ELECTION OF PAYMENT METHOD

Transcription

1 ELECTION OF PAYMENT METHOD Name of Participant: Name of Participant s Spouse: _ (indicate if unmarried) Address: Telephone: Address: Participant s Social Security #: _ Participant s Birthdate: Spouse s Birthdate: Plan Name: Murphy & Associates 401K Plan U/A DTD 07/01/1985 I have read the Summary Plan Description and after considering the options available to me described in the Summary, I elect to receive my benefit payments following my termination from the plan as follows (check one): lump-sum payment full cash distribution less federal income tax withholding (consent of spouse required) rollover to IRA or new plan (consent of spouse required) a single life annuity (consent of spouse required) a 50% joint and survivor annuity a 66 2/3% joint and survivor annuity a 100% joint and survivor annuity equal monthly/quarterly/annual installments over months/quarters/years (circle one) (consent of spouse required) If I have elected a method other than the joint and survivor annuity I understand that: 1. I am electing not to receive the joint and survivor annuity option. 2. If I am married at the time of my benefit payments are scheduled to begin, the joint and survivor annuity option would otherwise be in the form in which my benefits would be paid. 3. My spouse may not receive any benefits from the Plan after my death. 4. My spouse s consent is required for my election to be effective.

2 CONSENT OF SPOUSE (necessary only if noted on payment method selected) As the spouse of the participant named in the foregoing election form, I hereby irrevocably consent to the election by my spouse on the reverse not to have the benefits under the Plan paid in the form of a joint and survivor annuity. Further, I hereby acknowledge that I understand that (1) the effect of my consent may be to forfeit benefits I would otherwise be entitled to receive upon my spouse s death; (2) my spouse s election is not valid unless I consent to it; (3) my consent is irrevocable. Social Security Number Spouse s Signature Print Name STATE OF COUNTY OF THIS IS TO CERTIFY that on this day of _,, before me, the undersigned, a notary public in and for the state of, duly commissioned and sworn, personally appeared, to me known to be the individual described in and who executed the within and foregoing instrument, and acknowledged to me that said individual signed the same as said individual s free and voluntary act and deed for the uses and purposes therein mentioned. WITNESS my hand and official seal the day and year in this certificate first above written. Notary public in and for the state of residing at My appointment expires Received by: For the Plan Administrator

3 PARTICIPANT S WAIVER OF 30-DAY NOTICE REQUIREMENT UNDER SECTION 402(f) I wish to have my distribution from the plan made as soon as possible in accordance with the benefits election form(s) that I returned to the plan administrator. Therefore, I,, hereby waive the 30-day time period otherwise required between the date the Section 402(f) Notice was provided to me and the date that my election regarding my distribution is implemented. In connection with this waiver, I hereby confirm the following: 1. that I acknowledge receipt of a written Section 402(f) Notice, setting forth the various distribution options available to me; 2. that I understand that I am entitled to a reasonable period of not less than 30 days from the date the notice was provided to me in which to decide whether to make or not make a direct rollover of my distribution; and, 3. that, notwithstanding my waiver, I continue to have the opportunity within the 30-day period to reconsider my decision of whether or not to elect a direct rollover until my election is actually implemented. Social Security Number Print Name

4 PARTICIPANT S ELECTION FOR DIRECT ROLLOVER OF ELIGIBLE ROLLOVER DISTRIBUTION TO INDIVIDUAL RETIREMENT ACCOUNT (IRA) I hereby elect to make a direct rollover of either: [ ] all of my eligible rollover distribution, or [ ] a portion of my eligible rollover distribution in the amount of $ from Murphy & Associates 401K Plan U/A DTD 07/01/1985 (the Old Plan ) to the individual retirement account listed below (the IRA ). To the extent that I do not elect a direct rollover of all of my eligible rollover distribution, the portion not transferred by direct rollover shall be paid directly to me. I understand that the amount paid directly to me shall be subject to mandatory withholding in the amount of 20 percent. In making the election, I certify to the following: 1. I have established my individual retirement account ( IRA ) with an authorized bank or other financial institution. 2. The IRA is, or is intended to be, and individual retirement account under section 408(a) of the Internal Revenue Code. 3. The IRA will accept the direct rollover for my benefit. 4. If so requested, I have provided a copy of a written statement evidencing the above items to the plan administrator of the Old Plan. Therefore, I hereby direct my plan administrator of the Old Plan to make payment of my eligible rollover distribution to the following IRA: Name of IRA: Trustee or Custodian: Account #: Address: Employee s Name: Asset Instructions: [ ] Sell (cash-out) investments to rollover assets in cash, or [ ] Transfer investments to new account intact

5 PARTICIPANT S ELECTION FOR DIRECT ROLLOVER OF ELIGIBLE ROLLOVER DISTRIBUTION TO QUALIFIED PLAN I hereby elect to make a direct rollover of either: [ ] all of my eligible rollover distribution, or [ ] a portion of my eligible rollover distribution in the amount of $ from Murphy & Associates 401K Plan U/A DTD 07/01/1985 (the Old Plan ) to the qualified plan listed below (the New Plan ). To the extent that I do not elect a direct rollover of all of my eligible rollover distribution, the portion not transferred by direct rollover shall be paid directly to me. I understand that the amount paid directly to me shall be subject to mandatory withholding in the amount of 20 percent. In making the election, I certify to the following: 1. I am currently employed by the sponsor of the New Plan 2. The New Plan is, or is intended to be, a qualified plan under section 401(a) of the Internal Revenue Code which accepts rollovers by its terms, or an annuity plan under section 403(a) of the Internal Revenue Code. 3. The New Plan will accept the direct rollover for my benefit. 4. If so requested, I have provided a copy of a written statement evidencing the above items to the plan administrator of the Old Plan. Therefore, I hereby direct my plan administrator of the Old Plan to make payment of my eligible rollover distribution to the following retirement plan: Name of New Plan: Account #: Trustees: Address: Employee s Name: Asset Instructions: [ ] Sell (cash-out) investments to rollover assets in cash, or [ ] Transfer investments to new account intact

6 PARTICIPANT S ELECTION FOR DIRECT ROLLOVER OF ELIGIBLE ROLLOVER DISTRIBUTION TO SELF I hereby elect to make a direct rollover of either: [ ] all of my eligible rollover distribution, or [ ] a portion of my eligible rollover distribution in the amount of $ from Murphy & Associates 401K Plan U/A DTD 07/01/1985 (the Old Plan ) to myself ( Self ). In making the election, I certify I understand the following: 1. I will receive only 80% of the payment, because the Plan administrator is required to withhold 20% of the payment and send it to the IRS as income tax withholding to be credited against my taxes. 2. My payment will be taxed in the current year unless I roll it over. I may be able to use special tax rules that could reduce the tax I owe. However, if I receive the payment before age 59 ½, I also may have to pay an additional 10% tax. 3. I can roll over the payment by paying it to my IRA or to another employer plan that accepts my rollover within 60 days of receiving the payment. The amount rolled over will not be taxed until I take it out of the IRA or employer plan. 4. If I want to roll over 100% of the payment to an IRA or an employer plan, I must find other money to replace the 20% that was withheld. If I roll over only the 80% that I received, I will be taxed on the 20% that was withheld and that is not rolled over. Therefore, I hereby direct my plan administrator of the Old Plan to make payment of my eligible rollover distribution to me: Name: Address: