guidance, including the Pension Protection
Act of 2006, in accordance with the IRS’s remedial amendment period.
Authorized Signer Name (Please print.)
17. EMPLOYER, PLAN SPONSOR OR NAMED FIDUCIARY AUTHORIZED SIGNATURE AND CERTIFICATION
Signature Date (mm/dd/yyyy)
14. ACCOUNT HOLDER AUTHORIZED SIGNATURE AND TAX WITHHOLDING CERTIFICATION (Continued)
Date (mm/dd/yyyy) Account Holder Signature
Account Holder SSN (Required)
Those signing the form may rely conclusively on all information, including this certification, in processing this Withdrawal Request. In the
case of any conflicting information, the Company is entitled to rely exclusively on the information contained in this Withdrawal Request.
I certify that I have read and understand the Notice of your Right to Defer Distribution and the Special Tax Notice Regarding Important Tax
Information and, if applicable, waive the 30 day notice requirement.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifi cations
requir
ed to avoid backup withholding.
Your form will NOT be processed
without Account Holder SSN completed.
Order #153666 Sponsor 03/25/2011
Page 1 of 2
SPOUSAL CONSENT TO WITHDRAWAL
QUALIFIED JOINT AND SURVIVOR ANNUITY (QJSA)
ING Life Insurance and Annuity Company (“ILIAC”)
ING Institutional Plan Services, LLC (“IIPS”)
Members of the ING family of companies
PO Box 990063
Hartford, CT 06199-0063
1. GENERAL INFORMATION
Plan Name Billing Group/Plan #
Account Holder Name SSN (Required)
Spouse Name SSN Date of Withdrawal (mm/dd/yyyy)
2. ACCOUNT HOLDER CERTIFICATION
I have requested a withdrawal of my account under the Group Annuity Contract as specified in this request. Unless one of the
following conditions apply, I waive completely or consent to the reduction of benefits otherwise payable in the request of a Qualified
Pre-retirement Survivor Annuity (QPSA) and Qualified Joint and Survivor Annuity (QJSA).
Required to be completed regardless of marital status.
Marital Status (Check one.)
F
I am not married.
F
I am married. (Your spouse must consent to this request by completing the Spousal Consent section below.)
F
My spouse cannot be located or I am legally separated or abandoned within the meaning of local law. (Spousal consent is not
required unless a pending domestic relations order provides otherwise.)
I acknowledge that I have read and understand this form and certify that the above information is completed correctly to the best of
my knowledge. Under penalties of perjury, I certify that the SSN provided above is my correct taxpayer identifi cation number.
Account Holder Signature Date (mm/dd/yyyy)
3. SPOUSAL CONSENT
I have read the attached written explanation of survivor annuity payment options and hereby consent to the request of amounts to
my Spouse under the Plan and in so doing, consent to my Spouse’s election to waive the QPSA or QJSA. I understand if my Spouse
receives the amount of his or her account balance under the Plan, the value of benefi ts payable to me under a QPSA or a QJSA will
be reduced.
Spouse Signature Date (mm/dd/yyyy)
The above consent was signed or acknowledged in my presence.
Plan Representative/Notary Public Signature
Spousal consent must be witnessed by the Plan Representative or a Notary Public. If your spouse is unable to sign this form or
acknowledge consent in the presence of the Plan Representative, it must be signed or acknowledged in the presence of a Notary
Public. If signed or acknowledged in the presence of a Notary Public, the signature and seal of the Notary Public must appear in
SECTION 4 above.
IMPORTANT NOTE
4. PLAN REPRESENTATIVE OR NOTARY PUBLIC CERTIFICATION
This form must be completed in its entirety.
Plan Representative/Notary Public Name (Please print.)
State County Date (mm/dd/yyyy)
Spouse Name (Please print.)
Your future. Made easier.
®
As used on this form, the term “ING,” “Company,” “we,” “us” or “our” refer to ILIAC or IIPS as your plan’s funding agent
and/or administrative services provider. Contact us for more information.
Order #153666 Sponsor 03/25/2011
Page 2 of 2
UNDERSTANDING SURVIVOR ANNUITY PAYMENT OPTIONS
Under the Internal Revenue Code, some plans are required to make payments under one of the survivor annuity options described
here, unless you waive this right and your Spouse consents to your waiver. Even if your Plan is not subject to this provision of the law,
your Employer may have voluntarily chosen to administer their Plan as if it were.
The following information is provided to better help you understand the survivor annuity payment options available to you and your
Spouse. This only summarizes certain rules that might apply to the payment option you select. Since the Internal Revenue Code
is complex and contains many conditions and exceptions not included here, you may wish to consult a professional tax advisor or
fi nancial advisor before selecting a payment option.
QUALIFIED JOINT AND SURVIVOR ANNUITY (QJSA)
The Retirement Equity Act of 1984 (REA) requires that qualifi ed retirement Plans distribute benefi ts to married Plan Account Holders
in the form of a Qualifi ed Joint and Survivor Annuity (QJSA), unless the Account Holder elects to waive this form of benefi t and the
Account Holder’s Spouse consents in writing to that election. QJSA provides an annuity for the lives of you and your Spouse. At your
death, at least 50% of the payment will continue to your Spouse under this option. Your election to waive QJSA will have different
effects depending upon the alternative form of payment you elect. One effect may be that no benefi t will be payable to your Spouse
should your Spouse survive you.
You have a right to waive the QJSA at any time provided that (1) you make the election within the 180-day period before the date
on which your benefi ts are to begin, and (2) your Spouse consents to your election. Your Spouse’s consent must be in writing and
must be witnessed by a notary public or Plan Sponsor representative. You may revoke your waiver of QJSA at any time before your
benefi ts begin. Spousal consent of this revocation is not necessary. If you revoke your election, your benefi ts under the Plan will be
paid in the form of a QJSA.
QUALIFIED PRE-RETIREMENT SURVIVOR ANNUITY (QPSA)
If you are married and your death occurs before you retire, the law requires that any amount remaining in your account be paid to
your surviving Spouse in the form of a “Qualifi ed Pre-Retirement Survivor Annuity.” A QPSA will provide your Spouse with a series
of periodic payments over his or her life. The size of the periodic payments will depend on the amount remaining in your account
and the Plan provisions. You may elect to waive the requirement that your surviving Spouse be paid in the form of a QPSA, and if
applicable, the requirement that your Spouse be your benefi ciary. You may make either or both of these elections beginning with the
fi rst day after which you become a Account Holder in the Plan.
Any waiver election you sign before age 35 will become invalid the fi rst day of the plan year in which you attain age 35. At that time
you may again waive QPSA and the requirement that your Spouse be your benefi ciary. Your Spouse must consent in writing to either
waiver. You have the right to revoke any waiver that you have made at any time.
Your Spouse may need to consent to any subsequent change of benefi ciary. Please ask your Plan Administrator or Employer for more
information regarding changing benefi ciaries.
If your vested account balance is $5,000 or less at the time of your death, the Plan Administrator may make a distribution to your
surviving Spouse in a single payment even if you had not waived QPSA prior to your death.
Because a Spouse has certain rights under the law, you should inform your Plan Administrator or Employer immediately of any
changes in your marital status. A change in your marital status may require you to designate a new benefi ciary. For more information
regarding QJSA or QPSA, contact your Plan Administrator or Employer.
STATE INCOME TAX WITHHOLDING NOTIFICATION
401, 403(b), 408 and Governmental 457 Plan Distribution
NOTIFICATION
If you are a resident of Arkansas, California, Delaware, Iowa, Kansas, Maine, Maryland
1
, Massachusetts, Nebraska
1
, North Carolina
2
,
Oklahoma, Oregon, Vermont, or Virginia
1
, your state requires state income tax withholding on the taxable portion of your distribution
from your 401, 403(b), 408 Individual Retirement or Governmental 457 Plan. This state income tax withholding is in addition to the
mandatory 20% (or, in some cases, elected 10%) federal income tax withholding. Please note, when a state cost basis differs from
federal, the federal cost basis will be used in determining taxability for state income tax withholding purposes.
• If you are a resident of California, Oregon or Vermont, state income tax withholding will be calculated unless you complete
the bottom portion of this form indicating your election “out” of state income tax withholding, and return it to us with, and to
the same designated location as, your Withdrawal Request.
• If you are a resident of Arkansas, Delaware, Iowa, Kansas, Maine, Maryland
1
, Massachusetts, Nebraska
1
, North Carolina
2
or Oklahoma, state income tax withholding will be automatically calculated as these states do not allow an election “out”
of state income tax withholding when federal income tax withholding applies. Requesting North Carolina withholding over
mandatory amounts requires their Form NC-4P, Withholding Certifi cate for Pension or Annuity Payments.
• If you are a resident of Virginia
1
, state income tax withholding will be calculated automatically unless you meet certain income
criteria and claim an exemption from withholding. To claim an exemption for Virginia, complete Form VA-4P (obtained from
the Virginia Department of Taxation), and return the appropriate form to us with, and to the same designated location as, your
Withdrawal Request.
1
Maryland, Nebraska and Virginia state income tax are not applicable to 408 Plans.
2
North Carolina does not apply to distributions from NC state and local government or federal retirement systems for those vested as of 8/12/89.
PAYEE/ACCOUNT HOLDER ELECTION (Do not submit this form if you want state income tax to be withheld.)
I elect to have no state income tax withheld from this distribution and I am a resident of (check one):
F California F Oregon F Vermont
Date (mm/dd/yyyy) Payee/Account Holder Signature
Order #143703 Form #83006 10/01/2010
TM: MYOUTBCKUP
KEEP A COPY FOR YOUR RECORDS
Your future. Made easier.
®
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

EMPLOYEE TERMINATIONRETIREMENT WITHDRAWAL REQUEST EDUCATION, HEALTHCARE AND GOVERNMENTAL (Town of Brookline)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document