PREMIER 401(k) Plan DIRECT TRANSFER / IRA ROLLOVER

Transcription

1 DIRECT TRANSFER / IRA ROLLOVER To: Eligible Participants of the PREMIER 401(k) Plan Subject: Direct Transfers or Rollovers into the PREMIER 401(k) Plan As an Eligible Participant of the PREMIER 401(k) Plan, you have the opportunity to complete a direct transfer or rollover of amounts from other qualified retirement plans into the PREMIER 401(k) Plan. New EGTRRA tax laws allow a direct transfer or rollover from the following: 401(k) (Note: 401(k) and 403(b) Roth contributions are permitted rollovers.) 403(b) Eligible 457(b) government plans Taxable IRA s (Individual Retirement Accounts) Please note however, after-tax IRA s and Roth IRA s are not allowed for transfer into our plan. Qualified Plans To assist you in completing your direct transfer or rollover into the PREMIER 401(k) Plan, please follow these instructions Contact your previous employer to obtain and complete a qualified retirement plan distribution form. (This form will allow the transfer of funds out of a prior company-sponsored retirement plan.); and/or Contact your current IRA custodian to obtain and complete a direct transfer distribution form. (This form will allow the transfer of funds out of a current IRA.) Inform your previous employer or IRA custodian to have the distribution check made payable to: TD Ameritrade FBO: Participant name Note: If your rollover includes Roth contributions, please request that a breakdown between Regular (pre-tax) and Roth (after-tax) contributions be provided together with the Tax Year that Roth contributions were first made. You will be required to provide the Tax Year of your first Roth contribution on the Certification of Direct Transfer / IRA Rollover. The tax rules for distributions from Roth accounts differ significantly from those of traditional pre-tax accounts. No income tax will apply to a qualified Roth distribution if the distribution satisfies the five-year rule and is made on account of death, disability, retirement or age 59 ½. Please speak to your plan administrator for further information. Request to have your distribution check mailed to your home address and make a copy for your tax records. Please remember the check must be made payable to: TD Ameritrade FBO: Participant name Complete the attached PREMIER 401(k) Plan CERTIFICATION OF DIRECT TRANSFER / IRA ROLLOVER forms. Please note that the Certification indicates how you will elect to invest the direct transfer or rollover contribution in the plan. Please staple the distribution check to the CERTIFICATION OF DIRECT TRANSFER / IRA ROLLOVER forms and deliver or mail them to: First PREMIER Bank ATTN: Teresa DeBoer 3820 North Louise Avenue Sioux Falls, SD Your Human Resources department will send the direct transfer or rollover check via regular mail to the plan custodian, with the account number on the check, and fax a copy of the signed paperwork along with a copy of the rollover check to: processing department at (507) to the plan custodian but this shall be at your expense.) Alliance Benefit Group (You may request that the check be sent overnight If you have any questions or comments on the above procedures, please feel free to contact the Human Resources Department at First PREMIER Bank.

2 CERTIFICATION OF DIRECT TRANSFER / IRA ROLLOVER of Birth: Home Phone: Home Address: Spouse of Hire: Address (optional): Work Phone: Spouse of Birth: The money will be transferred from your prior Plan, (Transferor) to the PREMIER 401(k) Plan (Transferee). (Name of prior Plan) The Transferor is: Qualified Retirement Plan (i.e. 401(k) plan, profit sharing plan, pension plan) Governmental 457 Plan (Note: 457 Plans maintained by tax-exempt organizations are not eligible to be rolled over.) 403(b) Plan IRA or SEP (Note: Only a distribution from an IRA that would be includible in gross income may be rolled into a plan. After tax contributions may not be rolled into a plan.) the distribution was received from your prior Plan: (MM/DD/YYYY) (This date cannot be more than sixty (60) days prior to the date of this election.) Enter the amount of your rollover distribution: Pretax contributions and earnings (taxable amount of distribution): $ Roth after-tax contributions and earnings (total Roth after-tax contributions): $ Roth after-tax contributions (basis): $ Tax Year of first Roth contribution: (YYYY) Your Total Rollover Contribution: $ To the best of my knowledge, the above information is correct. I am rolling amounts from one of the above listed sources into the PREMIER 401(k) Plan. To the best of my knowledge, the funds being rolled over do not belong to a restricted 457 plan or IRA as discussed above. I acknowledge that no after-tax money, other than Roth contributions (if applicable), are being rolled over from a qualified plan into the Transferee plan. I understand that I may be required to provide supporting information to verify the above information and shall provide such information upon request. This information may include, but shall not be limited to, plan statements, determination letters and summary plan descriptions. Signature *F074064*

3 ELECTION FOR DIRECT TRANSFER / IRA ROLLOVER Section I. Direct Transfer / IRA Rollover I hereby confirm that I have received a distribution from my former employer s plan, as listed in the Certification of Direct Transfer or IRA Rollover. I have received, read and understand the Special Tax Notice Regarding Plan Payments from my former Employer which contains general information on the rules regarding rollover, direct rollover and withholding upon distribution. I have received this distribution from my former Employer in the total amount of $, and received on.(mm/dd/yyyy) Pursuant to the provisions of the PREMIER 401(k) Plan, I hereby elect to directly transfer or rollover into the PREMIER 401(k) Plan $. I do hereby certify that no part of such direct transfer or rollover contribution was a voluntary nondeductible contribution from my former employer s plan or from my IRA. Section II. Investment Selection I understand that the PREMIER 401(k) Plan permits me to invest contributions into various Funds each with a different investment strategy. The risks and rewards associated with each Fund have been explained to me, and I understand that the Plan Sponsor determines the various Funds available for the Plan. I understand that I may invest contributions as I choose or I may select one of the model portfolios. I acknowledge that I am ultimately responsible for the investment of all contributions made to the Plan among the Funds available to me. The Plan Sponsor has not offered or given me investment advice regarding my selection nor will the Plan Sponsor be responsible for any gain or loss that may result from my investment selection. Accordingly, I hereby elect my transfer or rollover contributions to be invested as follows:nondeductible contribution from my former employer s plan or from my IRA. Option 1. Invest my transfer or rollover contributions in the same manner as my current elections (this option may only be selected if you are currently deferring); or Option 2. Invest my transfer or rollover contributions as indicated on the following page (in whole percentages only and totaling 100)

4 Option 2 Investment Elections PREMIER 401(k) Plan ELECTION FOR DIRECT TRANSFER / IRA ROLLOVER - CONTINUED o OPTION 1 BUILD YOUR OWN PORTFOLIO INVESTMENT OPTIONS TICKER INVESTMENT Metlife Series Class 25 MF4915 American Funds US Govt Securities A AMUSX DFA Inflation-Protected Securities I DIPSX American Funds Bond Fd Am A ABNDX Templeton Global Bond A TPINX American Funds Am Balanced A ABALX MFS Value A MEIAX Vanguard 500 Index Admiral VFIAX American Funds Amcap A AMCPX T. Rowe Price New America Growth PRWAX T. Rowe Price Mid-Cap Value TAMVX Vanguard Mid Cap Index Admiral VIMAX T. Rowe Price Mid Cap Grow Adv PAMCX Vanguard Small Cap Index Admiral VSMAX American Funds Cap Wrld Gr & Inc Cl A CWGIX Dodge/Cox International Stk DODFX DFA Emerging Markets Value DFEVX ING Global Real Estate A IGLAX Smart Retirement Income Intst JSIIX Total Must Total 100 OPTION 2 SELECT A MODEL PORTFOLIO Conservative Mod. Conservative Moderate Mod. Aggressive Aggressive Only Select One OPTION 3 SELECT A TARGET DATE FUND SmartRetirement 2015 Instl SmartRetirement 2020 Instl SmartRetirement 2025 Instl SmartRetirement 2030 Instl SmartRetirement 2035 Instl SmartRetirement 2040 Instl SmartRetirement 2045 Instl SmartRetirement 2050 Instl SmartRetirement 2055 Instl Only Select One Target Fund SECTION III. Authorization I hereby authorize the foregoing election and investment allocation and understand that my direct transfer or rollover contribution will be governed by the terms and provisions of the PREMIER 401(k) Plan. I understand that if I choose above, only my rollover contributions will be allocated to this option until I either formally change my allocation or until such time that such Funds are no longer made available within the Plan (any existing account balance will not change based on this election). I further understand that if I choose one of the pre-determined model portfolios that my rollover contributions will continue to be invested within that model portfolio until I formally change my allocation. The model portfolio (not your entire account balance) will be realigned based on the allocation percentages within the model portfolio at the time of the realignment. The timing of the model portfolio realignment is at the discretion of your Plan Administrator. I verify that I have received or have been made available a Summary Plan Description and a prospectus for each investment option within the Plan and that I accept the provisions thereof. Plan Administrator Signature

5 MODEL PORTFOLIO INFORMATION Important Information Regarding Model s Your Retirement Plan offers a broad range of investment options known as Designated Investment Alternatives (DIAs). You have the right to pick and choose among these investment options, and to utilize them in any ratio or combination you desire to create your own investment portfolio. As a service to help you take advantage of the available investment options in a well-diversified manner, the Plan s Investment Advisor provides Risk-Based Model asset allocation strategies free of charge for your consideration. Think of the Plan s investment options as ingredients, and the Risk-Based Model asset allocation strategies as recipes you may choose to follow. If you choose to adopt a Risk-Based Model, any contribution you make to the Plan will divided among the Plan s DIAs according to the percentages shown in the table below. In the event that new investment options are added to the Plan, or there is any other material change to the Plan s investment menu, you will receive notification 30 days in advance of the effective date at which point the changes will automatically occur within your individual account. The Risk Based Model s may also be re-balanced periodically as per your Plan s provisions. You may change your investment strategy and adopt, switch, or discontinue the use of a Risk Based Model at any time. You should consult the Plan s Investment Advisor for assistance if you are uncertain of which Risk-Based Model strategy is appropriate for your unique personal circumstances, including your Risk Tolerance and Time Horizon. When implementing any asset allocation strategy, your net worth, annual income, other assets, investments, and expected future needs should all be carefully considered. Additional information regarding the Risk-Based Model s can be found by accessing your account online at or by calling the Plan s Investment Advisor. Conservative Mod. Conservative Moderate Mod. Aggressive Aggressive DODGX Dodge & Cox Stock Fund GIBIX Guggenheim Total Return Institutional GSSIX Goldman Sachs Small Cap Value MF4915 Metlife Series Class AMUSX American Funds US Govt Securities A DIPSX DFA Inflation-Protected Securities I ABNDX American Funds Bond Fd Am A TPINX Templeton Global Bond A ABALX American Funds Am Balanced A MEIAX MFS Value A VFIAX Vanguard 500 Index Admiral AMCPX American Funds Amcap A PRWAX T. Rowe Price New America Growth TAMVX T. Rowe Price Mid-Cap Value VIMAX Vanguard Mid Cap Index Admiral PAMCX T. Rowe Price Mid Cap Grow Adv VSMAX Vanguard Small Cap Index Admiral CWGIX American Funds Cap Wrld Gr & Inc Cl A DODFX Dodge/Cox International Stk DFEVX DFA Emerging Markets Value IGLAX ING Global Real Estate A

6 BENEFICIARY DESIGNATION FORM 1) Complete Your Personal Information Participant Participant Marital Status: Married Single Divorced Separated Spouse Spouse Spouse of Birth: A divorce decree revokes your prior designation, if any, of your spouse or former spouse as your Termination of under the plan unless (a) a QDRO provision provides otherwise; or (b) the Plan Marriage: document provides otherwise. 2) Designate Your Primary (ies) To, my spouse, if living at the time of my death. In equal shares to my lawful living children. Any deceased child s share shall be divided equally among my remaining living children. In equal shares to my lawful children, with one share for each then living child and one share divided equally among the children of any deceased child. Included are any children legally adopted by me and/or my spouse. Other: Complete information below. For more beneficiaries, please attach a sheet of paper with the information requested below. Address: of Birth: Relationship: Designate Your Contingent (ies) Equal Shares Percentage: To, my spouse, if living at the time of my death. In equal shares to my lawful living children. Any deceased child s share shall be divided equally among my remaining living children. In equal shares to my lawful children, with one share for each then living child and one share divided equally among the children of any deceased child. Included are any children legally adopted by me and/or my spouse. Other: Complete information below. For more beneficiaries, please attach a sheet of paper with the information requested below. Address: of Birth: Relationship: Equal Shares Percentage: 3) Spousal Consent If you are married and have designated someone other than your spouse as your sole primary beneficiary, the Participant s Spouse must sign this section. Note: As required by the Retirement Equity Act, spouse s signature must be witnessed by a Notary Public. Consent of Spouse to non-spouse primary beneficiary. I, the undersigned spouse of the Participant named in the foregoing Designation of, hereby certify I have read and understand the Designation of. I understand the property subject to the Designation of is my spouse s account balance under the Plan. I also understand that if my spouse predeceases me, my spouse s entire account in the Plan will become my property unless I give my written consent below for the account to pass to another beneficiary. Being fully satisfied with the provisions of the Designation of, I hereby consent to and accept the beneficiary designation, without regard to whether I survive or predecease my spouse. I understand that my consent is irrevocable unless my spouse changes the Designation of to someone other than me as the sole primary beneficiary I must execute and file with the Plan a similar consent to the new Designation of or the Participant s new Designation of is ineffective and I will be the sole primary beneficiary. Spouse Signature Notary Public 4) Sign and Participant Signature