Fillable Trust Transacon Form Secon A Employer Informaon Secure (MidAmerica)

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Trust Transacon Form Secon A Employer Informaon Secure (MidAmerica)

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Trust Transacon Form
Secure upload: www.myMidAmerica.com/le-upload/employers/
Select Employer File Upload, then Contribuons & Trust Transacons
F2103-004 (0521.v6) | MidAmerica Trust Transacon Form | Phone: (863) 688-4500 (See other side for instrucons on reming payment and subming your form)
Secon A
Employer Informaon
Employer
Contact First Name Contact Last Name
Mailing Address
City State Zip Telephone
Trust Contribuon Details
Not subming a contribuon? Check this box and leave Secon B blank:
NO CONTRIBUTION WILL BE SUBMITTED AT THIS TIME.
Secon B
Employer Name Total Trust Deposit
$
OPEB Poron of Deposit
Reree health care (medical, dental, vision, long-term care) and life
insurance benets
Non-OPEB Poron of Deposit
Reree spend and other cash payments not included in state pension.
$
$
Distribuon Elecon Details
Not requesng a distribuon? Check this box and leave Secon C blank:
NO DISTRIBUTION REQUESTED AT THIS TIME.
Secon C
I hereby make the following elecon (elect one of the opons below and complete all blank elds within that opon).
For ACH/WIRE, please complete all elds below. If requesng check, complete Name of Payee and Payee Address only.
OPEB
OPEB Poron of Distribuon
Reree health care (medical, dental, vision,
long-term care) and life insurance benets
$
Non-OPEB
Non-OPEB Poron of Distribuon
Reree spend and other cash payments not
included in state pension.
$
Payment Details:
Name of Payee (check only)
Name of Bank Bank Address
Distribuon Method (Select One)
Contribuon Method (Select One)
Tax ID
Email Address
ACH
ACH
Bank Account Number ABA Roung Number
Payee Address
(check only)
WIRE
WIRE
CHECK
CHECK
Authorizaon
Secon D
I hereby cerfy that the contribuon and/or distribuon details provided above are accurate. If I have elected to take a Trust distribuon, I cerfy that the requested distribuon
is for eligible expenses pursuant to the Trust agreement between MidAmerica Administrave & Rerement Soluons and the Employer named on this form.
Signature
Signature Date (mm/dd/yyyy)Title
Please complete the form in its enrety. Secons B or C may not apply to your current request—please check the appropriate boxes within those secons if not subming a
contribuon or requesng a distribuon at this me. For fastest processing, we encourage you to submit and request funding via ACH or Wire.
If you select Wire/ACH as your distribuon method, you must provide the
requested banking details within Secon C. For your protecon, we verify that
your banking details match what has already been provided every me we
process a request. For Wire transacons, please establish your wire details at least
15 days prior to your request (see page 2 for more details). Your transacon could
be delayed if we are missing or cannot verify your banking details.
Trust Administrave Procedures
Plan Sponsor Portal
Our Plan Sponsor portal, located at www.myMidAmerica.com, can be accessed at any me to view transacons and reports—including
quarterly and annual Trust statements. If you do not have a secure login, please contact your Account Representave. If you do not have your
Account Representave’s informaon, please call (863) 688-4500 for assistance.
Subming Transacon Requests
Funding
Timing Snapshot
Use ACH or Wire when possible
While paper check is sll an opon, the quickest and most secure way to submit and receive funding is via ACH or wire. Funds submied or
requested in this manner will be given priority when processing. Please note if you submit contribuon funding via paper check, a 3-day check
hold could be applied to ensure the check clears before posng funds to the account.
Wire Transfers / Same-day processing occurs if the following is completed:
• Trust Wire Authorizaon Form has been completed and submied 15 days prior to the request.
This allows us to quickly verify your Wire details and authorized contacts upon receiving your Trust Transacon Form. Download the Trust
Wire Authorizaon Form by selecng Forms from www.myMidAmerica.com.
• Trust Contribuon and Trust Distribuon requests are submied at the same me using the Trust Transacon Form.
Same-day processing is not available for stand-alone contribuon or distribuon requests.
• Funds submied via wire are received by 10:00 a.m. ET the day your Trust Transacon Form is submied.
To ensure we can process the contribuon and distribuon within the same day it’s requested, contribuon funds must be received by 10
a.m. ET.
Please note if the above items have not been completed, we cannot guarantee same day processing.
Funds will be posted according to the date they are received and processed. Backdang is not available.
To ensure your funds are posted within the me you need, please submit appropriately according to the meframes outlined above.
MidAmerica will not backdate any transacons on the account.
Trust Distribuon Requests / Distribuon requests are processed within 3–5 business days of receipt.
ACH Transacons / Same-day processing is not available. Funds will be processed and posted within 3–5 business days.
Include your Plan ID with your Trust contribuons.
In addion to your AUL Policy Number*, be sure to put your Plan ID and the word Trust in either your wire/ACH notes or the memo of the check.
MidAmerica Account Details
• ACH Roung Number: 063100277
• WIRE Roung Number: 026009593
• Account Number: 005561906347
• Title on Account: AUL Health Benet Trust/MidAmerica
Administrave & Rerement Soluons, LLC
• Bank name: Bank of America, N.A.
• Bank Branch: Lakeland, FL
• Bank Phone Number: (863) 616-5318
• Reference: (Employer Name) AUL Policy Number*
Make hardcopy checks payable to: AUL Health Benet Trust
To send hardcopy checks, mail to:
MidAmerica Administrave & Rerement Soluons
An: Contribuons Processing
PO Box 149
Lakeland, FL 33802-0149
For overnight or express deliveries:
MidAmerica Administrave & Rerement Soluons
2855 Interstate Drive, Suite 115
Lakeland, FL 33805
Upload your Trust Transacon Form through the Employer Upload Site
1. Go to www.myMidAmerica.com
2. Select Upload File from the top right-hand corner, then select For Employers/Partners
3. From the Employer Upload Site landing page, select Contribuons & Trust Transacons
4. Complete the series of idenfying quesons. If only requesng a distribuon, within the Primary: New Funds secon, do the following:
select None from the Funds Transfer Method dropdown menu, enter today’s date in the Funds Transfer Date eld and $0.00 in the
Amount eld.
5. Upload the completed Trust Transacon form using the blue upload buon located below the comments secon.
Note: If requesng funds via wire, please set up your banking details and authorized contacts at least 15 days prior to your transacon request
by compleng our Trust Wire Authorizaon Form. Download the form by selecng Forms from www.myMidAmerica.com.
F 2 1 0 3 - 0 0 4 ( 0 5 2 1 . v 6 ) | M i d A m e r i c a T r u s t T r a n s a c  o n F o r m | P h o n e : ( 8 6 3 ) 6 8 8 - 4 5 0 0
*The AUL Policy Number can be found on your New Business Agreement.
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Trust Transacon Form Secon A Employer Informaon Secure (MidAmerica)

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Completed 28 July 2021

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