Things to Remember. r Complete all of the sections on the Retirement Benefit Options form that apply to your request.

Transcription

1 Retiement Benefit 1

2 Things to Remembe Complete all of the sections on the Retiement Benefit fom that apply to you equest. If this is an initial equest, and not a change in a cuent distibution, emembe to have you fome employe complete the Payoll/Pesonnel Authoization section. If you ae equesting a payout lasting less than10 yeas (including a lump sum payout), complete the enclosed Fom W-4P, only if you want an additional amount withheld ove the 20% mandatoy withholding. Enclose the completed Retiement Benefit fom, and any othe equied documentation in the enclosed business eply envelope o emit to: Nationwide Retiement Solutions P.O Box Columbus, Ohio = Denotes an impotant note o citical infomation. Please ead any disclosues noted by the ed flag. 2

3 Retiement Benefit Plan Type Pesonal Infomation Select Plan Type: 457(b) Plan 401(a) Plan 401(k) Plan Rollove Account (All funds will be withdawn on a po-ated basis acoss the selected accounts within the plan.) Name Social Secuity Numbe Addess Date of Bith City, State, & Zip Code Contact Phone Numbe Action Requested Payoll/ Pesonnel Authoization Select an action: I am not equied to eceive a distibution at this time and I wish to defe payments until futhe notice o when minimum distibutions ae equied. If you chose this option, go diectly to the Authoization section. Initiate payout Stop cuent payments (Systematic Withdawal only.) Change/Restat (Wish to change/estat option o distibution amount.) This section must be completed if this is you initial payout equest Employe Entity Numbe Signatue of Authoized Repesentative Date Position & Title of Authoized Repesentative Contact Phone Numbe Date of Seveance Reason: Retiement Temination Disability Payout (Please elect only one option) Any defeal eceived afte the effective date of this payout will automatically be etuned to the above noted paticipant. Rolloves into you account ae held in a sepaate account and a distibution equest must be submitted fo each account. All funds will be withdawn on a po-ated basis acoss all investment options fo each equested distibution. The only exception to this would be a hand witten equest indicating the specific funding option fo the withdawal. In situations whee a ollove account exists, systematic withdawal equests ae distibuted po-ata fom all accounts and may be subject to an ealy withdawal penalty. Please contact us at to discuss whethe you distibution may be subject to an ealy withdawal penalty. Option 1 Lump Sum To eceive a Lump Sum distibution, please select one option: 1. Lump Sum fo the entie account balance. 2. Patial Lump Sum in the amount of $. Payout options continued on next page 3

4 Payout (continued) Option 2 Systematic Withdawal: All funds will be withdawn on a po-ated basis acoss all investment options. If you ae cuently eceiving a systematic withdawal, please note that all of you assets unde the plan, including ollove accounts, will be included in you new systematic withdawal election. To begin a Systematic Withdawal, please select one option: Payment Fequency: Monthly Quately Semi-Annually Annually 1. Fixed amount of $ Please check hee if you would like to include the COLA (cost of living adjustment) 2. Fixed peiod of yeas (1-30) Recalculate Payment Amount Pe Payment Recalculate Payment Amount Annually Please check one of the following options if you would to include an Assumed Gowth Rate 3% 4% 5% 6% 7% 8% 9% COLA (cost of living adjustment) 3. Life Expectancy / Joint Life Expectancy Life Expectancy - Payment amount calculated based on you life expectancy at time payments ae initiated. Joint Life Expectancy - Payment amount calculated based on joint life expectancy of you and you beneficiay at time payments ae initiated. Beneficiay s Date of Bith 4. Lifetime / Joint Lifetime Lifetime - Payment amount ecalculated annually based on you life expectancy at time of calculation. Joint Lifetime - Payment amount ecalculated annually based on joint life expectancy of you and you beneficiay at time of calculation. Beneficiay s Date of Bith 5. Requied Minimum Distibution (Must be at least age 70 1/2.) (See The Details pages fo additional infomation.) Nationwide Puchased Annuities (You election of a puchased annuity is ievocable.) Fo questions about Nationwide Puchased Annuities, contact the Poducts Sevice Cente at Payment Fequency: Monthly Quately Semi-Annually Annually 1. Single Life Annuity (No Beneficiay)* Fixed Vaiable 2. Life Income with Payments Cetain* Fixed Vaiable 5 ys cetain 10 ys cetain 15 ys cetain 20 ys cetain 25 ys cetain 30 ys cetain 3. Joint and Suvivo* Fixed Vaiable 50% 66 2/3% 75% 100% Suvivo Social Secuity Numbe Mailing Addess City, State, & Zip Code Date of Bith Contact Phone Numbe Continue on the next page 4

5 Payout (continued) 4. Fixed Designated Peiod of yeas (3-20) 5. Designated Amount of $. *Attach poof of date of bith fo Life Annuity, Life Income and Joint & Suvivo Fo Rolloves into an Individual Retiement Account (IRA) o anothe employe plan, please contact a Retiement Specialist by calling fo the appopiate foms. Beneficiay Designation Check hee if this is a change of beneficiay. (Beneficiaies listed below eplace any pio designation) PLEASE NOTE: Pecentage split must be in whole pecentages and must total 100%. If additional space fo beneficiaies is equied, attach additional sheets and mak this box: Beneficiay Name Social Secuity Numbe %Split Pimay Contingent Addess Date of Bith Phone# Beneficiay Name Social Secuity Numbe %Split Pimay Contingent Addess Date of Bith Phone# Diect Deposit Infomation Ovenight Check Option Cetification Authoization Check only one option: Checking Account Savings Account Bank/Cedit Union Name Account Numbe ABA NUMBER (Fist nine digits only) I: / / / / / / / / / / I: You ABA numbe appeas at the bottom of you checks between the makings indicated above. Bank o Cedit Union Telephone Numbe: ( ) Note: Diect Deposit is only offeed though membes of the Automatic Cleaing House (ACH). Is this account associated with a bokeage fim o othe investment fim? Yes No If yes, have you confimed that the ABA and account numbes ae coect? Yes No Please note: You must include a voided check if you distibution is being sent to you checking account. By initialing this line,, I elect to ovenight my payout check and I undestand thee is a $25.00 chage to my account fo this sevice. Please note: Checks cannot be sent ovenight to P.O. Boxes Unde penalties of pejuy, I cetify that: 1. The numbe shown on this fom is my coect taxpaye identification numbe (o I am waiting fo a numbe to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt fom backup withholding, o (b) I have not been notified by the Intenal Revenue Sevice (IRS) that I am subject to backup withholding as a esult of a failue to epot all inteest o dividends, o (c) the IRS has notified me that I am no longe subject to backup withholding, and 3. I am a U.S. citizen o othe U.S. peson. I cetify that I have eceived and ead the Special Tax Notice Regading Plan Payments. If I elect to eceive this distibution befoe the end of the 30-day minimum notice peiod, my signatue on this election shall constitute a waive of my ights to the 30-day notice equiement. Fedeal income tax will be withheld fom you payments as equied by the Intenal Revenue Code. If you select a lump sum o systematic withdawal lasting less than 10 yeas, 20% of the taxable potion of the distibution paid to you will be withheld fo fedeal income taxes. State taxes will be withheld whee applicable. State and fedeal taxes withheld will be epoted on a fom 1099R. Some mutual funds may impose a shot tem tade fee. Please ead the undelying pospectuses caefully. The Intenal Revenue Sevice does not equie you consent to any povision of this document othe than the cetifications equied to avoid backup withholding. IF YOU HAVE ANY QUESTIONS CONCERNING THIS FORM, PLEASE CONTACT US AT Paticipant Signatue Date NRI-0132AO

6 Lump Sum Payments Systematic Withdawals Benefit -The Details Patial Lump Sum Payment: This option povides fo a single payment in the amount equested (minimum of $25.00) fom the value of you account. Lump Sum Payment: This option povides fo the payment of the full value of you account in a single payment. Systematic Withdawal : You account is maintained on the Administato s Accumulation System. Thoughout the payout peiod,it continues to ean eithe ecuent inteest in the fixed etun o fund investment pefomance if in the vaiable etun option. You will continue to eceive quately statements. If you death occus pio to the account exhaustion, you beneficiay will eceive payments until the account is exhausted o a lump sum payment of the emaining account balance. All funds ae withdawn on a po-ated basis. Fixed Amount: This option allow you to choose a fixed payment amount (minimum of $25.00) until you account is exhausted. You may elect to apply the Cost of Living Adjustment (COLA) to you payment amount. COLA ates ae declaed annually by the fedeal govenment and the ate applied to you payment will also update annually. COLA can be 0% fo a given yea and would not impact you payment amount in this instance. The final payment will be the balance of you account. In the yea you obtain age 70 1/2, if you payment is less than the minimum amount equied unde fedeal egulations, you payment amount will be inceased. Please indicate the amount to be paid, you beneficiay, thei elationship, thei Social Secuity numbe and thei bith date. Exchanges ae pemitted, subject to annual exchange limitations. Paticipant dies pio to the exhaustion of the account. Beneficiay submites a claim and eceives monthly payments until the account is exhausted o a lump sum payment of the emaining account balance. Fixed Peiod: This option allows you to choose the numbe of yeas you will eceive payments. You may elect to include an assumed gowth ate equal to the Cost of Living Adjustment (COLA) o between 3-9% in the calculation. With an assumed gowth ate, the gowth ate is applied to you account balance when pocessing you initial withdawal each yea. This balance is divided by the numbe of yeas emaining on you withdawal to detemine you withdawal amount fo the cuent calenda yea. You may also elect the fequency at which you payments ae ecalculated annually o pe payment. If you select an assumed gowth ate the ecalculation fequency must be annually. You payment may fluctuate if some o all of you money is invested in the Vaiable Accounts o Mutual Fund. Please indicate the amount to be paid, you beneficiay, thei elationship to you, thei Social Secuity numbe and thei bith date. Exchanges ae pemitted, subject to annual exchange limitations. Paticipant dies pio to the exhaustion of the account. Upon thei claim, the beneficiay eceives monthly payments until the account is exhausted o a lump sum payment of the emaining account balance. Single Life Expectancy: This option povides payments to last though you calculated life expectancy at the time the payments ae initiated. The numbe of payments is not ecalculated afte the payments ae initiated. The payment amount is ecalculated annually. You payment may fluctuate if some o all of you money is invested in the Vaiable Accounts o Mutual Fund. Please indicate you beneficiay, thei elationship to you, thei Social Secuity numbe and thei bith date. Exchanges ae pemitted, subject to annual exchange limitations. Paticipant s cuent age is 65 and life expectancy is 89. Payments will be calculated to last 24 yeas. Joint Life Expectancy: This option povides payments to last though you and you beneficiay s calculated life expectancy at the time the payments ae initiated. The numbe of payments is not ecalculated afte the payments ae initiated. The payment amount is ecalculated annually. You payment may fluctuate if some o all of you money is invested in the Vaiable Accounts o Mutual Fund. Please indicate you beneficiay s date of bith,, thei elationship to you, and thei Social Secuity numbe. Exchanges ae pemitted, subject to annual exchange limitations. Paticipant s cuent age is 65 and beneficiay s age is 59. Paticipant s life expectancy is 89 and beneficiay s life expectancy is 90. Payments will be calculated to last 31 yeas Single Lifetime: This option povides payments to last though you calculated life expectancy at the time the payments ae initiated. The payment amount and numbe of payments is ecalculated annually based on updated life expectancy tables. You payment may fluctuate if some o all of you money is invested in the Vaiable Accounts o Mutual Fund. Please indicate you beneficiay, thei elationship to you, thei Social Secuity numbe and thei bith date. Exchanges ae pemitted, subject to annual exchange limitations. Paticipant s cuent age is 65 and life expectancy is 89. Payments will be calculated to last 24 yeas. Five yeas late, the life expectancy of the paticipant is changed to 91. Payments will be ecalculated to last an additional 2 yeas. 6

7 Benefit -The Details (continued) Systematic Withdawals (continued) Requied Minimum Distibution Puchased Annuity Joint Lifetime: This option povides payments to last though you and you beneficiay s calculated life expectancy at the time the payments ae initiated. The payment amount and numbe of payments is ecalculated annually based on updated life expectancy tables. You payment may fluctuate if some o all of you money is invested in the Vaiable Accounts o Mutual Fund. Please indicate you beneficiay s date of bith,, thei elationship to you, and thei Social Secuity numbe. Exchanges ae pemitted, subject to annual exchange limitations. Paticipant s cuent age is 65 and beneficiay s age is 59. Paticipant s life expectancy is 89 and beneficiay s life expectancy is 90. Payments will be calculated to last 31 yeas. Five yeas late, the life expectancy of the paticipant is changed to 91 and the life expectancy of the beneficiay is changed to 92. Payments will be ecalculated to last an additional 2 yeas. Requied Minimum Distibution: A minimum distibution of you account is equied to begin when you attain age 70 1/2, unless you ae still woking. This payment option will only pay the minimum that is equied to be paid to you each yea. The amount that is equied to be distibuted will be calculated fo each distibution yea in accodanc with poposed egulations unde Section 401(a)(9) of the Intenal Revenue Code. The Requied Minimum Distibution (RMD) will usually be diffeent fo each yea because of the changes in you account balance and the change in you life expectancy. This payment option is not available unless you have attained age 70 1/2 and cannot be olled ove to anothe eligible etiement plan o IRA. Please indicate the amount to be paid (a minimum of $25.00), you beneficiay, thei elationship, thei Social Secuity numbe and thei bith date. Annuitant dies pio to the exhaustion of the account. Beneficiay eceives monthly payments until the account is exhausted o a lump sum payment of the emaining account balance. Puchased Annuity : You account is emoved fom the Administato s Accumulation System and you account balance is used to puchase an annuity contact that you select. Puchase ates ae subject to change monthly. Howeve, once you have puchased an annuity, the benefit amount will emain the same fo the life of the annuity (except fo vaiable annuities). You will eceive an annuity cetificate stating the tems of the contact. You will no longe eceive quately statements. (Not all plans have this option available. Please call custome sevice at to confim availability.) Single Life Annuity: This option povides equal payments ove you lifetime. At the paticipant s death, payments will stop. Thee is no named beneficiay. Attach poof of date of bith. Annuitant dies afte two payments ae made - no death benefit payable. Life Income with Payments Cetain: This option povides payments fo you lifetime. If you die befoe the selected numbe of guaanteed payments has been made, payments will continue to you named beneficiay until the tota numbe of guaanteed payments (5, 10, 15, 20, 25, o 30 yeas) has been made to you and you beneficiay. If you die afte the guaanteed numbe of payments has been made, no death benefit is payable. Please select a guaanteed peiod and indicate you beneficiay, thei elationship, thei Social Secuity numbe, thei bith date, and attach poof of date of bith. 20 Yeas Cetain Annuitant dies in the 5th yea. Beneficiay eceives 15 yeas of monthly payments o an adjusted lump sum payment. Joint & Suvivo: This option povides payments fo you and you suvivo fo you lifetimes. Upon you death, payments will continue to suvivo, if he o she is living. No othe beneficiaies ae pemitted unde this option. Payments to the suvivo may be a pecentage (50%, 66 2/3%, 75% 100%) of the oiginal amount. Please name you suvivo, thei elationship, thei Social Secuity Numbe and thei date of bith on the lines povided and attach poof of date of bith fo both you and you suvivo. Annuitant dies and suvivo is still living. Suvivo eceives the monthly benefit fo as long as they live at 50%, 66 2/3%, 75%, o 100% of the oiginal amount. Annuitant dies and suvivo is also deceased. Fixed Designated Peiod: This option povides fo payments fo the numbe of yeas chosen. You may select any whole numbe of yeas between 3 and 20, inclusive. If you should die befoe the end of the peiod, payments will continue to the beneficiay. Please indicate the numbe of yeas to be paid and indicate you beneficiay, thei elationship, thei Social Secuity numbe and thei bith date. Annuitant dies pio to the end of the designated numbe of yeas. Beneficiay eceives payments to the end of the designated peiod o an adjusted lump sum payment. Designated Amount: This option povides fo payments of a specified dolla amount, not less than $ The length of the payout is detemined by the account value and a set puchase ate. If you should die befoe the annuity is exhausted, you beneficiay could eithe continue the payout o eceive the emaining lump sum. Annuitant dies befoe all annuity payments ae eceived. Beneficiay eceives payments to end of annuity amount o adjusted lump sum. 7

8 NRI-0132AO