Social Security Number Change my address on record as indicated below OR This is a temporary address to be used for this check only
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- Nathaniel Skinner
- 6 years ago
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1 For use with: Multi-Fund 1-4 Multi-Fund Select Lincoln Life Group Fixed Annuity DIStrIbutIon request ForM to be used for: General Distributions, rollovers, plan-to-plan transfers, transfers, Contract Exchanges, return of Contributions or purchase of permissive Service Credits. 1. IMportAnt InForMAtIon Incomplete information will cause processing delays. please submit all pages of this form. If you need assistance completing this form, please reference the How to Complete this Form section on Page MArKEt - choose one. 403(b) 401(a) 401(k) 457(b) Governmental Roth 403(b) 403 (b) ORP 401(a) ORP Roth 401(k) Roth 457(b) Governmental 3. ContrACt owner/participant InForMAtIon - please print. Contract/Account Number REQUIRED (refer to your statement) Name Social Security Number Change my address on record as indicated below OR This is a temporary address to be used for this check only Mailing Address City, State, ZIP (If mailing address is a P.O. Box, street address is also required.) Daytime phone number Evening Phone Number 4. DIStrIbutIon ELIGIbILItY - Select all that apply in Section A or Section b. Under Internal Revenue Code, an employee is only eligible to make a partial withdrawal, full withdrawal (surrender), or Rollover of salary reduction contributions if a reason listed below is applicable. Section A - 403(b), 403(b) ORP, 401(a), 401(a) ORP, 401(k), Roth 401(k) and Roth 403(b) Plans Age 59½ or older In-service withdrawal - pre-age 59½ (refer to plan administrator to determine eligibility) In-service withdrawal - age 59½ or older (refer to plan administrator to determine eligibility) Severance from employment Termination Date Hardship (Complete Section 5 and refer to Section 9, Option C) Required Minimum Distribution (RMD) (only applicable if age 70½ or older) (Complete Section 5) Plan Termination (refer to plan administrator to determine eligibility) Death Total/permanent disability ( both total and permanent (divorce or legal separation, copy of court order required) Return of excess deferral: Year of excess (Complete Section 5) Return of excess aggregate contribution: Year of excess (Complete Section 5 and Section 9). Employer completes Section 14. Withdrawal of pre-1989 grand-fathered value from a 403(b) plan Active duty date (Please provide date participant went on active duty. This type of distribution is not subject to the 10% tax penalty provided the participant is currently on active duty and has served more than 180 days.) Public Safety Employee Direct Payment for Insurance Section B - 457(b) Governmental Deferred Compensation and Roth 457(b) Governmental Deferred Compensation Plans Age 70½ or older In-service withdrawal of $5,000 or less (refer to plan administrator to determine eligibility) Severance from employment Termination Date Required Minimum Distribution (RMD) of (only applicable if age 70½ or older) (Complete Section 5) Death Total/permanent disability ( both total (divorce or legal separation, copy of court order required) Return of excess deferral: Year of excess (Complete Section 5) Active duty date Public Safety Employee Direct Payment for Insurance Unforeseeable emergency (see Section 6) EM18804-MF9 Page 1 of 10 PAD /12
2 5. withdrawal options - This section must be completed. partial withdrawal: $ OR % of the vested account balance (Write dollar amount or whole percent) If taxes are being withheld, do you want the check to equal the amount requested? Yes no Please see Section 9 for more information regarding income tax withholding. Please indicate which subaccounts you would like the withdrawal to be processed from. If not indicated, the withdrawal will be pro-rata from each vested subaccount balance. Subaccount name Choose one (Dollar amount or Whole Percent) If percentages, indicate a total of 100% $ OR % $ OR % $ OR % Surrender (Total Withdrawal) hardship withdrawal (Complete Hardship Distribution Checklist, EM26033-MF) Payable to me in the amount of $ (Dollar amount must be stated.) note: Check here if you are requesting Lincoln to withdraw your required Minimum Distribution (rmd) before your request for Contract Exchange/rollover/plan-to-plan transfer is completed as noted in Section 8 (complete RMD area below). required Minimum Distribution (RMD) (Only applicable if 70½ or older) $ (dollar amount). This is a one time distribution. required. return of Excess Deferral, Excess Contribution, or Excess Aggregate Contribution (If no amount given in this section, Lincoln will calculate). Indicate Subaccount Name. i4life Advantage Excess withdrawal (where available): $ If taxes are being withheld, do you want the check to equal the amount requested? Yes no EM18804-MF9 Page 2 of 10 PAD /12
3 6. 457(b) unforeseeable EMErGEnCY DIStrIbutIon Under a 457(b) plan, a hardship distribution can only occur when the participant is faced with an unforeseeable emergency. If you answer No to any of these questions, you may not be eligible for an unforeseeable emergency distribution. All available sources of money must be used before an unforeseeable emergency distribution may be taken. If you answer Yes to any of these questions please provide your employer with supporting documentation. Yes No medication. Yes No and and stated. provide EM18804-MF9 Page 3 of 10 PAD /12
4 7. LoAn InForMAtIon Yes No If you have an active loan balance, you may choose to: Leave Loan(s) with Lincoln OR Close the active loan, withdraw the balance from the account (an eligible distribution reason must be indicated in Section 4). If no selection is made, the loan will remain active. any % If you have a defaulted loan, the loan balance will automatically be deducted from your account balance upon meeting an eligible reason for distribution. If you currently have two outstanding active loans, please indicate which loan should be withdrawn from the account balance: withdraw only the balance of loan number. Approximate principal balance $ withdraw the balance of both loans If your active loan balance(s) is/are being withdrawn from your account balance, the amount will be reported to the IRS as a EM18804-MF9 Page 4 of 10 PAD /12
5 8. rollover/plan-to-plan transfer/transfer/permissive SErvICE CrEDIt/ ContrACt ExChAnGE check. Direct Deposit and wire transfer are not options. If your new account is sponsored by a different employer, please provide the name of the new Employer/Contract holder You must choose one of the following options: rollover: To type of plan: 403(b) 403(b) ORP 401(a) 401(a) ORP 401(k) 457(b) Governmental IRA Roth 403(b) Roth 401(k) Roth 457(b) Government Roth IRA* plan-to-plan transfer: A transfer that moves assets from one 403(b) plan to another 403(b) plan. A distributable event is not To type of plan: 403(b) 403(b) ORP Roth 403(b) transfer: A transfer is used to change investment carriers between the same plan type, but assets remain in the To type of plan: 401(a) 401(k) 457(b) Governmental Contract Exchange: The transfer of one 403(b) contract to another 403(b) contract under the same plan. A distributable event To type of plan: 403(b) 403(b) ORP Roth 403(b) permissive Service Credit: be made before the participant has a severance from employment. To type of plan: 401(a) Transfer 401(a) Rollover vendor Information: other vendor s name Contract # other vendor s Address other vendor s City, State, ZIp If the complete address is not provided above or if the mailing address is not legible, the check will be made payable to the new/ other vendor and will be mailed to you. You will then be responsible for mailing the check to the new/other vendor. Contract Exchange Disclosure EM18804-MF9 Page 5 of 10 PAD /12
6 9. InCoME tax withholding form for more information. A. Mandatory Federal tax withholding Mandatory 20% withholding, or increase to %. If no selection is made, a mandatory 20% will be withheld. b. Exceptions to Federal Income tax withholding apply: Financial hardship Distribution. required Minimum Distribution If you elect not to have taxes withheld, you will still be liable for payment of federal and state income tax, if applicable, at the time you prepare your personal tax filing. You may also be subject to tax penalties under the estimated tax payment rules if your payment of estimated tax and withholding, if any, are not adequate. You may wish to discuss your withholding election with a qualified tax advisor. You elect not to withhold the 10% federal tax You elect to withhold 10% federal tax You elect to withhold more than the 10% federal tax - %. If no selection is made, a 10% federal withholding tax will be withheld. C. hardship withdrawals only Additional amount to cover 10% penalty tax D. State tax withholding order to assist us with this, please provide your state of residence in the space below. State of Residence: The following choices apply only if your state withholding), we will withhold the higher amount. amount. withholding. you may have regarding your state's withholding laws. Do not withhold state taxes unless required by law withhold state taxes at the rate of: $ or % and VT percentage will be based upon the federal withholding amount. Note: The dollar amount or percentage withheld must meet the minimum withholding guidelines for your state. If you are a resident of north Carolina If you are a resident of Michigan, you must complete and return a Form MI W-4P in order to complete your withholding EM18804-MF9 Page 6 of 10 PAD /12
7 10. DIStrIbutIon MEthoD - Must choose a selection below Choose one: Direct Deposit Check Direct Deposit: You, the participant, authorize deposit your distribution the institution. A check will be issued if all of the direct deposit requirements are not complete. type of account (complete the following): Savings ABA number (nine digit bank routing number) Account number Attach copy of voided check EM18804-MF9 Page 7 of 10 PAD /12
8 11. ContrACt owner/participant S SIGnAturE Your employer s authorization may be required, check with them before submitting your request. Prior to full withdrawal, if you are still contributing, please notify your employer to stop your payroll deduction. It is the individual taxpayer s responsibility for meeting the Internal Revenue Code requirements to qualify for this distribution. All signatures must be dated (mm/dd/yy) within 180 days of the date received by Lincoln to be valid. If your Plan requires spousal consent then your spouse must sign the waiver of rights in Section 12 and agree to this distribution. You elect to waive the thirty (30) day notice period for electing a rollover required by the IRS before a distribution can be processed. is made from the recipient investment/contract provider. Procedure before processing future distributions or loans. By signing below, you certify that you have read and understand this form. You also represent that all of the information provided terms and conditions outlined in Section 9, Option C, Hardship Withdrawals Only or Section 6, 457(b) Unforeseeable Emergency any insurance company or other person, files or submits an application or statement of claim containing any materially false or deceptive information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a For Maryland residents only: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be For Pennsylvania residents only: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of such person to criminal and civil penalties. any benefit, coverage or right, governed by Delaware state law, provided to a person considered a spouse by marriage will also be provided to a party to a civil union and any benefit, coverage or right, governed by Delaware state law, provided to a child of a marriage will also be provided to a child of a civil union. Date EM18804-MF9 Page 8 of 10 PAD /12
9 12. plans SubjECt to SpouSAL ConSEnt waiver requirements provided to me by the Plan Administrator. I hereby approve of, and consent to, the payment option elected by my spouse as Annuity, unless I consent to a different form of payment as provided above. I also understand that the effect of my consent may Date no spouse (must check here if applicable) notary public/plan Administrator Date 13. MAnDAtorY DIStrIbutIon option (Employer use only) balance is $5,000 or less, please read the following and sign below: mailed to him/her and has had at least 30 days (but less than 180) to consider his/her options with respect to this distribution. investment provider without cost or penalty. with respect to mandatory/force out distributions. rollover occurs. Date EM18804-MF9 Page 9 of 10 PAD /12
10 14. plan ADMInIStrAtor/truStEE/thIrD party ADMInIStrAtor SIGnAturES Date of Hire: Date of Severance: Date of Retirement: Years of Service: Yes No %. ErISA plans otherwise directed. non-erisa plans or ErISA plans with contracts excluded under Field Assistance bulletins and by is accurate to the best of your knowledge and is in compliance with all provisions of your Plan Document. Date how to CoMpLEtE this ForM General Distribution (Section 13 Employer option only). rollover (Section 13 Employer option only). plan-to-plan transfer transfer Contract Exchange purchase of permissive Service Credit Field Assistance Bulletins and FAB / , please contact your employer. Customer. and billing address of this account. If information provided is not a valid match, your distribution will be sent via standard mail service. Fort Wayne, IN South Clinton Street IF FAxInG, do not mail in originals. Multi-Fund Contractual obligations are backed by the claims-paying ability of The Lincoln National Life Insurance Company. EM18804-MF9 Page 10 of 10 PAD /12
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(If mailing address is a P.O. Box, street address is also required.)
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