Comprehensive Health Management, Inc. 401(k) Retirement Savings Plan Rollover Contribution Instructions

Transcription

1 T. Rwe Price Retirement Plan Services, Inc. P.O. Bx Baltimre, Maryland Painters Mill Rad Owings Mills, Maryland Cmprehensive Health Management, Inc. 401(k) Retirement Savings Plan Rllver Cntributin Instructins Use this frm t rll ver yur eligible rllver distributin frm a 401(a) qualified retirement plan (including a 401(k) plan) (r cnduit IRA), 403(b) plan, gvernmental 457 plan, Traditinal IRA¹, r SIMPLE IRA t yur current emplyer's plan. The plan will accept a direct r indirect rllver f taxable amunts frm a frmer emplyer's plan, a rllver frm a Traditinal IRA r SIMPLE IRA and a direct rllver f a Rth 401(k) accunt frm a frmer emplyer s plan. After-tax cntributins frm a frmer emplyer's plan and nndeductible r after-tax cntributins yu made t an IRA are nt eligible fr rllver int this plan. Yu must use yur frmer emplyer's plan frms r ther prcedures t request a distributin frm yur frmer emplyer's plan. Direct rllver frm plan r Traditinal IRA. The check will be issued frm yur frmer plan r IRA custdian and must be made payable t the current plan fr yur benefit. Fr example: Trustee f the Cmprehensive Health Management, Inc. 401(k) Retirement Savings Plan Fr the benefit f (FBO): [yur name] Nte: Payments frm a designated Rth accunt in a Cde Sectin 401(a) qualified plan r annuity r frm a Cde Sectin 403(b) tax-sheltered annuity may be directly rlled ver t the plan. Please have yur frmer Plan Administratr cmplete the apprpriate sectin f the frm certifying the Rth 401(k) cntributin basis and the year f the first Rth cntributin. Indirect rllver frm plan r rllver frm Traditinal/SIMPLE IRA. The distributin must be depsited int the current plan within 60 days f yur receipt f it. It is pssible fr yu t use persnal funds t make up the amunt that was withheld fr taxes. Yu may endrse the check frm yur frmer plan (r Traditinal/SIMPLE IRA) t the current plan, r yu may send a certified check, cashier's check r mney rder. If this is a rllver frm a Traditinal r SIMPLE IRA, yu must attach a check stub r ther statement frm yur IRA identifying the accunt as an IRA and shwing the date and grss amunt f the IRA distributin, as well as the amunt f federal incme taxes withheld frm the IRA distributin t yu. If this is a rllver frm a SIMPLE IRA and the IRA statement indicates that the SIMPLE IRA maintained by yur emplyer was held at the IRA institutin fr less than tw years, yu must prvide dcumentatin, such as IRA statements frm ther IRA institutins, t substantiate that yu participated in the IRA f yur emplyer fr tw years befre the distributin was made. ¹ This includes SEP-IRAs, SAR-SEPs, and cnduit IRAs WCHR (Rev. 7/29/2010) WCHRLTR 9/10

2 If yu have any questins, please cntact T. Rwe Price at Representatives are available Mnday thrugh Friday between 7 a.m. and 10 p.m. eastern time. Fr TDD access, call Yu may als access yur accunt by visiting the T. Rwe Price Web site at rps.trweprice.cm, available 24 hurs a day. Sincerely, T. Rwe Price Retirement Plan Services WCHR (Rev. 7/29/2010) WCHRLTR 9/10

3 Cmprehensive Health Management, Inc. 401(k) Retirement Savings Plan Rllver Cntributin Frm Mail t: T. Rwe Price Retirement Plan Services Special Attn.: Frms Enclsed P.O. Bx Baltimre, Maryland OVERNIGHT MAIL T. Rwe Price Retirement Plan Services Mail Cde Painters Mill Rad Owings Mills, MD : YOUR INFORMATION Yur Name Scial Security Number Date f Birth (MM/DD/YY) Street r P.O. Bx (please include street address if using a P.O. Bx) City/State/ZIP Daytime Phne Evening Phne Address 2: WHICH INVESTMENTS DO YOU WANT YOUR MONEY ROLLED INTO? Select the investment ptin(s) in which yu wuld like yur rllver invested. If yu wuld like the mney invested in accrdance with yur investment electin fr new cntributins, yu may check the bx belw. A list f available investment ptins is included with this kit. Any rllver mney yu wish t invest in the plan must be allcated t ne f thse investment ptins. Please invest my rllver cntributin accrding t my current investment electin fr new cntributins. Please invest my rllver cntributin accrding t my electin belw. One-Step Mix T invest in ne f the Retirement Funds belw, yur existing balance and investment mix in the Plan must be invested 100% in the same Retirement Fund. If yur existing balance and investment mix are nt in the Retirement Fund, yu must chse yur wn mix. % f assets being rlled ver Investment ptin 100% RETIREMENT 2005 FUND 100% RETIREMENT 2015 FUND 100% RETIREMENT 2025 FUND 100% RETIREMENT 2035 FUND 100% RETIREMENT 2045 FUND 100% RETIREMENT 2055 FUND % f assets being rlled ver Investment ptin 100% RETIREMENT 2010 FUND 100% RETIREMENT 2020 FUND 100% RETIREMENT 2030 FUND 100% RETIREMENT 2040 FUND 100% RETIREMENT 2050 FUND 100% RETIREMENT INCOME FUND OR Chse Yur Own Mix Yu may als chse yur wn mix by investing in any f the funds belw. The ttal electin belw must equal 100%. % f assets being rlled ver Investment ptin % f assets being rlled ver Investment ptin % AF EUROPACIFIC GROWTH R5 % AF GROWTH FUND OF AMERICA R5 % BLACKROCK HEALTH SCI OPS INV A % COHEN & STEERS REAL ESTATE % COLUMBIA ACORN FUND,Z % COLUMBIA ACORN INTL Z % DAVIS NEW YORK VENTURE A FUND % EQUITY INCOME FUND % FRANKLIN SMALL CAP VALUE ADV % GOLDMAN SACHS MIDCAP VAL, INST % JPMORGAN SM CAP GROWTH INST % OPPENHEIMER DEVELOP MKTS, A *RBAR *

4 % PIMCO REAL RETURN % PIMCO TOTAL RETURN INSTL % PIONEER STRATEGIC INCOME A % TRP STABLE VALUE FUND SCH E % VANGUARD 500 INDEX FUND % VANGUARD MID-CAP INDEX FUND % VANGUARD SMALL CAP INDEX, INV 3: EMPLOYEE CERTIFICATION (fr indirect/60-day rllver r rllver frm a Traditinal IRA r SIMPLE IRA) I certify t the fllwing statements regarding the rllver funds: I did nt receive the funds as a nnspuse beneficiary f a death benefit. I did nt receive the funds as ne f a series f peridic payments. I did nt receive the funds as a hardship distributin. I am rlling ver the funds within 60 days f the date I received the funds frm the eligible emplyer plan, Traditinal IRA, r SIMPLE IRA. These funds wuld be included in my grss incme if nt rlled ver (n after-tax funds). If I am ver age 70½, the funds d nt include any required minimum distributins. If this is a rllver frm a Traditinal IRA, I have attached the required IRA dcumentatin. If this is a rllver frm a SIMPLE IRA, I received the funds after the expiratin f the tw-year perid beginning n the date that I first participated in the SIMPLE IRA Plan maintained by my emplyer. Signature Date 4: SIGNATURE I understand that, if a determinatin is made that the rllver was an invalid rllver, the amunt f the invalid rllver, plus any earnings attributable t it, will be distributed t me within a reasnable time after such determinatin is made. I agree t ntify the trustees f the plan upn receipt f infrmatin abut such determinatin. I agree t be bund by the terms f the prspectus fr each fund I have selected as an investment ptin. I understand that I will receive the prspectus after I purchase shares in the fund. I agree that neither the trustee, T. Rwe Price Grup, Inc., its affiliates, nr its funds, will be liable fr any lss when acting upn instructins believed t be genuine. Signature Scial Security Number Date The frmer emplyer plan administratr shuld cmplete the infrmatin belw. 5: PLAN DISTRIBUTION INFORMATION - Yur rllver cannt be prcessed unless this sectin is cmplete. Please prvide the fllwing infrmatin cncerning the plan frm which the distributin was made. Plan Name Plan Type: 401(a) (including a 401(k) plan) 403(b) Gvernmental 457 plan I certify that the plan named abve is intended t satisfy the requirements f the Internal Revenue Cde fr the plan type abve, and I am nt aware f any plan prvisin r peratin that wuld result in the disqualificatin f the plan. Grss amunt f distributin: $ Date distributin issued: Pretax cntributins and earnings (Taxable amunt f distributin): $ After-tax cntributins (Excluding Rth 401(k) cntributins): $ Rth 401(k) cntributins and earnings (Ttal Rth 401(k) distributin): $ Rth 401(k) cntributins (basis): $ Year f initial Rth cntributin: Des the distributin qualify as an "eligible rllver distributin" under 402(c) f the Internal Revenue Cde? *RBAR *

5 Please sign this frm in the space prvided t certify that the infrmatin cntained abve is accurate. Signature f Frmer Emplyer Plan Administratr Print Name Title Date Address Cntact Phne Number Nte t plan administratr: Please return this frm t the frmer assciate at the address given in Sectin 1.

6 yur investment ptins fr the Cmprehensive Health Management, Inc. 401(k) Retirement Savings Plan This retirement plan allws yu t invest yur cntributins amng a number f different investment chices. Each ptin is categrized by its ptential return and risk. Please call t request a prspectus, which includes investment bjectives, risks, fees, expenses, and ther infrmatin that yu shuld read and cnsider carefully befre investing. Please nte that sme fund families assess redemptin fees n shares purchased thrugh rllver cntributins that are then held fr less than a designated perid. The amunt f fee charged and transactins affected may vary. Cnsult each fund's prspectus r call fr mre infrmatin. One-Step Mix Higher Risk/Return Ptential Lwer Risk/Return Ptential T. ROWE PRICE RETIREMENT FUNDS RET. INCOME Chse-Yur-Own-Mix Higher Risk/Return Ptential Lwer Risk/Return Ptential Stcks B nds M ney M arket/stable V alue AF EUROPACIFIC GROWTH R5 AF GROWTH FUND OF AMERICA R5 BLACKROCK HEALTH SCI OPS INV A COHEN & STEERS REAL ESTATE COLUMBIA ACORN FUND,Z COLUMBIA ACORN INTL Z DAVIS NEW YORK VENTURE A FUND EQUITY INCOME FUND FRANKLIN SMALL CAP VALUE ADV GOLDMAN SACHS MIDCAP VAL, INST JPMORGAN SM CAP GROWTH INST OPPENHEIMER DEVELOP MKTS, A VANGUARD 500 INDEX FUND VANGUARD MID-CAP INDEX FUND VANGUARD SMALL CAP INDEX, INV PIMCO REAL RETURN PIMCO TOTAL RETURN INSTL PIONEER STRATEGIC INCOME A TRP STABLE VALUE FUND SCH E Nte: Investment ptins are placed in general risk/return categries based n their past perfrmance r, fr newer investment ptins, the perfrmance f the types f securities in which they invest. There is n assurance past trends will cntinue. Use Plan Accunt Line fr investing Call and key in r say yur Scial Security number and fur-digit persnal identificatin number (PIN). Yu may als btain investment infrmatin r make changes t yur accunt thrugh the T. Rwe Price Web site at rps.trweprice.cm. Fr TDD access, call T. Rwe Price Investment Services, Inc., distributr, T. Rwe Price mutual funds.