State of New Mexico Distribution Request for Deferred Compensation Plan

Transcription

1 State of New Mexio Distribution Request for Deferred Compensation Plan DC-4075 (12/2015) For help, please all

2 Things to Remember Complete all of the setions on the Distribution Request form that apply to your request. If this is an initial request, and not a hange in a urrent distribution, remember to have your former employer omplete the Payroll/Personnel Authorization setion. If you are requesting a payout lasting less than 10 years (inluding a lump sum payout), omplete the enlosed Form W-4P, only if you want an additional amount withheld over the 20% mandatory withholding. Enlose the ompleted Distribution Request, and any other required doumentation in the enlosed business reply envelope. 2 DC-4075 (12/2015) For help, please all

3 State of New Mexio Deferred Compensation Plan Distribution Request Personal Information Name: SS#: Address: Aount #: City, State*, ZIP: Phone #: Address: How would you like to be ontated if additional information is required? Telephone *NRS will use the state provided as your state of resideny for tax purposes, unless instruted otherwise. Ation Requested (hek the option that applies) I am not required to reeive a distribution at this time and I wish to defer payments until further notie or when minimum distributions are required. If you hose this option, go diretly to the Authorization setion. Initiate Payout Stop Current Payments (for Systemati Withdrawals only) Change/Restart (You wish to hange or restart payout option or distribution amount) Employer Authorization Your employer MUST omplete this setion if this is your first distribution request. This setion is not required for 1) partiipants with previous distributions from the plan, 2) distributions from deemed IRAs, and 3) partiipants who are urrently employed and age 70 1 / 2 and older. If you are retired or have not been employed for the last 45 days, you an ontat NMPERA to help with this setion. Authorized Representative (PRINT): Authorized Representative Signature: Authorized Representative Position/Title: Date: Plan Year End: Hire Date: Reason: Severane of Employment Retirement Disability Severane Date: Benefiiary Designation Chek here if this is a hange of benefiiary. (Benefiiaries listed below replae any prior designation) PLEASE NOTE: Perentage split must total 100% for eah ategory of benefiiary. If additional spae for benefiiaries is required, attah additional sheets and mark this box: Primary Benefiiary(ies) (must total 100%): Name Relationship Soial Seurity # Phone # Address Date of Birth % Split Name Relationship Soial Seurity # Phone # Address Date of Birth % Split Contingent Benefiiary(ies) (must total 100%): Total = 100% Name Relationship Soial Seurity # Phone # Address Date of Birth % Split Name Relationship Soial Seurity # Phone # Address Date of Birth % Split Total = 100% DC-4075 (12/2015) For help, please all

4 One Time Payment Selet One Option: Entire aount balane Partial amount of $ (Amount inluding tax withholding, minimum of $25*) * The terms of the Plan Doument govern the minimum amount allowed for partial one-time payments. Some Plans require a $1,000 minimum for a partial one time payment. On-Going Systemati Payments Frequeny: Monthly Quarterly Semi-Annually Annually If no payment frequeny is seleted, payment will be set-up for the default option of monthly. Start Date (Month/Day/Year): If start date is not provided, the payment start date will be the date your request is proessed. The reeipt date of your payment is dependent upon the payment method you selet. SELECT ONE SYSTEMATIC PAYMENT OPTION OPTION 1: Fixed Dollar Payment Speified amount (minimum of $25) paid to you until your aount balane is zero (final payment may be less). The number of payments you reeive will vary depending on the earnings (gains/losses) your aount experienes. Payment Amount: $ (Amount inluding tax withholdings) Please hek to inlude the ost of living adjustment (COLA) OPTION 2: Fixed Period Payment Aount balane paid to you for the number of years seleted. The atual dollar amount will vary depending on the earnings (gains/losses) your aount experienes, and the duration requested. You must hoose a alulation method for your payment. If no alulation method is seleted, payments will default to the standard method with annual alulations. Number of Years (1 30 years) Please selet a alulation method: Standard: Annually (Default Option) OR Per Pay Period Assumed Growth Rate: COLA* 3% 4% 5% 6% 7% 8% 9% *Cost of living adjustment OPTION 3: Life Expetany and Lifetime Payment Please selet a alulation method: Life Expetany / Joint Life Expetany*: Life Expetany OR Joint Life Expetany* Lifetime / Joint Lifetime*: Lifetime OR Joint Lifetime* *Joint Life and Joint Lifetime alulations will be based on the joint life expetany of you and your primary benefiiary at the time of alulation. Benefiiary s Date of Birth(Month/Day/Year): OPTION 4: Required Minimum Distribution Must be at least 70½ years of age to selet this option. The benefit ommenement date must be no later than April 1 st of the alendar year following the year in whih a partiipant attains the age 70½, unless still employed. Note, if you elet to defer the required minimum distribution for the year in whih you attain age 70½ to the following year, you will be required to take two required minimum distributions in that year. If the RMD requirement is eliminated by the IRS for any given tax year, you must ontat NRS to stop the payment for that year. 4 DC-4075 (12/2015) For help, please all

5 Payment Method Send hek by first lass mail to my address of reord. Allow 5 to 10 business days from proess date for delivery. (Default option, if no other option is seleted) Send hek overnight by UPS at my expense to my address of reord. I understand there is an additional $25.00 fee that will be deduted from my aount. P.O. Box addresses are not eligible for overnight delivery and Saturday delivery may not be available in your area. Allow 2 to 4 business days from proess date for delivery. ACH Instrutions on File Send funds to my bank aount that NRS has on file. Diret Deposit by ACH: Chek only one option: Cheking Aount Savings Aount Bank/Credit Union Name ( ) Bank/Credit Union Phone Number ABA (Routing) Number* (first nine digits only) Aount Number Note: Diret Deposit is only offered through members of the Automati Clearing House (ACH). We annot aept a deposit slip for banking numbers. If ACH information is not ompleted orretly a hek will be sent to your address on file. Is this aount assoiated with a brokerage firm or other investment firm? If yes, have you onfirmed that the ABA and aount numbers are orret? Yes No Yes No I hereby authorize NRS to initiate automati deposits to my aount at the finanial institution named above. In the event an error is made, I authorize NRS to make a withdrawal from this aount. Further, I agree not to hold NRS responsible for any delay or loss of funds due to inorret or inomplete information supplied by me or by my finanial institution or due to an error on the part of my finanial institution in depositing funds to my aount. This agreement will remain in effet until NRS reeives a written notie of anellation from me or my finanial institution, or until I submit a new diret deposit authorization form to NRS. In the event this diret deposit authorization form is inomplete or ontains inorret information, I understand a hek will be issued to my address of reord. Tax Withholding Federal Tax: NRS will withhold federal tax as required by the IRS from the payment you hoose. See the Speial Tax Notie Regarding Plan Payments for speifi tax information and IRS required withholding before ompleting. You may elet below to have no withholding from your required minimum distribution or systemati payments that last 10 years or more. The standard federal tax withholding rate is 20%. Please skip this setion unless you would like a different amount or perentage to be withheld. I would like additional federal tax withheld above the IRS mandatory 20% in the amount of $ or % I have a required minimum distribution or systemati payment lasting 10 years or more and would like federal tax withheld based on my eletion on Form W-4P Do Not withhold federal tax in aordane with my eletion of Form W-4P from my required minimum distribution or systemati payment lasting 10 years or more. State Tax: State taxes will be automatially withheld if you are a resident in a state that mandates state inome tax withholding. If you would like to adjust your state taxes, please omplete and attah a state tax withholding form. These forms an be obtained from the State web site, NRS does not supply these forms. DC-4075 (12/2015) For help, please all

6 Certifiation Under penalties of perjury, I ertify that: 1. The number shown on this form is my orret taxpayer identifiation number (or I am waiting for a number to be issued to me), and 2. I am not subjet to bakup withholding beause: (a) I am exempt from bakup withholding, or (b) I have not been notified by the Internal Revenue Servie (IRS) that I am subjet to bakup withholding as a result of a failure to report all interest or dividends, or () the IRS has notified me that I am no longer subjet to bakup withholding, and 3. I am a U.S. itizen or other U.S. person. 4. The FATCA ode entered on this form (if any) indiating that the payee is exempt from FATCA reporting is orret. Authorization By signing this form, if I have an outstanding loan and I am requesting a total distribution of my aount, I understand the outstanding loan balane will be part of this total distribution and may be taxable inome reported to the IRS on Form 1099-R. Any pending loan payments may delay the proessing of this withdrawal. By signing below, I hereby aknowledge the following information: 1. Rollover ontributions to governmental 457(b) plans that originated from qualified plans, IRAs and 403(b) plans are subjet to the early distribution tax that applies to 401(a) / 401(k) plans unless an exeption appliable to 401(a) / 401(k) plans applies. 2. Rollover ontributions are subjet to the Required Minimum Distribution (RMD) rules of the plan they are rolled into, not the plan or IRA from whih they ame. Federal inome tax will be withheld from your payments as required by the Internal Revenue Code. If you selet a lump sum or systematiwithdrawal lasting less than 10 years 20% of the taxable portion of the distribution paid to you will be withheld for federal inome taxes. Statetaxes will be withheld where appliable. You must submit a Form W-4P (available at if you selet a different form of distribution.state and federal taxes withheld will be reported on a form 1099-R. The Internal Revenue Servie does not require your onsent to any provision of this doument other than the ertifiations required to avoid bakup withholding. I onsent to a distribution as eleted above. I understand that the terms of the plan doument will ontrol the amount and timing of any payment from the plan. Further, I ertify that I have read and reeived the attahed Speial Tax Notie Regarding Plan Payments. If I elet to reeive this distribution before the end of the 30 day minimum notie period, my signature on this eletion form shall onstitute a waiver of my rights to the 30 day notie requirement, if appliable. I ertify that I have not beome re-employed prior to the distribution eleted on this form and to the extent that I have eleted a systemati payment method, I will notify NRS that I am no longer eligible for a systemati payment. I hereby authorize the above eleted benefit and attest to the auray of the information. IF YOU HAVE ANY QUESTIONS CONCERNING THIS FORM, PLEASE CONTACT US AT NMEX (6639). Partiipant Signature: Date: Form Return MAIL TO: Nationwide Retirement Solutions P.O Box Columbus, Ohio For assistane with ompleting this form, please all NMEX (6639) 6 DC-4075 (12/2015) For help, please all

7 Important Information Money Soures Funds will be withdrawn equally aross all money soures and investment options for eah requested distribution unless instruted otherwise. Distributions from rollover and Roth soures may be subjet to an additional exise tax. Distribution Reasons The terms of the Plan Doument govern the availability of distribution types. All distribution types offered on this form may not be permitted under the terms of your Plan. Self-Direted Brokerage Aount If you have money in the Self-direted Brokerage aount and the requested amount exeeds your ore aount balane, you will need to transfer funds bak to the ore aount before your request an be proessed. If you selet a systemati payment, you will need to maintain a suffiient balane in your ore aount to over your eleted amount. If you would like to onfirm or update your benefiiary information, please visit our website at or ontat our ustomer servie enter at DC-4075 (12/2015) For help, please all

8 8 DC-4075 (12/2015) For help, please all