Elevator Constructors Annuity and 401(k) Retirement Plan Distribution Form Account Number 60041-1 Name: Social Security No. Address: Date: Legal State of Residence:. If the Legal State of Residence is not provided, MassMutual will use the state provided in the Mailing Address for state tax purposes. RETURN THIS FORM TO: MassMutual Retirement Services P.O. Box 219062 Kansas City, MO 64121-9062 Page 1 of 8 By Overnight Mail: MassMutual Retirement Services 430 W 7 th Street Kansas City, MO 64105 Email: You may also email this form to MassMutual at rscsoprocessing@massmutual.com Fax: You may also fax this form to MassMutual at (1-816-701-3922) PLEASE READ THIS ENTIRE FORM CAREFULLY, COMPLETE ALL APPLICABLE SECTIONS, AND SIGN AT THE END. PART 1: ELECTION OF SOURCES YOUR SUBACCOUNTS The Individual Account you have with the Elevator Constructors Annuity and 401(k) Retirement Plan ( Plan ) may consist of as many as four (4) subaccounts: (1) An Elective Contribution Account, which is comprised of your Elective Contributions plus investment gains or losses on those Elective Contributions (401(k) Account); (2) The portion of your Non-Elective Contribution Account comprised of the non-elective Annuity contributions made on your behalf and received by the Plan prior to January 1, 2011 plus investment gains or losses on those nonelective contributions (Old Annuity Account); (3) The portion of your Non-Elective Contribution Account comprised of the non-elective Annuity contributions made on your behalf and received by the Plan on or after January 1, 2011 plus investment gains or losses on those nonelective contributions (New Annuity Account); and (4) If you contributed a Qualifying Rollover Distribution to the Plan, you have a Qualifying Rollover Distribution Account with the Plan (Rollover Account). The Plan s rules governing your eligibility to receive a distribution from each of these subaccounts are as follows: 401(k) Account: A full or partial distribution can be made from your 401(k) Account as long as: (a) you continue to have no Annuity contributions made to this Plan on your behalf for 6 consecutive months and you are not working for a participating employer in this Plan; or (b) you attain age 59½, or (c) you attain age 55 and are either receiving a pension from the National Elevator Industry Pension Fund or Social Security Retirement benefits; or (d) you are Disabled. Old Annuity Account: A full or partial distribution can be made from your Old Annuity Account as long as: (a) you continue to have no Annuity contributions made to this Plan on your behalf for 6 consecutive months and you are not working for an employer participating in this Plan; or (b) you attain age 55 and are either receiving a pension from the National Elevator Industry Pension Fund or Social Security Retirement benefits; or (c) you are Disabled. This distribution rule also applies to your Rollover Account (if any). New Annuity Account: A full distribution can be made from your New Annuity Account as long as: (a) you attain age 55 and are either receiving a pension from the National Elevator Industry Pension Fund or Social Security
Retirement benefits; or (b) you are Disabled. (Part 1 Continued) YOUR ELECTION OF SOURCES I have read the above description of the Plan s distribution eligibility rules concerning each of my subaccounts in the Plan, and I hereby elect to have the amount distributed to me drawn from my following subaccounts: I elect to have 100% of my Individual Account (all of my subaccounts) distributed in the manner described in Part 2 below. I elect to have only a portion of my Individual Account distributed to me at this time in the manner described in Part 2 below: OR, My 401(k) Account: My Old Annuity Account: Dollar Amount: or Percentage: Dollar Amount: or Percentage: My New Annuity Account (Check only one): Yes, I wish to have my New Annuity Account distributed in the manner described Part 2 below. No, I wish to keep my New Annuity Account in the Plan My Rollover Account (if any): Dollar Amount: or Percentage: If you elect to have less than 100 percent of your Individual Account distributed at this time, the balance of your Individual Account will be left in your respective subaccounts. Page 2 of 8
PART 2: ELECTION OF DISTRIBUTION OPTIONS I elect to have my distribution paid in the manner described below (Please select only one): Single Lump Sum. I elect to have the portion of my Individual Account I have designated for distribution in Part 1 of this Form paid in a single lump sum, and I do not wish to have any portion of my distribution directly rolled over to an IRA or eligible employer plan. (Do not complete Parts 3 or 5 of this Form) Direct Rollover (or Partial Direct Rollover with Single Lump Sum). I have read the enclosed Special Tax Notice (For Payments not from a Designated Roth Account) and I elect to make a direct rollover of: Dollar Amount: or Percent Amount: (enter 100% if you wish to have your entire distribution directly rolled over) of the portion of my Individual Account I have designated for distribution in Part 1 of this Form to the IRA or eligible employer plan designated below: Name of Plan or IRA Trustee Account Number Mailing Address I elect to have the balance of my distribution, if any, that is not directly rolled over paid in a single lump sum (Do not complete Parts 3 and 5 of this Form). Installment Payments. I elect to have the portion of my Individual Account designated for withdrawal in Part 1 of this Distribution Form paid in Installment Payments (You must complete Part 3 of this Form). Partial Direct Rollover with Installment Payments. I have read the enclosed Special Tax Notice (For Payments not from a Designated Roth Account) and I elect to make a direct rollover of: Dollar Amount: or Percent Amount: of the portion of my Individual Account I have designated for withdrawal in Part 1 of this Distribution Form to: Name of Plan or IRA Trustee Account Number Mailing Address I elect to have the balance of my distribution that is not directly rolled over paid in Installment Payments (You must complete Part 3 of this Form). Page 3 of 8
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PART 3: INSTALLMENT PAYMENTS Complete this Part only if you selected the Plan s Installment Payments option or Partial Direct Rollover with Installment Payments option in Part 2 above. The Plan s Installment Payment option is flexible. At any time you can change the frequency of the payments, the amount of each payment, or the period over which the payments will be made as long as the total period for the payments remains less than 10 years (maximum 119 months) and also less than your life expectancy or the life expectancy of you and your spouse. Contact MassMutual for more information. A Participant who elects to take his or her benefit in installments and later returns to work for a participating employer may not continue to receive the installment payments. The portion of my Individual Account I designated for withdrawal in Part 1 of this Distribution Form should be paid out in installments over (select one): 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 119 Months I wish to have my Installment Payments made on a (select one): Monthly Basis Quarterly Basis Semi-Annual Basis Annual Basis Page 5 of 8
Federal Income Tax Withholding PART 4: TAX WITHHOLDING Single lump sum distributions and installment payments over a period of fewer than 10 years are subject to 20% mandatory federal income tax withholding. For more information regarding federal income tax treatment of distributions from this Plan, please read the enclosed Special Tax Notice (For Payments not from a Designated Roth Account). Contact your tax advisor or the IRS if you have any questions concerning tax withholding. Additional Federal Income Tax Withholding If you would like an amount withheld in addition to the 20% mandatory federal income tax withholding, complete the following: Deduct the 20% mandatory Federal tax withholding from the taxable portion of my distribution and an additional amount of % federal income tax withheld from my payment(s). State Income Tax Withholding Contact your tax advisor or your state s tax department if you have any questions concerning state tax withholding. Refer to the enclosed State Tax Information document for important information regarding State Withholding in your Legal State of Residence. If you make an election that is not in compliance with your state s regulations, MassMutual will default to your state s requirements. No State Tax Withholding Election. I have read the State Tax Information document and I elect to have no state income tax withheld from my payment(s). Voluntary State Income Tax Withholding. I have read the State Tax Information document and I elect to have the following voluntary state income tax withheld from my payment(s) (choose one): %, or $ (whole dollar amount), or check here if you wish to have the amount of state income tax withheld determined based on your state's tax table formula, if applicable (MassMutual will apply the default tax allowance) Additional State Income Tax Withholding I have read the State Tax Information document and I elect to have an additional % or $ (whole dollar amount) state income tax withheld from my payment(s). Page 6 of 8
PART 5: DIRECT DEPOSIT AGREEMENT (Available only if you elected Installment Payments or Partial Direct Rollover with Partial Installment Payments) I authorize MassMutual to make all installment payments due to me under the above-numbered account by Electronic Direct Deposit to the bank account designated below. I also authorize MassMutual to initiate debits to that bank account for overpayment made to me and the bank named below to debit my account and refund any such overpayment to MassMutual. Payments made under this agreement fully satisfy any obligation to make payments to me. I also agree that, to cancel this agreement, I must give at least one month's written notice to MassMutual s Home Office. Upon my death, my executors or administrators will pay to MassMutual from my estate the amount of any payments collected by the bank which may have been considered as an overpayment depending upon the type of distribution election made. Direct deposit to my bank account (Deposited within 3 business days from date of processing). Checking - Please include a voided check Savings - Please include a pre-printed deposit slip or a bank specification sheet from your bank. Bank Name Bank ABA/Routing (9 digits) Bank Account No. Please note that we can only send funds via direct deposit to banks with a valid U.S. routing number. I understand that if I do not fully complete this section or the bank account information I have provided is invalid, a check will be mailed. Subsequent withdrawals will be processed in the same manner (up to 180 days from the date of the original distribution) unless I notify MassMutual in writing to distribute the money differently. I also authorize MassMutual to initiate a debit to my account for any overpayment or payments made in error. Send payment by check (Allow up to 10 business days for postal service delivery). Bank Name Area Code & Telephone Street Address City, State, Zip Please indicate only one account category below. Checking Account Number (enclose copy of voided check) Savings Account Number (enclose savings deposit slip) Bank Routing/Transit Number Some international wires (or wire transfers) are processed by intermediary banks. Please check with your financial institution to ensure that no additional instructions are necessary. Page 7 of 8
PART 6: SIGNATURE(S) AND WAIVER OF MINIMUM NOTICE PERIOD and PARTICIPANT CERTIFICATION (You must complete this section in order for your elections to be processed.) Waiver of Minimum Notice Period: I consent to an immediate distribution in the payment form I have selected above. I affirmatively waive any unexpired portion of the 30 day notice period during which I may consent to a distribution from the Plan. I understand that there may be administrative fees deducted from my account and, if all required items are not completed on this form, processing will be delayed. Participant Certification: I certify that I am no longer working for a participating employer in this Plan and that I have not worked in the trade as an Elevator Constructor in the last six months. Participant / / Date Participant s Phone Number (Please provide your phone number in the event we have questions regarding your distribution election.) Page 8 of 8