REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT

Transcription

1 Pentegra Retirement Services Colorado East Bank & Trust REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT NON- STOCK Balance IMPORTANT NOTICE: Please carefully review the Special Tax Notice Regarding Plan Payments, which you previously received, prior to completing this form. If you cannot locate this document, contact your Employer, log on to the Pentegra website, or contact Pentegra and a copy will be sent to you. PARTICIPANT DATA (Please Type or Print clearly): (Only to be completed by participants who have separated from service) Name: Current Address: Last First Middle Initial Street City State Zip Social Security Number: Home Phone Number Former Employer Name: Plan ID: TOTAL WITHDRAWAL REQUEST Total Available Vested Balance Check this box if this withdrawal is due to disability FORM OF PAYMENT I irrevocably elect to have (check one): all of my withdrawal directly rolled over to the IRA, Roth IRA or plan listed below. $ or % of the taxable portion of my withdrawal directly rolled over to the IRA, Roth IRA or plan listed below and the remaining portion of my withdrawal paid directly to me. the total amount of my withdrawal (including any taxable portion eligible for rollover) paid directly to me. Other Some or all of your distribution may be subject to Federal and state income tax withholding. If required by law, Federal income tax will be withheld at a flat rate of 20%. If required by your state, state income tax will be withheld at the prevailing rate for your state. Income taxes that have been withheld cannot be refunded by the Plan for any reason. I further understand that this withdrawal will be deducted proportionately from the value of my account in each of the available investment funds. DIRECT ROLLOVER INSTRUCTIONS I hereby instruct the Plan to directly roll over the portion of my taxable distribution indicated above to: Type of Plan (check one): IRA Roth IRA Qualified retirement plan (e.g., 401(k), profit sharing, 403(a), etc.) Eligible Section 457(b) plan Name of Receiving Plan, IRA or Roth IRA: Address of Receiving Plan, IRA or Roth IRA: Annuity Contract under Section 403(b) of the Internal Revenue Code PSI Form 508 Deferred Withdrawal w/out partial payments

2 Please send my payment via: A check sent regular mail. ACH (Automated Clearing House electronic transfer) - complete bank information below: ABA# Account # Branch # Name of receiving institution Address of receiving institution Account Name: I hereby certify that I have reviewed the Special Tax Notice Regarding Plan Payments within the period required by federal tax law and that I hereby waive the 30 day waiting period as allowed by law. I further certify that the plan or account that I have selected above (if any) is eligible and willing to receive my rollover distributions. I acknowledge a $75 distribution fee will be deducted from the proceeds of my withdrawal. I also certify as outlined in the Special Tax Notice Regarding Plan Payments and in the Plan s Summary Plan Description that my spouse may be required to consent to this withdrawal. If so, a fully completed and executed PSI Form 514, Spousal Consent for a Withdrawal, will be submitted. Signature of Participant Date State of: ss.: County of: On this day of, personally appeared before me the said named, to me known and known to me to be the person described in and who executed the foregoing instrument, and he(she) acknowledged that he(she) executed the same. (Seal) STAMP OR SEAL REQUIRED My commission expires Date (Notary Public) PSI Form 508 Deferred Withdrawal w/out partial payments Pentegra Retirement Services 701 Westchester Ave, Suite 320E White Plains NY Phone Fax

3 Pentegra Retirement Services Colorado East Bank & Trust REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT STOCK Balance IMPORTANT NOTICE: Please carefully review the Special Tax Notice Regarding Plan Payments, which you previously received, prior to completing this form. If you cannot locate this document, contact your Employer, log on to the Pentegra website, or contact Pentegra and a copy will be sent to you. PARTICIPANT DATA (Please Type or Print clearly): (Only to be completed by participants who have separated from service) Name: Current Address: Last First Middle Initial Street City State Zip Social Security Number: Home Phone Number Former Employer Name: Plan ID: TOTAL WITHDRAWAL REQUEST Total Available Vested Balance Check this box if this withdrawal is due to disability FORM OF PAYMENT I irrevocably elect to have (check one): A. The distribution from the Stock Fund is to be made: 1. Cash 2. In-Kind (There is a $150 administrative fee applied to in- kind distributions) If 2. is selected above, I elect stock certificate, OR DTC registration (check DTC eligibility with human resources) DTC instructions: Institution Name: Contact Person: DTC #: Account #: Contact Phone #: B. I irrevocably elect to have (check one): all of my withdrawal directly rolled over to the IRA, Roth IRA or plan listed below. $ or % of the taxable portion of my withdrawal directly rolled over to the IRA, Roth IRA or plan listed below and the remaining portion of my withdrawal paid directly to me. the total amount of my withdrawal (including any taxable portion eligible for rollover) paid directly to me. Other Some or all of your distribution may be subject to Federal and state income tax withholding. If required by law, Federal income tax will be withheld at a flat rate of 20%. If required by your state, state income tax will be withheld at the prevailing rate for your state. Income taxes that have been withheld cannot be refunded by the Plan for any reason. I further understand that this withdrawal will be deducted proportionately from the value of my account in each of the available investment funds. PSI Form 508S 150 Deferred Withdrawal w/o partial payments

4 DIRECT ROLLOVER INSTRUCTIONS I hereby instruct the Plan to directly roll over the portion of my taxable distribution indicated above to (please attach a statement from the plan, IRA or Roth IRA certifying its eligibility and willingness to accept this rollover): Type of Plan (check one): IRA Roth IRA Qualified retirement plan (e.g., 401(k), profit sharing, 403(a), etc.) Eligible Section 457(b) plan Annuity Contract under Section 403(b) of the Internal Revenue Code Name of Receiving Plan, IRA or Roth IRA: Address of Receiving Plan, IRA or Roth IRA: Please send my payment via: A check sent regular mail. ACH (Automated Clearing House electronic transfer) - complete bank information below: ABA# Account # Branch # Name of receiving institution Address of receiving institution Account Name: I hereby certify that I have reviewed the Special Tax Notice Regarding Plan Payments within the period required by federal tax law and that I hereby waive the 30 day waiting period as allowed by law. I further certify that the plan or account that I have selected above (if any) is eligible and willing to receive my rollover distributions. I acknowledge a $75 distribution fee will be deducted from the proceeds of my withdrawal.. I also certify as outlined in the Special Tax Notice Regarding Plan Payments and in the Plan s Summary Plan Description that my spouse may be required to consent to this withdrawal. If so, a fully completed and executed PSI Form 514, Spousal Consent for a Withdrawal, will be submitted. Signature of Participant Date State of: ss.: County of: On this day of, personally appeared before me the said named, to me known and known to me to be the person described in and who executed the foregoing instrument, and he(she) acknowledged that he(she) executed the same. (Seal) (Notary Public) STAMP OR SEAL REQUIRED My commission expires Date PSI Form 508S 150 Deferred Withdrawal w/o partial payments Pentegra Retirement Services 701 Westchester Ave, Suite 320E White Plains NY Phone Fax

5 Colorado East Bank & Trust Termination When can I withdraw a 401k balance (non-stock balance)? A non-stock balance is available for a distribution 30 days after a termination of employment. When can I withdraw a stock balance from my account? Your stock balance can be withdrawn 1 year after your termination of employment but not until the annual stock valuation is complete. Will I receive two different distribution forms? Yes, Pentegra Retirement Services will send you an information kit which will include two distribution forms. Individual forms must be completed for your non-stock balance and you r stock balance. Where do I send the distribution forms? Mail all forms to the following address: Colorado East Bank & Trust Attn: Brenda May 100 W. Pearl PO Box 1019 Lamar, CO 81052