IMPORTANT PLEASE READ THIS INFORMATION VERY CAREFULLY!

Transcription

1 Dear Participant: IMPORTANT PLEASE READ THIS INFORMATION VERY CAREFULLY! Enclosed you will find the Special Tax Notice Regarding Plan Payments and the official application which must be completed in order to apply for a distribution from the Chicago Regional Council of Carpenters Supplemental Retirement Fund (the Fund ). No other type of application will be accepted. Please fill the application out carefully. Please be certain to use ink to complete the application. We suggest that you keep a copy of the completed application for your records. Before a distribution can be approved, you must submit a completed application and furnish the Retirement Benefits Department with any required supporting documentation. Once the Retirement Benefits Department receives your completed application and any required supporting documentation, approximately ten (10) business days are required for the Retirement Benefits Department to make a determination on your eligibility for a distribution. If you are eligible for a distribution, the Retirement Benefits Department will send your approved application to Mercer, the Fund s record keeper. Mercer will issue your distribution. In general, it takes Mercer an additional three to five (3-5) business days to process the distribution. Supporting documentation typically is not required for a Retirement distribution or a 24 Month Separation distribution. If you are applying for a Disability Termination Distribution, you must submit either a copy of a favorable disability determination from the Social Security Administration or an original completed Retirement Benefits Department Medical Examination Report form (completed by your doctor with the doctor s certification of disability). Note that, along with the application and any other required supporting documentation, you must submit a copy of a government issued photo ID (ex: driver s license) for yourself and (if you are married) for your spouse. Common errors on the application include the following items. Please check these items carefully before submitting your application to the Retirement Benefits Department. If any of these items are not correct, the application will be denied. If your application is denied, you will need to re-start the application process from the beginning by completing a new distribution application. Failure to provide your Union Identification Number (UID#) in Part 1 of the form. Failure to indicate a form of distribution in Part #3 of the form. You must indicate if you are electing a lump sum distribution or installment payments. If you are married, failure to have your spouse consent to the distribution by signing and dating Part #6 of the form in the presence of a notary public. The date your spouse signs the form must be identical to the date that the form is notarized. CV(11) /15/14

2 Failure to sign and date Part #8 the form in the presence of a notary public. The date you sign the form must be identical to the date that the form is notarized. Information regarding direct deposit is enclosed. You cannot set up direct deposit through the Retirement Benefits Department. Simply submitting your bank information or a voided check with your application is not sufficient to set up direct deposit. If you would like your distribution directly deposited, you must follow the instructions on the enclosed material to set up direct deposit through Mercer, the Fund s record keeper. If you have questions about completing the application, you may telephone or visit the Fund Office. Office hours are from 8:00am to 4:30pm Central Standard Time. If you choose to visit the Fund Office, we suggest that you telephone ahead of time to schedule an appointment with a Retirement Benefits Representative. Although an appointment is not mandatory (and you will, of course, still be assisted even if you have not made one), making an appointment will help to ensure that you will not have to wait long to speak with a Representative once you arrive at the Fund Office. Additionally, if you decide to visit the Fund Office, please make certain that you (and anyone else accompanying you) bring a government issued photo ID (ex: driver s license) with you to verify your identity. Please contact the Retirement Benefits Department at (312) , option # 4 if you have any questions. Sincerely, The Retirement Benefits Department Fax: (312) pension@crccbenefits.org CV(11) /15/14

3 CHICAGO REGIONAL COUNCIL OF CARPENTERS SUPPLEMENTAL RETIREMENT PLAN TERMINATION DISTRIBUTION FORM UNION-44 ( ) READ the instructions on this form carefully and be sure to submit all of the required supporting documentation. You must complete this entire form in ink. This form is not valid without your signature. If you are married, your spouse must consent to this distribution in Section 7 of this form. This form must be notarized. Your choices on this entire form may affect your taxes. You should carefully review the Special Tax Notice Regarding Plan Payments. You may wish to consult your own financial tax advisor. If your distribution will be sent to an address outside of the United States, Puerto Rico, the U.S. Virgin Islands or Guam, you must also submit either an IRS Form W-9 to certify you are a U.S. person or a Form W-8BEN if you are a non-resident alien with respect to the U.S. To obtain these forms or for assistance in determining which form you should submit, please go to the IRS website at or consult with a tax advisor. If you do not submit one of these forms along with this form, 30% tax withholding will be applied to your distribution. You must return the entire completed form to: Chicago Regional Council of Carpenters Supplemental Retirement Plan, 12 East Erie Street, Chicago, Illinois PART 1. PARTICIPANT INFORMATION (PRINT CLEARLY IN INK) You must submit a copy of a government issued photo ID (ex: driver s license) for yourself and (if you are married) for your spouse to the Retirement Benefits Department along with this application. Last Name First Name M.I. Mailing Address (Number & Street) Apt. # City State Zip Code ( ) Home Telephone Number ( ) Mobile (Cell) Telephone Number Your Address Date of Birth - - Month Day Year Must Provide Local Union Number Union Identification Number (UID#) You must provide your full SSN and/or ITIN below. Social Security Number If you have an Individual Taxpayer Identification Number (ITIN) you must list it here. How do you file your Federal Income Taxes? *3743F* 01001DIST I file my Federal Income Taxes under the above listed SSN I file my Federal Income Taxes under the above listed ITIN Page 1 of 7 CV(11) /15/14

4 Your Marital Status: Never Married Married Widowed Divorced Legally Separated If you were previously divorced or are legally separated and you have not already provided the Retirement Benefits Department with a copy of the divorce decree, separation papers, settlement agreement, and/or Qualified Domestic Relations Order, you must do so at this time. Your Supplemental Retirement Plan distribution application cannot be processed without this information. If a former spouse has claimed an interest in your Supplemental Retirement Plan Account, the processing of your distribution may be delayed. I was previously divorced OR I AM currently involved in divorce proceedings. I have never been divorced AND I am NOT currently involved in divorce proceedings. Note that, if you have more than one former spouse, all former spouses and dates of divorce must be listed on this application. Attach an additional sheet if more space is needed. Date of Divorce Name of Former Spouse Date of Divorce Name of Former Spouse If you are CURRENTLY married complete the following information: Date of Marriage - - Spouse Date of Birth - - Month Day Year Month Day Year Spouse s Name (last / first / middle) Spouse s Social Security Number - - If your spouse in not currently listed on the Fund Office records, you must submit your original county certified marriage document along with this application. PART 2. TYPE OF DISTRIBUTION Select one option below. Disability -- You must submit either a copy of a favorable Title II disability determination from the Social Security Administration or an original completed Supplemental Retirement Fund "Medical Examination Report" form (completed by your physician with the physician's certification of disability). 24 Month Separation -- Failure to receive a Plan contribution for 24 consecutive months Retirement Page 2 of 7 CV(11) /15/14

5 PART 3. FORM OF DISTRIBUTION You must check ONE option below. Note that, once a distribution is processed, it can NOT be returned. Once installment payments have begun, the amount and/or frequency of the installments can NOT be changed. I request a distribution in: Lump Sum (Note that if your total balance is $1,000 or less, you MUST take a lump sum payment.) Installment Payments: Paid in (number) of monthly quarterly annual payments. (Note: Installment Payments paid over a fixed number of payments cannot exceed 10 years). Installment Payments: Paid in monthly quarterly annual payments of $. PART 4. ROLLOVER ELECTION Lump sum payments and installment payments paid over a period of less than ten (10) years are eligible for rollover, as described in the "Special Tax Notice Regarding Plan Payments." If any part of your distribution is eligible for rollover, you may elect a direct rollover of that amount to another qualified employer plan or to an IRA. If you do not elect a direct rollover of an eligible rollover distribution amount, your distribution will be paid directly to you. The Plan is required by law to withhold 20% federal income tax from the distribution. If you wish to roll over your distribution, you must check the following box and complete and return a Direct Rollover Form along with this distribution form. Note: Do not check this box if you want your distribution paid directly to you. I am electing a direct rollover of all or part of my eligible rollover distribution. I am enclosing a completed Supplemental Retirement Plan Direct Rollover Form along with this distribution form. Please note that you must complete the Supplemental Retirement Plan s Direct Rollover Form. We are unable to accept the receiving IRA or Qualified Plan s Rollover form without the Plan s Rollover Form. *519DC* 01001DSTA Page 3 of 7 CV(11) A 08/15/14

6 PART 5. DELIVERY OF DISTRIBUTION Under standard procedure, a distribution is processed as a paper check and is mailed to you via the U.S. Postal Service. Electronic funds transfer (EFT), also known as direct deposit into a personal bank account, is available for all distributions, except for rollovers. EFT is provided free of charge to all participants. Please refer to the enclosed Electronic Funds Transfer for Plan Withdrawals page for more information about setting up an EFT. It is very important to understand that, if you previously set up EFT for a prior distribution and have not cancelled your previous EFT setup, this current distribution will also be sent to the same bank account that you previously designated for EFT, even if you check the expedited check delivery box below. To cancel or change a previous EFT setup you must either call Mercer at or make the changes online at Be advised that EFT setup, changes, or cancellations take 24 hours to process. Expedited delivery of paper checks is available for a $40.00 fee (if you did not elect EFT). Expedited delivery is optional and is not available for distributions that are being sent to P.O. Boxes. Please note that the $40.00 fee is non-refundable and will be deducted from your account before your distribution is processed. This means that, if your distribution is approved for 100% of your account balance, the fee will reduce the amount of your distribution by $ If you are electing expedited delivery, you must check the box below after reading the following statement. Note: Do not check this box if you have set up an EFT or if you want your distribution check mailed to you via the U.S. Postal Service. By checking this box, I agree to pay a $40.00 fee for expedited delivery of my check. I understand that my check will be mailed to me by overnight delivery the day the check is written based on the settlement period(s) of the investments being liquidated for this withdrawal or distribution. I understand that if I elect any other distribution method, including direct deposit, prior to delivery of my check, my withdrawal or distribution may be delivered by that method and I will not receive a refund of this fee. Page 4 of 7 CV(11) A 08/15/14

7 PART 6. NOTICE OF FEDERAL INCOME TAX WITHHOLDING FOR INSTALLMENT PAYMENTS TO BE PAID FOR 10 YEARS OR LONGER If you are receiving a distribution from the Plan in the form of Installment Payments to be paid for ten (10) years or longer, you must read this notice. Distributions paid in the form of Installment Payments for a period of ten (10) years or longer are not eligible for rollover and are subject to immediate Federal income tax withholding unless you elect not to have withholding apply. An election not to have tax withholding apply to a payment or distribution to be made by the Plan will remain in effect until revoked in writing. You may revoke your election at any time regarding future payments. Any election or revocation will be effective no later than the first day of the calendar month after it is received. Any election made after a payment or distribution is made will not apply to that payment or distribution. You may make and revoke elections not to have withholding apply as often as you wish. If you elect not to have withholding apply or if you do not have enough Federal Income Tax withheld, you may be responsible for the payment of estimated tax. You may incur penalties under the estimated tax payment rules if your withholding and estimated tax payments are not sufficient. Withholding Election for Installment Payments to be Paid for 10 Years or Longer I have read the above Notice of Federal Income Tax Withholding and I understand the Federal Income Tax withholding options that I may elect. I have elected Installment Payments to be paid for ten (10) years or longer and I elect to have the following Federal Income Tax withholding apply to my benefit payments: No Federal Income Tax withheld Yes, Federal Income Taxes withheld as indicated below: Total number of allowances and marital status I am claiming: (For periodic payments you must enter a number of allowances and marital status) Number of allowances: Marital Status: Married Single Married, but withhold at higher single rate. (Choosing this option will default to the appropriate Tax Table.) I would like an additional dollar amount of $ withheld from my payments. *52AD6* 01001TWHF Page 5 of 7 CV(11) /15/14

8 PART 7. SPOUSAL CONSENT & NOTARY SIGNATURE/STAMP If you are married, your spouse must consent to this distribution by signing below. Your spouse s signature below must be witnessed by a notary public. Your spouse should not sign below until in the presence of the notary. The notary is responsible for confirming your spouse s identity. The date your spouse signs this document must be the same date on which the notary witnesses your spouse s signature. If the dates do not match or if either date is missing, your spouse will be required to complete another form. I hereby consent to the elections that my spouse has made on this application for distribution of benefits from the Chicago Regional Council of Carpenters Supplemental Retirement Plan. Signature of Spouse THE FOLLOWING MUST BE COMPLETED BY NOTARY PUBLIC. Date Signed by Spouse I certify that personally appeared before me and signed this document Printed Name of Spouse in my presence this day of in the year. Signature of Notary Public (Notary Stamp) 8. NOTICE ON YOUR RIGHT TO DEFER YOUR RETIREMENT BENEFIT AND CONSEQUENCES OF A DISTRIBUTION Under federal law, we are required to inform you that if the balance of your Account under the Supplemental Retirement Plan is over $1,000 you have the right to defer the receipt of your retirement benefit until the April 1 following the calendar year in which you reach age 70½. Because you have this right, you should consider the consequences of electing to receive your benefits now instead of waiting until later. It is important that you read this notice before you make your choice. If you do not take your retirement benefit now, your Account will continue to be subject to the gains and losses of the investments you elect for your Account and also subject to investment fees. The fees for maintaining your Account will not change as a result of your termination of employment; however, the Trustees may change investment options in the future and consequently, the fees associated with such options may also change. In addition to investment fees, the Plan will deduct other administrative expenses from assets that remain in the Plan. As other considerations, some currently available investment options in the Supplemental Retirement Plan may not be available on similar terms outside the plan and the investment fees and expenses outside the plan may be either higher or lower from those you would pay if you leave your benefit in the Supplemental Retirement Plan. Please contact Mercer at for additional information on investment options for the Supplemental Retirement Plan. Once you take your retirement benefit, you will not be able to change your mind and defer it until a later date. You will generally be required to pay income tax on the benefits you receive unless the amounts are eligible for special tax treatment if paid in a direct rollover as described in the enclosed Special Tax Notice. You may want to consult with a financial or tax advisor before deciding to receive a distribution of your retirement benefit. For additional information on the consequences of taking your retirement benefit now instead of later, you should refer to your Summary Plan Description for the Supplemental Retirement Plan. A copy of the Summary Plan Description is available free of charge on the Plan's website or by contacting the Chicago Regional Council of Carpenters Supplemental Retirement Plan, 12 East Erie Street, Chicago, IL , (312) , telephone menu option #4. Page 6 of 7 CV(11) B 08/15/14

9 PART 9. PARTICIPANT SIGNATURE & NOTARY SIGNATURE/STAMP I hereby apply for a distribution from the Chicago Regional Council of Carpenters Supplemental Retirement Fund. I acknowledge that I have received and read the Special Tax Notice Regarding Plan Payments." I understand that I have at least 30 days to decide whether or not to elect a direct rollover of any eligible rollover distribution. I understand that, once a distribution is processed, it can NOT be returned. All of the information that I have provided on this application as well as any records or documents I have supplied in support of this application are true and complete to the best of my knowledge and belief. I understand that making a false statement and/or furnishing incomplete information may disqualify me for benefits and that the Trustees shall have the right to recover any payments made to me because of a false statement(s) and/or incomplete information. I understand that, in the event of an overpayment of benefits, the Trustees are entitled to recover any amounts overpaid to me. By signing below, I authorize any employer for whom I have worked, my Local Union, the Chicago Regional Council of Carpenters, and the Chicago Regional Council of Carpenters Welfare Fund to release any information they may possess concerning my identity (including but not limited to: photo IDs; birthdate; Social Security Number; Union Identification Number; address information; and signature samples) to the Chicago Regional Council of Carpenters Supplemental Retirement Fund. Your signature below must be witnessed by a notary public. Do not sign below until you are in the presence of the notary. The notary is responsible for confirming your identity as well. The date you sign this document must be the same date on which the notary witnesses your signature. If the dates do not match or if either date is missing, you will be required to complete another form. This application cannot be notarized by your spouse. Signature of Participant Date THE FOLLOWING MUST BE COMPLETED BY NOTARY PUBLIC State of County of My Commission Expires I certify that personally appeared before me and signed this document Printed Name of Participant in my presence this day of in the year. Signature of Notary Public (Notary Stamp) Return this completed form with all of the required current supporting documentation to: Chicago Regional Council of Carpenters Supplemental Retirement Fund 12 E. Erie St., Chicago, IL Fax: (312) pension@crccbenefits.org PART 10. FUND OFFICE AUTHORIZATION Signature of Fund Office Representative *519E5* 01001DSTB Date Page 7 of 7 CV(11) B 08/15/14

10 CHICAGO REGIONAL COUNCIL OF CARPENTERS SUPPLEMENTAL RETIREMENT PLAN DIRECT ROLLOVER FORM UNION-44 ( ) Use this form to provide information needed to make a direct rollover of all or a portion of your eligible rollover distribution from the Plan to an individual retirement account ( IRA ) or other qualified plan. You must complete this entire form in ink. This form is not valid without your signature. This form must be notarized. This form must be accompanied by an In-Service Distribution Form, a Termination Distribution Form, or a Beneficiary and Alternate Payee Distribution Form. You must return the entire completed form to: Chicago Regional Council of Carpenters Supplemental Retirement Plan, 12 East Erie Street, Chicago, Illinois PART 1. PARTICIPANT INFORMATION (PRINT CLEARLY IN INK) Last Name First Name M.I. Mailing Address (Number & Street) Apt. # City State Zip Code ( ) ( ) Home Telephone Number Mobile (Cell) Telephone Number Date of Birth - - Month Day Year You must provide your full SSN and/or ITIN below. Social Security Number If you have an Individual Taxpayer Identification Number (ITIN) you must list it here. How do you file your Federal Income Taxes? I file my Federal Income Taxes under the above listed SSN I file my Federal Income Taxes under the above listed ITIN 2. DIRECT ROLLOVER AMOUNT Note that amounts not rolled over are subject to 20% mandatory withholding. I have elected a direct rollover of my eligible rollover distribution as follows (check one): Roll over my entire eligible rollover distribution. Roll over a portion of my eligible rollover distribution per the following. Check one and complete: (Note that the minimum direct roll over amount is $500.) Roll over % of my distribution. Roll over $ and pay the balance to me. Pay $ to me and roll over the balance. Note: Effective July 1, 2010 Non-spousal beneficiaries may only roll over to an inherited IRA. Please refer to the enclosed Special Tax Notice. *2F0B2* 01001DROL Page 1 of 2 OVER CV(11) /17/13

11 3. RECEIVING IRA OR QUALIFIED PLAN My direct rollover should be paid to the following IRA or qualified plan: employer plan traditional IRA Roth IRA* (check one and complete this section, attach additional pages if necessary) NAME OF TRUSTEE OR CUSTODIAN PLAN NAME MAILING ADDRESS CITY STATE ZIP CODE Payments will be directly mailed to new trustee or custodian. Account # : (If an account number is not provided or if your account number is your social security number, your direct rollover will be made payable to the trustee or custodian designated above but mailed to your address of record.) *Please refer to the Special Tax Notice Regarding Plan Payments for the tax consequences associated with rolling over to a Roth IRA. PART 4. PARTICIPANT SIGNATURE & NOTARY SIGNATURE/STAMP I make the direct rollover elections indicated on this form. I acknowledge that I have received and read the Special Tax Notice Regarding Plan Payments." I understand that I have at least 30 days to decide whether or not to elect a direct rollover of any eligible rollover distribution. I have read the Notice of Distribution Options and understand my distribution alternatives and my right to defer distributions under the Plan. I understand that, once a distribution is processed, it can NOT be returned. I represent that I have taken all necessary action so that the receiving IRA or qualified plan will accept my rollover contribution. Your signature below must be witnessed by a notary public. Do not sign below until you are in the presence of the notary. The notary is responsible for confirming your identity as well. The date you sign this document must be the same date on which the notary witnesses your signature. If the dates do not match or if either date is missing, you will be required to complete another form. This application cannot be notarized by your spouse. Signature of Participant THE FOLLOWING MUST BE COMPLETED BY NOTARY PUBLIC Date State of County of My Commission Expires I certify that personally appeared before me and signed this document Printed Name of Participant in my presence this day of in the year. Signature of Notary Public (Notary Stamp) Return this completed form along with the required accompanying distribution form to: Chicago Regional Council of Carpenters Supplemental Retirement Fund 12 E. Erie St., Chicago, IL Fax: (312) pension@crccbenefits.org Page 2 of 2 BACK CV(11) /17/13

12 CHICAGO REGIONAL COUNCIL OF CARPENTERS SUPPLEMENTAL RETIREMENT PLAN ELECTRONIC FUNDS TRANSFER (EFT) OPTION UNION-44 ( ) ELECTRONIC FUNDS TRANSFER FOR PLAN WITHDRAWALS The Chicago Regional Council of Carpenters Supplemental Retirement Plan (Supplemental Retirement Plan) allows you to receive eligible withdrawals from the Supplemental Retirement Plan by electronic funds transfer (EFT), or direct deposit into a personal bank account. An EFT allows you faster access to your money and is available for all eligible plan disbursements, except for rollovers. If you select an EFT, the information needs to be set up prior to the plan withdrawal request being received and processed. If an EFT is not set up in advance, the plan withdrawal will be processed in the form of a paper check. SETTING UP AN EFT You can set up an EFT for your plan withdrawals quickly and easily, either online at or by phone at ENROLLING ONLINE Follow these seven steps to set up an EFT online. STEP 1: Log on to your account at You will need to enter your User Name and password to access your account. STEP 2: Click on the plan name in the What do I have? box. STEP 3: Click on the Electronic Funds Transfer link within the Withdrawals tab. STEP 4: Fill in the information for the bank account where you want your Supplemental Retirement Plan payment to be deposited. Indicate the type of account: savings or checking. Fill in the bank s routing number. You can find this nine-digit number at the bottom left-hand corner of a personal check (see illustration below). If the account is a savings account, you can find the routing number on a deposit slip. Fill in the savings or checking account number. Fill in the name on the bank account, exactly as it appears on the checks or the account statement. Click Continue at the bottom of the screen. STEP 5: Read the statement thoroughly and click the disclaimer at the bottom of the screen if you agree with the terms and conditions stated. Then click Continue at the bottom of the screen. STEP 6: Review the bank account information. If it is correct, click Submit at the bottom of the screen to process your EFT enrollment. If not, click Modify to return to the first EFT Election screen and make changes. STEP 7: You will see a message stating that your EFT request has been received, along with a confirmation number. It is a good idea to write down this number or print this screen for your records. Effective immediately, after your EFT request is received, your future disbursements will be transferred electronically to the account you indicated. You can always override your EFT choice at any time by going on to the Supplemental Retirement Plan s website, www. ibenefitcenter.com. ENROLLING BY PHONE To set up an EFT by phone, call between 7:00 a.m. and 9:00 p.m. Central Time, any business day, to speak with a Service Representative. You will need to provide the representative with your User Name and personal identification number (PIN) to access your Supplemental Retirement Plan account. You will also need the same information required for online EFT setup: type of account, bank routing number, account number, and name on the bank account. QUESTIONS? If you have any questions about setting up an EFT, please call a Service Representative toll-free at , between 7:00 a.m. and 9:00 p.m. Central Time, any business day. # CVR(11) A 06/17/13

13 CHICAGO REGIONAL COUNCIL OF CARPENTERS SUPPLEMENTAL RETIREMENT PLAN MEDICAL EXAMINATION REPORT TO BE COMPLETED IF APPLYING FOR A DISTRIBUTION DUE TO DISABILITY Participant Participant Participant Name SS# OR UID# Date of Birth ALL OF THE FOLLOWING INFORMATION MUST BE COMPLETED BY THE PHYSICIAN DIAGNOSIS INCLUDING SUBJECTIVE SYMPTOMS, OBJECTIVE CLINICAL FINDINGS, OBJECTIVE DIAGNOSTIC STUDIES AND RESULTS, COMPLICATIONS, AND THE BASIS FOR YOUR ULTIMATE FINDING OF TOTAL DISABILITY (CONTINUE ON REVERSE SIDE IF MORE SPACE IS NEEDED) ICD diagnostic code(s): This disability originally commenced on or about:. (MONTH/DAY/YEAR) Has the disability been continuous since the original commencement date indicated above? O YES O NO If the disability has not been continuous, please indicate the date that the current period of disability commenced. (MONTH/DAY/YEAR) The individual was most recently examined on. (MONTH/DAY/YEAR) Is medical treatment required at the present time? O YES O NO Re-examination is recommended on or about. IMPORTANT -- PHYSICIAN MUST INITIAL WHICHEVER APPLIES I certify that I have reviewed the Pension Plan disability information that appears on the reverse side of this form. After reviewing this information, I hereby certify that: I am of the opinion that this individual is unable to engage in any substantial gainful activity due to a medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. I am of the opinion that this individual is able to engage in substantial gainful activity as follows: Physician Physician Date Completed Printed Name Signature by Physician (must be LEGIBLE) Physician Office Address Number &Street City State Zip Physician Telephone Federal Tax I.D. # (Area Code) Number Physician License # Physician License Issued by State of *51A17* 01001MEF OVER CV(11) MEF 06/17/13

14 Definition of Disability. A condition whereby a Participant is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. The Participant shall furnish, on a form provided by the Plan, the certification of a duly licensed physician acceptable to the Board of Trustees that the Participant is Disabled within the meaning of Section 1.2(g) as proof of his disability. In the sole discretion of the Board of Trustees, a finding by the Social Security Administration that the Participant is Disabled so that he qualifies for disability benefits under Title II of the Social Security Act may be substituted in lieu of the physician's certification. BACK CV(11) MEF 06/17/13

15 LEGAL NOTICES REGARDING PLAN BENEFITS These legally required notices contain important information about benefits payable from your Plan. The notices are general in nature, and some of the notices may not apply to your Plan or the type of distribution you have requested from your Plan. The paper forms or the telephone, Internet or other electronic instructions used to process your benefit transaction will refer to the notices below that are applicable to the particular distribution(s) you are requesting. You should refer to the summary plan description for a full description of the features of your Plan. Special Tax Notice Regarding Plan Payments YOUR ROLLOVER OPTIONS You are receiving this notice because all or a portion of a payment you are receiving from the Plan is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide whether to do such a rollover. This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan, you will be provided a different notice for that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each account. Rules that apply to most payments from a plan are described in the General Information About Rollovers section below. Special rules that only apply in certain circumstances are described in the Special Rules and Options section below. 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 ESOP dividends 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 Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax consequences if you roll over a distribution of S corporation stock to an IRA). 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 Payments after your death Payments of ESOP dividends 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 Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution. 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). 1 CV(11)FORM MEGA 12/28/09

16 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 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 your payment includes employer stock that you do not roll over If you do not do a rollover, you can apply a special rule to payments of employer stock (or other employer securities) that are either attributable to after-tax contributions or paid in a lump sum after separation from service (or after age 59½, disability, or the participant s death). Under the special rule, the net unrealized appreciation on the stock will not be taxed when distributed from the Plan and will be taxed at capital gain rates when you sell the stock. Net unrealized appreciation is generally the increase in the value of employer stock after it was acquired by the Plan. If you do a rollover for a payment that includes employer stock (for example, by selling the stock and rolling over the proceeds within 60 days of the payment), the special rule relating to the distributed employer stock will not apply to any subsequent payments from the IRA or employer plan. The Plan administrator can tell you the amount of any net unrealized appreciation. 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 you roll over your payment to a Roth IRA 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 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 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). You cannot roll over a payment from the Plan to a designated Roth account in an employer plan. 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 does 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, 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, 2 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 S. See Form W-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 You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can find more detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590, Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from a local IRS office, on the web at or by calling TAX-FORM.