Fillable Mid America Disbursement Request Form APPLE (Pasadena City College)

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Mid America Disbursement Request Form APPLE (Pasadena City College)

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APPLE_Monthly_RSA_Form_2013.0515 Page 1 of 2
Accumulation Program for Part-Time and Limited-service Employees
PARTICIPANT INSTRUCTIONS
For Completing a ‘Request for Settlement of Account Form’ to
Request a Distribution from the APPLE PLAN
A participant in the APPLE Plan must meet one of the following conditions to qualify for a distribution:
1. Termination of employment
2. Retirement
3. Permanent Disability
4. Death
5. Change in employment status
Distributions from the APPLE Plan will be processed monthly, according to the following processing dates:
Deadline for MidAmerica to receive the RSAs
Must be terminated or had a status change by:
Checks will be issued between:
1/31
12/15
3/15-3/31
2/28
1/15
4/15-4/30
3/31
2/15
5/15-5/31
4/30
3/15
6/15-6/30
5/31
4/15
7/15-7/31
6/30
5/15
8/15-8/31
7/31
6/15
9/15-9/30
8/31
7/15
10/15-10/31
9/30
8/15
11/15-11/30
10/31
9/15
12/15-12/31
11/30
10/15
1/15-1/31
12/31
11/15
2/15-2/28
To withdraw funds from the APPLE Plan, please follow each of the steps below:
A. Fill in your Name, your Current Address, your Daytime and Evening Phone Numbers, your Social Security Number, and your Date of
Birth. If the name on the form is different from the name we have in our records, please provide proof of your name change (i.e. copy of
Social Security Card) so that we may update our records and process your request. NOTE: If you will not be remaining at the listed
address, a permanent address (e.g. relative’s address or P.O. Box) should be used to avoid lost checks and tax forms or other processing
delays.
B. Check the payment option you wish to elect under the section titled ACCOUNT SETTLEMENT ELECTION. NOTE: If you are
transferring to PERS or STRS and you have Money Purchase Plan funds (MPP), your MPP funds are not available for this type of
distribution. IRS rules require that Money Purchase Plan (MPP) funds will not be available for distribution until you have terminated
working for the District in any capacity or reached age 70 ½. To determine if you have Money Purchase Plan funds (MPP), please call
customer service at 800-634-1178 or visit the APPLE Plan Website, (go to www.keenan.com, Client Login, Apple Plan).
C. To request the purchase of STRS or PERS service credits using your APPLE Account Balance, you must first obtain written approval
directly from STRS or PERS. They will provide you with a letter specifying the approved dollar amount needed to process your purchase.
Please contact your local STRS or PERS office and request a ‘cost information analysis’ before submitting your distribution request
paperwork to MidAmerica. Once you receive your STRS or PERS cost information analysis, indicating the appropriate dollar amount
required to process your purchase, please attach a copy of it to your signed and executed APPLE Plan Request for Settlement of Account
(RSA) Form and then submit both documents to MidAmerica for processing. Your request will be processed according to the approximate
dates indicated in the Distribution Processing Chart above.
D. Sign and date the form at the bottom of the page in the space labeled PARTICIPANT SIGNATURE. Participants should also check the
appropriate reason for settlement and effective date of change.
Mail the completed, signed ‘REQUEST FOR SETTLEMENT OF ACCOUNT FORM’, plus the certified copy of the death certificate and PERS or
STRS cost information analysis letter, if applicable, directly to MidAmerica Administrative Solutions, Attn: APPLE, 402 South Kentucky Ave., Suite
500, Lakeland, FL 33801, or fax to (863) 688-4200.
PLEASE NOTE: You MUST complete the attached W-9 in order for your distribution to be processed.
I. All participants requesting a distribution must complete a ‘REQUEST FOR SETTLEMENT OF ACCOUNT FORM’ (RSA). Please
obtain the RSA Form from APPLE Plan Customer Service by dialing 1-800-634-1178, or simply print the RSA Form yourself directly
from the “APPLE Plan Website” at www.keenan.com.
II. If the distribution is due to the death of the Participant, the Beneficiary must include an actual certified copy of the death certificate
with the complete ‘Request for Settlement of Account Form’ (RSA).
APPLE_Monthly_RSA_Form_2013.0515 Page 2 of 2
Accumulation Program for Part-Time and Limited-service Employees
Request for Settlement of Account Form
Employer (please print or type):
Name of Participant:
Email Address:
Social Security #:
Date of Birth:
Phone #:
DETERMINATION OF ELIGIBILITY
Termination of Employment Retirement Permanent Disability Change in Active Employment Status
ACCOUNT SETTLEMENT ELECTION
1.
Distribute a check made payable to me for the lump sum of the entire account balance (less 20% federal tax withholding
and any applicable state withholding, if taxable distribution is in excess of $200).
2.
Distribute a rollover of (A) my entire benefit, OR (B) $ __________________ (insert dollar amount of at least
$200) of my account balance to the IRA, 457 plan, annuity plan, or qualified plan designated in the Direct Rollover
Information section of this form. Please distribute any remaining portion of my benefit that is not transferred to the
rollover plan, less income tax withholding, directly to me.
* To request a purchase of PERS or STRS service credits with your APPLE Plan Account Balance, you must obtain written approval directly
from PERS or STRS first. Please contact your local PERS or STRS office and request a ‘cost information analysis’ letter. Once you receive your
cost information analysis letter indicating the approved dollar amount needed to process your purchase, attach a copy of the letter to the signed
and properly executed RSA Form and submit both documents to MidAmerica for processing.
3.
Death Distribution of entire account balance (less 10% federal tax withholding if made payable to the Estate of Participant).
I do not want Federal Income Tax withheld. I want to have Federal Income Tax withheld.
Beneficiary Name:
Social Security #:
Relationship to Participant:
Date of Birth:
Current Mailing Address:
Date of Death:
City, State, Zip:
Phone #:
PLEASE NOTE: The Beneficiary MUST include a certified copy of the Death Certificate with the completed distribution request form.
The SSN and address must be provided to avoid tax withholding. (Spouses not rolling over distribution must have 20% withheld.)
DIRECT ROLLOVER INFORMATION
Complete this section only if you checked option 2 of the Account Settlement Election section above. (Check will be made payable to the IRA account, 457 plan,
annuity plan, or qualified plan listed below). I represent that the IRA, 457 plan, annuity plan, or qualified plan designated below is a proper recipient plan for a direct
rollover. Please note that your account is not eligible to be rolled into a Roth IRA. (please print)
Name of IRA, 457 Plan, Annuity Plan, or Qualified Plan Account No.
Make Check Payable To:
Name of Payee (“FBO” - For the Benefit Of)
Address to Send Direct Rollover
City, State Zip Code
ACKNOWLEDGEMENT AND AUTHORIZATION
I hereby request my APPLE Plan distribution be paid to me in accordance with my election above. . I understand that distribution can only be made if I
have terminated employment, retired, become permanently disabled, or changed my employment status to participate in PERS, STRS, or other public
retirement plan. By signing below, I hereby acknowledge that I have received and read the “Special Tax Notice Regarding Plan Payments” provided to me.
I understand that if I choose to roll over my distribution(s) to another Plan or account within 60 days of receipt of my distribution check, I will have to replace the
withheld funds with my own out-of-pocket money or I may be required to pay income taxes on the 20% that was withheld. Additional information is contained on
the Tax Information Notice immediately following this form. Upon receipt of my distribution, I release the Contract Administrator, Consultant, Trustee(s),
Plan Sponsor, and Financial Institutions from and against any and all claims with respect to my interest in the APPLE Plan. I understand that the
distribution will be based on the value of my account as of the last valuation date following my request for distribution.
__________________________
Participant or Beneficiary Signature Date
Return this completed ‘Request for Settlement of Account Form’ plus the certified copy of the death certificate and PERS or STRS cost information
analysis letter, if applicable, directly to:
Mail: MidAmerica Administrative Solutions, Attn: APPLE, 402 South Kentucky Ave., Suite 500, Lakeland, FL 33801 or Fax: 863-688-4200
Plan Type:
(Check one)
IRA
403(b)
457
Other _____
Form W-9
(Rev. December 2011)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
Name (as shown on your income tax return)
Business name/disregarded entity name, if different from above
Check appropriate box for federal tax classification:
Individual/sole proprietor
C Corporation S Corporation Partnership
Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)
▶
Other (see instructions)
▶
Exempt payee
Address (number, street, and apt. or suite no.)
City, state, and ZIP code
Requester’s name and address (optional)
List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line
to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
Social security number
– –
Employer identification number
–
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified 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 notified me that I am
no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign
Here
Signature of
U.S. person
▶
Date
▶
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Purpose of Form
A person who is required to file an information return with the IRS must
obtain your correct taxpayer identification number (TIN) to report, for
example, income paid to you, real estate transactions, mortgage interest
you paid, acquisition or abandonment of secured property, cancellation
of debt, or contributions you made to an IRA.
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the
requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of any partnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners’ share of
effectively connected income.
Note. If a requester gives you a form other than Form W-9 to request
your TIN, you must use the requester’s form if it is substantially similar
to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax on any foreign partners’ share of income from such business.
Further, in certain cases where a Form W-9 has not been received, a
partnership is required to presume that a partner is a foreign person,
and pay the withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the United
States, provide Form W-9 to the partnership to establish your U.S.
status and avoid withholding on your share of partnership income.
Cat. No. 10231X
Form W-9 (Rev. 12-2011)
Form W-9 (Rev. 12-2011)
Page 2
The person who gives Form W-9 to the partnership for purposes of
establishing its U.S. status and avoiding withholding on its allocable
share of net income from the partnership conducting a trade or business
in the United States is in the following cases:
• The U.S. owner of a disregarded entity and not the entity,
• The U.S. grantor or other owner of a grantor trust and not the trust,
and
• The U.S. trust (other than a grantor trust) and not the beneficiaries of
the trust.
Foreign person. If you are a foreign person, do not use Form W-9.
Instead, use the appropriate Form W-8 (see Publication 515,
Withholding of Tax on Nonresident Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a “saving clause.” Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of income, you must attach a statement
to Form W-9 that specifies the following five items:
1. The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption
from tax.
5. Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if his or her stay in
the United States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows
the provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
protocol) and is relying on this exception to claim an exemption from tax
on his or her scholarship or fellowship income would attach to Form
W-9 a statement that includes the information described above to
support that exemption.
If you are a nonresident alien or a foreign entity not subject to backup
withholding, give the requester the appropriate completed Form W-8.
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS a percentage
of such payments. This is called “backup withholding.” Payments that
may be subject to backup withholding include interest, tax-exempt
interest, dividends, broker and barter exchange transactions, rents,
royalties, nonemployee pay, and certain payments from fishing boat
operators. Real estate transactions are not subject to backup
withholding.
You will not be subject to backup withholding on payments you
receive if you give the requester your correct TIN, make the proper
certifications, and report all your taxable interest and dividends on your
tax return.
Payments you receive will be subject to backup
withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the Part II
instructions on page 3 for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4. The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject to
backup withholding under 4 above (for reportable interest and dividend
accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding.
See the instructions below and the separate Instructions for the
Requester of Form W-9.
Also see Special rules for partnerships on page 1.
Updating Your Information
You must provide updated information to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
and anticipate receiving reportable payments in the future from this
person. For example, you may need to provide updated information if
you are a C corporation that elects to be an S corporation, or if you no
longer are tax exempt. In addition, you must furnish a new Form W-9 if
the name or TIN changes for the account, for example, if the grantor of a
grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such failure
unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you
make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a $500 penalty.
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of
federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Name
If you are an individual, you must generally enter the name shown on
your income tax return. However, if you have changed your last name,
for instance, due to marriage without informing the Social Security
Administration of the name change, enter your first name, the last name
shown on your social security card, and your new last name.
If the account is in joint names, list first, and then circle, the name of
the person or entity whose number you entered in Part I of the form.
Sole proprietor. Enter your individual name as shown on your income
tax return on the “Name” line. You may enter your business, trade, or
“doing business as (DBA)” name on the “Business name/disregarded
entity name” line.
Partnership, C Corporation, or S Corporation. Enter the entity's name
on the “Name” line and any business, trade, or “doing business as
(DBA) name” on the “Business name/disregarded entity name” line.
Disregarded entity. Enter the owner's name on the “Name” line. The
name of the entity entered on the “Name” line should never be a
disregarded entity. The name on the “Name” line must be the name
shown on the income tax return on which the income will be reported.
For example, if a foreign LLC that is treated as a disregarded entity for
U.S. federal tax purposes has a domestic owner, the domestic owner's
name is required to be provided on the “Name” line. If the direct owner
of the entity is also a disregarded entity, enter the first owner that is not
disregarded for federal tax purposes. Enter the disregarded entity's
name on the “Business name/disregarded entity name” line. If the owner
of the disregarded entity is a foreign person, you must complete an
appropriate Form W-8.
Note. Check the appropriate box for the federal tax classification of the
person whose name is entered on the “Name” line (Individual/sole
proprietor, Partnership, C Corporation, S Corporation, Trust/estate).
Limited Liability Company (LLC). If the person identified on the
“Name” line is an LLC, check the “Limited liability company” box only
and enter the appropriate code for the tax classification in the space
provided. If you are an LLC that is treated as a partnership for federal
tax purposes, enter “P” for partnership. If you are an LLC that has filed a
Form 8832 or a Form 2553 to be taxed as a corporation, enter “C” for
C corporation or “S” for S corporation. If you are an LLC that is
disregarded as an entity separate from its owner under Regulation
section 301.7701-3 (except for employment and excise tax), do not
check the LLC box unless the owner of the LLC (required to be
identified on the “Name” line) is another LLC that is not disregarded for
federal tax purposes. If the LLC is disregarded as an entity separate
from its owner, enter the appropriate tax classification of the owner
identified on the “Name” line.
Form W-9 (Rev. 12-2011)
Page 3
Other entities. Enter your business name as shown on required federal
tax documents on the “Name” line. This name should match the name
shown on the charter or other legal document creating the entity. You
may enter any business, trade, or DBA name on the “Business name/
disregarded entity name” line.
Exempt Payee
If you are exempt from backup withholding, enter your name as
described above and check the appropriate box for your status, then
check the “Exempt payee” box in the line following the “Business name/
disregarded entity name,” sign and date the form.
Generally, individuals (including sole proprietors) are not exempt from
backup withholding. Corporations are exempt from backup withholding
for certain payments, such as interest and dividends.
Note. If you are exempt from backup withholding, you should still
complete this form to avoid possible erroneous backup withholding.
The following payees are exempt from backup withholding:
1. An organization exempt from tax under section 501(a), any IRA, or a
custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2),
2. The United States or any of its agencies or instrumentalities,
3. A state, the District of Columbia, a possession of the United States,
or any of their political subdivisions or instrumentalities,
4. A foreign government or any of its political subdivisions, agencies,
or instrumentalities, or
5. An international organization or any of its agencies or
instrumentalities.
Other payees that may be exempt from backup withholding include:
6. A corporation,
7. A foreign central bank of issue,
8. A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a possession of the United
States,
9. A futures commission merchant registered with the Commodity
Futures Trading Commission,
10. A real estate investment trust,
11. An entity registered at all times during the tax year under the
Investment Company Act of 1940,
12. A common trust fund operated by a bank under section 584(a),
13. A financial institution,
14. A middleman known in the investment community as a nominee or
custodian, or
15. A trust exempt from tax under section 664 or described in section
4947.
The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 15.
IF the payment is for . . . THEN the payment is exempt
for . . .
Interest and dividend payments All exempt payees except
for 9
Broker transactions Exempt payees 1 through 5 and 7
through 13. Also, C corporations.
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 5
Payments over $600 required to be
reported and direct sales over
$5,000
1
Generally, exempt payees
1 through 7
2
1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2
However, the following payments made to a corporation and reportable on Form
1099-MISC are not exempt from backup withholding: medical and health care
payments, attorneys' fees, gross proceeds paid to an attorney, and payments for
services paid by a federal executive agency.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and
you do not have and are not eligible to get an SSN, your TIN is your IRS
individual taxpayer identification number (ITIN). Enter it in the social
security number box. If you do not have an ITIN, see How to get a TIN
below.
If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN. However, the IRS prefers that you use your SSN.
If you are a single-member LLC that is disregarded as an entity
separate from its owner (see Limited Liability Company (LLC) on page 2),
enter the owner’s SSN (or EIN, if the owner has one). Do not enter the
disregarded entity’s EIN. If the LLC is classified as a corporation or
partnership, enter the entity’s EIN.
Note. See the chart on page 4 for further clarification of name and TIN
combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, get Form SS-5, Application for a Social Security
Card, from your local Social Security Administration office or get this
form online at www.ssa.gov. You may also get this form by calling
1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer
Identification Number, to apply for an ITIN, or Form SS-4, Application for
Employer Identification Number, to apply for an EIN. You can apply for
an EIN online by accessing the IRS website at www.irs.gov/businesses
and clicking on Employer Identification Number (EIN) under Starting a
Business. You can get Forms W-7 and SS-4 from the IRS by visiting
IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).
If you are asked to complete Form W-9 but do not have a TIN, write
“Applied For” in the space for the TIN, sign and date the form, and give
it to the requester. For interest and dividend payments, and certain
payments made with respect to readily tradable instruments, generally
you will have 60 days to get a TIN and give it to the requester before you
are subject to backup withholding on payments. The 60-day rule does
not apply to other types of payments. You will be subject to backup
withholding on all such payments until you provide your TIN to the
requester.
Note. Entering “Applied For” means that you have already applied for a
TIN or that you intend to apply for one soon.
Caution: A disregarded domestic entity that has a foreign owner must
use the appropriate Form W-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or
resident alien, sign Form W-9. You may be requested to sign by the
withholding agent even if item 1, below, and items 4 and 5 on page 4
indicate otherwise.
For a joint account, only the person whose TIN is shown in Part I
should sign (when required). In the case of a disregarded entity, the
person identified on the “Name” line must sign. Exempt payees, see
Exempt Payee on page 3.
Signature requirements. Complete the certification as indicated in
items 1 through 3, below, and items 4 and 5 on page 4.
1. Interest, dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
certification.
2. Interest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. If
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
3. Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification.
Form W-9 (Rev. 12-2011)
Page 4
4. Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. “Other payments” include
payments made in the course of the requester’s trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments to certain fishing boat crew
members and fishermen, and gross proceeds paid to attorneys
(including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), IRA, Coverdell ESA, Archer MSA or
HSA contributions or distributions, and pension distributions. You
must give your correct TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account:
Give name and SSN of:
1. Individual
The individual
2. Two or more individuals (joint
account)
The actual owner of the account or,
if combined funds, the first
individual on the account
1
3. Custodian account of a minor
(Uniform Gift to Minors Act)
The minor
2
4. a. The usual revocable savings
trust (grantor is also trustee)
b. So-called trust account that is
not a legal or valid trust under
state law
The grantor-trustee
1
The actual owner
1
5. Sole proprietorship or disregarded
entity owned by an individual
The owner
3
6. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulation section 1.671-4(b)(2)(i)(A))
The grantor*
For this type of account:
Give name and EIN of:
7. Disregarded entity not owned by an
individual
The owner
8. A valid trust, estate, or pension trust
Legal entity
4
9. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
The corporation
10. Association, club, religious,
charitable, educational, or other
tax-exempt organization
The organization
11. Partnership or multi-member LLC
The partnership
12. A broker or registered nominee
The broker or nominee
13. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
The public entity
14. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulation section 1.671-4(b)(2)(i)(B))
The trust
1
List first and circle the name of the person whose number you furnish. If only one person on a
joint account has an SSN, that person’s number must be furnished.
2
Circle the minor’s name and furnish the minor’s SSN.
3
You must show your individual name and you may also enter your business or “DBA” name on
the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you
have one), but the IRS encourages you to use your SSN.
4
List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the
personal representative or trustee unless the legal entity itself is not designated in the account
title.) Also see Special rules for partnerships on page 1.
*Note. Grantor also must provide a Form W-9 to trustee of trust.
Note. If no name is circled when more than one name is listed, the
number will be considered to be that of the first name listed.
Secure Your Tax Records from Identity Theft
Identity theft occurs when someone uses your personal information
such as your name, social security number (SSN), or other identifying
information, without your permission, to commit fraud or other crimes.
An identity thief may use your SSN to get a job or may file a tax return
using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a
notice from the IRS, respond right away to the name and phone number
printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotline
at 1-800-908-4490 or submit Form 14039.
For more information, see Publication 4535, Identity Theft Prevention
and Victim Assistance.
Victims of identity theft who are experiencing economic harm or a
system problem, or are seeking help in resolving tax problems that have
not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration at 1-800-366-4484. You can forward
suspicious emails to the Federal Trade Commission at: spam@uce.gov
or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT
(1-877-438-4338).
Visit IRS.gov to learn more about identity theft and how to reduce
your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with
the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation
of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS,
reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District
of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies
to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to
file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a
TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.
Special Tax Notice Page 1 of 4
SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS
This notice contains important information you will need before you decide how to receive your Plan benefits.
This notice is provided to you by your Plan Administrator because all or part of the payment that you will soon receive from your Qualified
Retirement Plan may be eligible for rollover by you or your Plan Administrator to a Traditional IRA, Roth IRA, another qualified employer plan,
eligible 457(b) plan, 401(a) or 403(b) plan. A "Traditional IRA" does not include a SIMPLE IRA or Coverdell Education Savings Account.
If you have additional questions after reading this notice, you can contact your Plan Administrator.
There are two ways you may be able to receive a Plan payment that is eligible for rollover: (1) certain payments can be made directly to a Traditional
IRA, Roth IRA, or, if you choose, another qualified employer plan, eligible 457(b) plan, 401(a) or 403(b) plan, that will accept it ("direct rollover"),
or (2) the payment can be paid to you.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do not do a rollover, you will also have to pay a
10% additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you
receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59½ (or if an exception
applies).
Where may I roll over the payment?
You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax-
qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that
holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal
consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the
IRA or employer plan.
How do I do a rollover?
There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.
If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRA sponsor or the
administrator of the employer plan for information on how to do a direct rollover.
If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will
have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of the
payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over
the entire payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the
payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are under age
59½ (unless an exception applies).
How much may I roll over?
If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover,
except:
Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you
and your beneficiary)
Required minimum distributions after age 70½ (or after death)
Hardship distributions
Corrective distributions of contributions that exceed tax law limitations
Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends)
Cost of life insurance paid by the Plan
Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.
If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?
If you are under age 59½, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including
amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular
income tax on the payment not rolled over.
The 10% additional income tax does not apply to the following payments from the Plan:
Payments made after you separate from service if you will be at least age 55 in the year of the separation
Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life
expectancy (or the lives or joint life expectancy of you and your beneficiary)
Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety employee and
you are at least age 50 in the year of the separation
Payments made due to disability or after your death
Special Tax Notice Page 2 of 4
Corrective distributions of contributions that exceed tax law limitations
Cost of life insurance paid by the Plan
Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment
Payments made directly to the government to satisfy a federal tax levy
Payments made under a qualified domestic relations order (QDRO)
Payments up to the amount of your deductible medical expenses
Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001
for more than 179 days
If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?
If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10% additional income tax on early distributions from
the IRA, unless an exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same as
the exceptions listed above for early distributions from a plan. However, there are a few differences for payments from an IRA, including:
There is no exception for payments after separation from service that are made after age 55.
The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a
divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).
The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to
whether you have had a separation from service.
There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified
first-time home purchase, and (3) payments after you have received unemployment compensation for 12 consecutive weeks (or would have
been eligible to receive unemployment compensation but for self-employed status).
Will I owe State income taxes?
This notice does not describe any State or local income tax rules (including withholding rules).
SPECIAL RULES AND OPTIONS
If your payment includes after-tax contributions
After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax
contributions is generally included in the payment. If you have pre-1987 after-tax contributions maintained in a separate account, a special rule may
apply to determine whether the after-tax contributions are included in a payment.
You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track
of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the
IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include
an allocable portion of the after-tax contributions. If you do a 60-day rollover to an IRA of only a portion of the payment made to you, the after-tax
contributions are treated as rolled over last.
You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the
receiving plan separately accounts for after-tax contributions and is not a governmental section 457(b) plan). You can do a 60-day rollover to an
employer plan of part of a payment that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled
over.
If you miss the 60-day rollover deadline
Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain
extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. To apply for
a waiver, you must file a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For
more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).
If you have an outstanding loan that is being offset
If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The
loan offset amount is treated as a distribution to you at the time of the offset and will be taxed (including the 10% additional income tax on early
distributions, unless an exception applies) unless you do a 60-day rollover in the amount of the loan offset to an IRA or employer plan.
If you were born on or before January 1, 1936
If you were born on or before January 1, 1936 and receive a lump sum distribution that you do not roll over, special rules for calculating the amount
of the tax on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.
If your payment is from a governmental section 457(b) plan
If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice generally apply, allowing you to roll over the
payment to an IRA or an employer plan that accepts rollovers. One difference is that, if you do not do a rollover, you will not have to pay the 10%
additional income tax on early distributions from the Plan even if you are under age 59½ (unless the payment is from a separate account holding
Special Tax Notice Page 3 of 4
rollover contributions that were made to the Plan from a tax-qualified plan, a section 403(b) plan, or an IRA). However, if you do a rollover to an
IRA or to an employer plan that is not a governmental section 457(b) plan, a later distribution made before age 59½ will be subject to the 10%
additional income tax on early distributions (unless an exception applies). Other differences are that you cannot do a rollover if the payment is due to
an “unforeseeable emergency” and the special rules under “If your payment includes employer stock that you do not roll over” and “If you were born
on or before January 1, 1936” do not apply.
If you are an eligible retired public safety officer and your pension payment is used to pay for health coverage or qualified long-term care
insurance
If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal
retirement age, you can exclude from your taxable income plan payments paid directly as premiums to an accident or health plan (or a qualified long-
term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this
purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or ambulance crew.
If you roll over your payment to a Roth IRA
You cannot roll over a payment from the Plan to a designated Roth account in an employer plan. You can roll over a payment from the Plan made
before January 1, 2010 to a Roth IRA only if your modified adjusted gross income is not more than $100,000 for the year the payment is made to you
and, if married, you file a joint return. These limitations do not apply to payments made to you from the Plan after 2009. If you wish to roll over the
payment to a Roth IRA, but you are not eligible to do a rollover to a Roth IRA until after 2009, you can do a rollover to a traditional IRA and then,
after 2009, elect to convert the traditional IRA into a Roth IRA.
If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax
amounts) will be taxed. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of
the Roth IRA within 5 years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that are rolled over to a
Roth IRA, the taxable amount can be spread over a 2-year period starting in 2011. If you roll over the payment to a Roth IRA, later payments from
the Roth IRA that are qualified distributions will not be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a
payment made after you are age 59½ (or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000) and after
you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the year for which your first contribution was
made to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent of earnings after the rollover,
including the 10% additional income tax on early distributions (unless an exception applies). You do not have to take required minimum distributions
from a Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).
If you are not a plan participant
Payments after death of the participant. If you receive a distribution after the participant’s death that you do not roll over, the distribution will
generally be taxed in the same manner described elsewhere in this notice. However, the 10% additional income tax on early distributions and the
special rules for public safety officers do not apply, and the special rule described under the section “If you were born on or before January 1, 1936”
applies only if the participant was born on or before January 1, 1936.
If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the
same rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover
to an IRA, you may treat the IRA as your own or as an inherited IRA.
An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59½ will be subject
to the 10% additional income tax on early distributions (unless an exception applies) and required minimum distributions from your IRA do
not have to start until after you are age 70½.
If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional income tax on early
distributions. However, if the participant had started taking required minimum distributions, you will have to receive required minimum
distributions from the inherited IRA. If the participant had not started taking required minimum distributions from the Plan, you will not
have to start receiving required minimum distributions from the inherited IRA until the year the participant would have been age 70½.
If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the participant’s death and you
are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA.
Payments from the inherited IRA will not be subject to the 10% additional income tax on early distributions. You will have to receive
required minimum distributions from the inherited IRA.
Payments under a qualified domestic relations order. If you are the spouse or former spouse of the participant who receives a payment from the Plan
under a qualified domestic relations order (QDRO), you generally have the same options the participant would have (for example, you may roll over
the payment to your own IRA or an eligible employer plan that will accept it). Payments under the QDRO will not be subject to the 10% additional
income tax on early distributions.
If you are a nonresident alien
If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan is
generally required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may
happen if you do a 60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-
Special Tax Notice Page 4 of 4
8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication
519, U.S. Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.
Other special rules
If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in the
series (unless you make a different choice for later payments).
If your payments for the year are less than $200 (not including payments from a designated Roth account in the Plan), the Plan is not required to
allow you to do a direct rollover and is not required to withhold for federal income taxes. However, you may do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a designated Roth account in the Plan) will be
directly rolled over to an IRA chosen by the Plan administrator or the payor. A mandatory cashout is a payment from a plan to a participant made
before age 62 (or normal retirement age, if later) and without consent, where the participant’s benefit does not exceed $5,000 (not including any
amounts held under the plan as a result of a prior rollover made to the plan).
You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces’
Tax Guide.
FOR MORE INFORMATION
This notice summarizes only the federal (not state or local) tax rules that might apply to your payment. The rules described above are complex and
contain many conditions and exceptions that are not included in this notice. Therefore, you may want to consult with the Plan Administrator or a
professional tax advisor before you take a payment of your benefits from your Plan. Also, you can find more specific information on the tax
treatment of payments from qualified retirement plans in IRS Publication 575, Pension and Annuity Income, IRS Publication 590, Individual
Retirement Arrangements, and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from your local
IRS office, on the IRS's Internet Web Site at www.irs.gov, or by calling 1-800-TAX-FORM.
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