Alaska Carpenters Defined Contribution Trust Fund Physical Address 375 W. 36th Avenue Suite 200 Anchorage, Alaska 99503 Mailing Address PO Box 93870 Anchorage, Alaska 99509 Phone (800) 478-4431 Fax (907) 561-4802 Website www.alaskacarpenterstrusts.com Administered by Labor Trust Services, Inc. APPLICATION FOR PENSION BENEFITS This is your application for Pension Benefits. We recommend that you send your application to this office, along with any other required documents noted in the application, at least ONE MONTH in advance of the first of the month in which you want your pension benefit payments to start. The accuracy and completeness of the information you send to us will speed the processing of your application and provide faster payment of the benefits to which you may be entitled. Please answer all questions carefully. If you have any questions on completing and submitting the application and/or proof of age, please feel free to call the Administrative Office for assistance. Sincerely, ALASKA CARPENTERS DEFINED CONTRIBUTION TRUST FUND You and your dependents m a y be eligible to continue health benefits under the Alaska Carpenters Health & Security Trust Fund s Retiree Medical Plan. If you would like additional i nformation, please check the box below. Yes, please send me information about the Alaska Carpenters Health & Security Trust Fund s Retiree Medical Plan. Member s Signature Date S:\Forms\Pension\F40\F40-13-Form-ApplicationForPensionBenefits-2013.docx 1
Alaska Carpenters Defined Contribution Trust Fund Complete this form, and send the entire original copy to the Administrative Office, and keep a photocopy for your personal records. Please answer each question as accurately as possible. AN INCORRECT OR INCOMPLETE APPLICATION MAY DELAY YOUR BENEFIT PAYMENT. I. GENERAL INFORMATION 1. Full name: (Last name) (First name) (Middle name or initial) 2. Permanent mailing address: (Number and street) (City and state) (Zip code) 3. Telephone number: 4. Local Union Number: (Area code) (Alaska) 5. Social Security Number: Male Female 6. Date of birth: 7. Are you married?... Yes No 8. Name of most recent employer in the building trades industry: 9. My last date of employment in the Building and Construction Trades Industry was/or will be: (month) (day) (year) 10. Are there any court orders pending relating to the assignment of all or part of your benefit to another? II. APPLICATION TYPE Please check ONE box. Normal Pension (age 60+). Please attach proof of age as described in Section III. Early Pension (ages 53 through 59) and you have separated from service (defined as termination of all employment with a contributing plan employer) for at least 30 consecutive days and have not returned to covered employment prior to receipt of your distribution. You must submit a copy of your employer issued layoff slip or of a current unemployment check stub to prove your termination date and attach proof of age as described in Section III. Inactive (24 consecutive months without employment covered by the Plan). Inactive (Covered by Plan for less than 12 months, followed by 12 months without covered employment). Withdrawal of Rollover Contribution Account Only. Disability Pension. Please request a copy the plan s disability questionnaire to be completed by your doctor. If you are receiving a Disability Benefit from Social Security, please attach a photocopy of your Award Letter from Social Security. Death Benefit. Please include a photocopy of the Participant s Death Certificate. Member s Name: Member s Date of Death: Member s SS#: Applicant s Relationship to Member: Applicant s Name: Applicant s SS#: Applicant s Address: City: State: Zip: Applicant s Phone #: NOTE: Non-spouse beneficiaries may not choose the direct rollover option in Section IV. Qualified Domestic Relations Order (QDRO). Please provide a complete copy of the relevant court order. 2
III. PROOF OF AGE Participants applying for benefits must provide proof of age before their application can be approved. Documents accepted for proof of age are listed below. Additional proof of age may be requested if the document you submit is not acceptable. Please do NOT send originals. SUBMIT ONE OF THESE: 1. An Official Birth Certificate from the Bureau of Vital Statistics from records made at time of birth. 2. An affidavit from a city, county or state bureau of vital statistics stating that your birth was registered and including certification of the date that your birth registered. 3. A baptismal certificate or a statement as to the date of birth shown by a church record certified by the custodian of such record. 4. Hospital birth records, certified by the custodian of such record. 5. A letter from the Social Security Administration certifying your age as it appears on their records. 6. A signed statement by the physician or midwife who was in attendance at birth, as to the date of birth shown on their record. 7. Certification of age by the United States Census Bureau. 8. Original Naturalization Record. 9. Original Immigration Paper. 10. A foreign church or government record indicating evidence of age. (OR) SUBMIT TWO OF THESE: 11. School or college record, certified by the custodian of such record. 12. Confirmation certification stating your age or date of birth. 13. Military record. 14. Original U.S. Passport. 15. A life insurance or annuity policy at least five years old stating your age or date of birth. 16. Marriage record. 17. Vaccination record, certified by the custodian of such record. 18. Other evidence, such as voting records, poll tax receipts, or driver s license. 3
IV. DISTRIBUTION CHOICES FORM OF PAYMENT: Please check ONE box. Single Lump Sum. Annuity (purchased from an insurance company). Skip the Payment Destination, Direct Rollover Information, and Annuity Waiver sections below. Call the Administrative Office for further information. Equal Annual Installments of $. I am aware that these equal annual installments will continue until the earlier of my receipt of 10 annual installments OR such time as my account is exhausted. Partial Lump Sum. At this time, I wish to withdraw $ from my Account Balance. I understand that, at a later date, I may elect to receive the remainder of my Account Balance in another payment form offered under the Plan at that time. Recurring Partial Lump Sum. I wish to withdraw $ every (month, quarter, year) until my account is exhausted or I provide new payment instructions to the Administrative Office. I understand that, at a later date, I may elect to receive the remainder of my Account Balance in another payment form offered under the Plan at that time. PAYMENT DESTINATION: Please check ONE box. Please pay my requested distribution directly to me after withholding 20% for federal income taxes plus any state or local withholding as required by law. I realize that I may also be subject to an additional 10% early withdrawal penalty if I am under age 59½ and have not yet retired. Skip the Direct Rollover Information section below. Please rollover my ENTIRE requested distribution into a qualified retirement plan or the traditional IRA named below. I have verified that this qualified plan/financial institution will accept my rollover distribution. I understand that this rollover will not be subject to any tax withholding. Please rollover $ into the qualified retirement plan or traditional IRA named below. I have verified that this qualified plan/financial institution will accept my rollover distribution. I understand that this rollover will not be subject to any tax withholding. In addition, please pay the remainder of my requested distribution in a lump sum to me after withholding 20% for federal income taxes plus any state or local withholding as required by law. I realize that I may also be subject to an additional 10% early withdrawal penalty if I am under age 59½ and have not yet retired. DIRECT ROLLOVER INFORMATION: Complete if applicable. Name of Qualified Retirement Plan or/ Financial Institution: Account Number: Mailing Address: City State Zip Code Attention: Telephone #: F40-13/App/Website 4
V. SINGLE LIFE ANNUITY NOTICE 1. Annuity Information (Unmarried Participants) If you are not married, your benefits will be paid to you in the form of a Single Life Annuity unless you elect otherwise. A Single Life Annuity provides you with monthly payments for your life. No benefits are paid to your estate or beneficiaries after your death. Unless you elect otherwise, your vested account balance will be used to purchase a Single Life Annuity contract from an insurance company. The contract will be distributed to you as evidence of your right to receive the annuity payments from the insurance company. The amount of the monthly payments under the Single Life Annuity contract will depend on the annuity purchase rates used by the insurance company, your age at the time the distribution begins, and the amount of your vested account balance at the time the contract is purchased. Your account will be charged for any commissions incurred incident to the purchase of the contract. You may choose to waive the Single Life Annuity form of payment. To make a valid waiver, you must complete the "Election to Waive Single Life Annuity" in section VII. You must make your election during the 90-day period before your benefits are due to be paid. However, you may revoke this election before benefits begin. If you waive the Single Life Annuity, you will receive your vested account balance in the form or forms of benefit you elect. 2. Deferred Annuity If you do not make any decision about your account, it will be distributed as a deferred annuity beginning after the date you reach age 60. At any time before 60, you can make a further election about the time and manner of payment of the benefit under the annuity. Any form of payment allowed under the Plan will remain available under the deferred annuity. If you do nothing before you reach age 60, the deferred annuity will start then as a straight life annuity if you are unmarried. 3. Immediate Annuity If you chose an immediate annuity and you are unmarried, you will be paid in the form of a straight life annuity ending with your death. Your account will be applied to buy an annuity contract, and the payments to you will start immediately in regular monthly installments. If you are very young, your account may not buy a very large immediate annuity.
VI. JOINT AND SURVIVOR ANNUITY NOTICE 1. Annuity Information (Married Participants) If you are married, your benefits will be paid to you in the form of a Joint and Survivor Annuity unless you elect otherwise. Under a Joint and Survivor Annuity, you and your spouse will receive lifetime income. A Joint and Survivor Annuity provides you with a monthly payment for your life and, upon your death, a continuing monthly payment to your spouse for life equal to 100 percent of the payment you received prior to your death. No death benefits are paid to other beneficiaries after the death of both you and your spouse. Unless you elect otherwise, your vested account balance will be used to purchase a Joint and Survivor Annuity contract from an insurance company. The contract will be distributed to you as evidence of your right to receive the annuity payments from the insurance company. The actual monthly payments made under the Joint and Survivor Annuity contract will depend on the annuity purchase rates used by the insurance company, your age and your spouse's age at the time the distribution begins, and the amount of your vested account balance at the time the contract is purchased. Your account will be charged for any commissions incurred incident to the purchase of the contract. You may waive the Joint and Survivor Annuity form of payment. To make a valid waiver, you must complete the "Election to Waive Joint and Survivor Annuity" in section VII, and your spouse must consent to the waiver by signing the "Spouse's Consent to Waiver" in section VII. A notary public must witness your spouse's signature. Your waiver is not valid unless you and your spouse make the election during the 90-day period before your benefits are due to be paid. Within the 90-day election period, you may revoke a waiver election, or make a new waiver election following a revocation, as often as you wish. You may revoke a waiver election without your spouse's consent, but your spouse would have to consent to a new waiver election. 2. Deferred Annuity If you do not make any decision about your account, it will be distributed as a deferred annuity beginning after the date you reach age 60. At any time before 60, you can make a further election about the time and manner of payment of the benefit under the annuity. Any form of payment allowed under the Plan will remain available under the deferred annuity. If you do nothing before you reach age 60, the deferred annuity will start then as a [50/100] percent continuation survivor annuity with your spouse if you are married. The survivor annuity would pay a smaller amount during your lifetime, and half of that amount would continue after your death if your spouse survives you. 3. Immediate Annuity If you chose an immediate annuity and you are married, you will receive a survivor annuity with one-half of your lifetime payments continued to your surviving spouse. Your account will be applied to buy an annuity contract, and the payments to you will start immediately in regular monthly installments. If you receive a survivor annuity with your spouse, one-half of your lifetime payments will be paid for the life of your surviving spouse if you die and your present spouse survives you. If you are very young, your account may not buy a very large immediate annuity.
VII. ANNUITY WAIVER (REQUIRED FOR PARTIAL OR TOTAL LUMP SUMS OR DIRECT ROLLOVERS) Please check ONE Box and complete associated section. UNMARRIED PARTICIPANTS: The normal form of payment is a Single Life Annuity purchased f r o m an insurance company. I have read and understood the Single Life Annuity Notice enclosed in Section V and hereby elect to waive the single life annuity form of payment. Executed this day of, 20 Participant (Print Name) Participant Signature MARRIED PARTICIPANTS: The normal form of payment is a Qualified Joint & Survivor Annuity purchased from an insurance company. If you wish to receive your Account Balance in another form of payment, your spouse must consent below to your election of another payment form other than the Qualified Joint & Survivor Annuity. I, swear that I am the legal spouse of Spouse Name, who is currently applying for Member Name Pension Benefits from the Alaska Carpenters Defined Contribution Trust Fund. THE SIGNATURES BELOW MUST BE WITNESSED BY A NOTARY OR PLAN REPRESENTATIVE I have read and understood the Joint and Survivor Annuity Notice enclosed in Section VI and hereby consent to my Spouse s rejection of the Qualified Joint & Survivor Annuity in order to receive another form of payment under the Plan. I understand that as a result, I will not be paid a pension from the Alaska Carpenters Defined Contribution Trust Fund after my Spouse s death. Spouse s Signature Date NOTARIZATION OF SPOUSE S SIGNATURE Subscribed and sworn to before me this day of, 20. Notary Public Signature Notary Public in and for the State of Residing at My commission expires: VIII. MEMBER SIGNATURE NOTARY SEAL Spouse s Signature Print Spouse s Name Mailing Address: _ BY MY SIGNATURE, I ATTEST THAT ALL OF THE PRECEDING INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THE ADMINISTRATIVE OFFICE MAY TAKE UP TO 60 DAYS TO PROCESS MY REQUEST, AND I WILL NOTIFY THEM OF ANY MATERIAL CHANGES IMMEDIATELY. Member s Signature Date NOTARIZATION OF MEMBER S SIGNATURE Subscribed and sworn to before me this day of, 20. Notary Public Signature Notary Public in and for the State of Residing at My commission expires: F40-13/App/Website NOTARY SEAL Member s Signature Print Member s Name Mailing Address:
Alaska Carpenters Defined Contribution Trust Fund ACH INSTRUCTIONS FOR ELECTRONIC DEPOSIT Plan Name: Participant Name: Please print Participant SSN: Participant Mailing Address: Home phone: Cell phone: _ Bank Name: Bank s Branch Phone Number: Bank s Address (Check one) Checking Savings Other Account Number: ABA Routing Number: Participant Signature: Dated: *All information requested above must be provided. If the ACH Instructions are not complete, a Check will be mailed to your home address.