SPECIAL TAX NOTICE REGARDING DISTRIBUTIONS FROM A QUALIFIED RETIREMENT PLAN This notice contains important information on options and regulations concerning distributions made from a qualified retirement plan [i.e., 401(k) plan, profit sharing plan, money purchase plan, defined benefit pension plan, or 403(b) plan]. SUMMARY Payment or distribution from a retirement plan can generally be taken in two ways. All or any portion of a distribution can be either 1) PAID AS A "DIRECT ROLLOVER" or 2) PAID AS A "DIRECT PAYMENT TO THE PARTICIPANT." DIRECT ROLLOVER: A rollover is a payment of the Plan benefits to an Individual Retirement Arrangement (IRA) or to another Employer's qualified retirement plan. * No income tax will be withheld until the year funds are removed from the IRA or Employer's Plan. DIRECT PAYMENT TO PARTICIPANT: *The Employer as an income tax payment in the year of distribution will withhold 20%. *If this distribution is made before age 59-1/2, an additional 10% tax penalty might be required when income taxes are filed. *A 60-day grace period is allowed after a Direct Payment is received in which the entire amount can be placed in an IRA or another Employer's Plan. This will be considered a rollover and not taxed. If only the 80% is rolled during this grace period, then taxes will be due on the 20% withheld. ADDITIONAL INFORMATION I. DIRECT ROLLOVER: A terminating participant of a qualified retirement plan can choose a direct rollover of all or any portion of the distribution amount "eligible as a rollover distribution." In a direct rollover, the eligible rollover distribution is paid directly from the Plan to an IRA or another Employer plan that accepts rollovers. Direct rollovers are not taxed until removed from the IRA or the Employer plan. A. Direct Rollover to an IRA: An IRA can be opened at a bank or other financial institution by the terminating Participant to receive the direct rollover "for the benefit of (FBO)" the terminating Participant. The IRA sponsor (usually a financial institution) will give appropriate instructions for the transfer of funds from the Employer's Trust Account as a direct rollover to an IRA at that institution. An IRA can be temporarily established if the Participant is unsure of how or where to invest the money. In choosing an IRA, consideration should be given as to whether this IRA will allow movement of all or a part of the amount to another IRA at a later date, without penalties or other limitations. See IRS Publication 590, Individual Retirement Arrangements, for more information on IRAs (including limits on how often rollovers can be made between IRA's). B. Direct Rollover to a Plan: Specific instructions concerning the acceptability and/or timing of the movement of funds with the exact name and address of the receiving Plan/Trust must be furnished by the new Employer/Administrator to their new Employee who is rolling all or a portion of his distribution from his old Employer's plan to the new Employer's plan. An Emp loyer's plan is not legally required to accept a rollover. If the new Employer's plan does not accept a rollover, then the only other rollover option is to an IRA. C. Payments that CANNOT be Rolled Over: The following types of payments cannot be rolled over:
* "After-tax" Employee Contributions to a Plan: These contributions will be nontaxable when distributed and cannot be rolled over. (After-tax employee contributions generally are contributions made from compensation that was taxed when earned.) * Beginning in the year that age 70 1/2 is reached, a certain portion of a distribution cannot be rolled over because according to IRS Code it is a "required minimum payment" that must be paid. II. DIRECT PAYMENT TO PARTICIPANT: If payment is made directly to the Participant, it is subject to 20% income tax withholding. The payment is taxed in the year the distribution is received. A. Income Tax Withholding: 1. Mandatory Withholding: If any portion of the distribution is paid directly to the Participant, the Employer is required by law to withhold 20% of that amount unless the amount is less than $200. This 20% is sent to the IRS as income tax withholding. For example, if the eligible distribution is $10,000, only $8,000 will be paid tithe Participant because the Employer must withhold $2,000 as income tax. However, when the Participant's income tax return is filed for the year, the full $10,000 must be reported as payment from the Plan with $2,000 as taxes withheld, which will be credited against any income tax owed for the year. The Form 1099R sent to the terminated Participant from the Plan Administrator for the year of distribution will reflect the entire amount distributed as well as taxes withheld whether it was a rollover or not. If it were a direct rollover, it will be coded as such on the 1099R so that additional tax will not be required. 2. Sixty-Day Rollover Option: If the distributable amount is considered eligible for a rollover distribution (see "Payments that cannot be rolled over" above) and is paid directly to the Participant, the Participant can decide to roll over all or part of it to an IRA or another Employer plan (that accepts rollovers). The amount must be rolled within sixty days of the date the distribution was received by the Participant. This rolled amount does not have to be included as taxable income in the year it was rolled. It will not be taxable until the year it is withdrawn from the IRA. The Participant can roll over up to 100% of the eligible rollover distribution, including an amount equal to the 20% that was withheld. If the Participant chooses to roll over 100%, the Participant must find other money within the 60-day period to contribute to the IRA or the new Employer plan to replace the 20% that was withheld. On the other hand, if the Participant rolls over only the 80% that the Participant received, the Participant will be taxed on the 20% that was withheld. Example: The Participant's eligible rollover distribution is $10,000, and the Participant chooses to have it paid to the Participant. The Participant will receive $8,000 with $2,000 being sent to the IRS as income tax withholding. Within 60 days after receiving the $8,000, the Participant may roll over the entire $10,000 to an IRA or new Employer plan. To do this, the Participant will roll over the $8,000 he/she received from the Plan and will have to find $2,000 from other sources (the Participant's savings, a loan, etc.). In this case, the entire $10,000 is not considered as taxable income until the tax year in which the Participant takes it out of the IRA or new Employer plan. If the Participant rolls over the entire $10,000, when the Participant files his/her income tax return he/she is eligible to receive a refund of the $2,000 withheld. If, on the other hand, the Participant rolls over only $8,000, the $2,000 that the Participant did not roll over (but was withheld for taxes) is considered as income and taxed accordingly. When the Participant files his/her income tax return, he/she may then receive a partial refund of the $2,000 withheld. 3. Additional 10% tax if the Participant is under Age 59-1/2: If the Participant receives a payment before reaching age 59-1/2 and did not select a rollover, then, in addition to
the regular income tax, the Participant may have to pay an extra tax equal to 10% of the taxable portion of the payment. The additional 10% tax does not apply to the Participant's payment if it is (1) paid to the Participant because the Participant separated from service with the Participant's Employer during or after the year the Participant reached age 55, (2) paid because the Participant retired due to disability, (3) paid to the Participant as equal (or almost equal) payments over the Participant's life or life expectancy (or the Participant and the Participant beneficiary's lives or life expectancies), or (4) used to pay certain medical expenses. See IRS Form 5329 for more information on the additional 10% tax. 4. Special Tax Treatment: If the Participant's eligible rollover distribution is not rolled over, it will be taxed in the year the Participant receives it. However, if it qualifies as a "lump sum distribution," it may be eligible for special tax treatment. A lump sum distribution is a payment, within one year, of the Participant's entire balance under the Plan (and certain other similar plans of the employer) that is payable to the Participant because the Participant reached age 59-1/2 or separated from service with the Participant's employer (or, in the case of a selfemployed individual, because the Participant reached age 59-1/2 or have become disabled.) For a payment to qualify as a lump-sum distribution, the Participant must have been a Participant in the Plan for at least 5 years. The special tax treatment for lump-sum distributions is described below. 5. Five-Year Averaging: If the Participant receives a lump-sum distribution after the Participant is age 59-1/2, the Participant may be able to make a one-time election to figure the tax on the payment by using "5-year averaging." Five-year averaging often reduces the tax the Participant owes because it treats the payment much as if it were paid over 5 years. 6. Ten-Year Averaging If The Participant Were Born Before January 1, 1936. If the Participant receives a lump-sum distribution and the Participant was born before January 1, 1936, the Participant can make a one-time election to figure the tax on the payment by using "10-year averaging" (using 1986 tax rates) instead of 5-year averaging (using current tax rates). Like the 5-year averaging rules, 10-year averaging often reduces the tax the Participant owes. IV. SURVIVING SPOUSES, ALTERNATE PAYEES, AND OTHER BENEFICIARIES In general, the rules summarized above that apply to payments to employees also apply to payments to surviving spouses of employees and to spouses or former spouses who are "alternate payees." You are an alternate payee if your interest in the Plan results from a "qualified domestic relations order," which is an order issued by a court, usually in connection with a divorce or legal separation. Some of the rules summarized above also apply to a deceased employee's beneficiary who is not a spouse. However, there are some exceptions for payments to surviving spouses, alternate payees, and other beneficiaries that should be mentioned. A surviving spouse may choose to have an eligible rollover distribution paid in a direct rollover to an IRA or paid directly to him/her. If paid directly to the surviving spouse, he/she may keep it or roll it over to an IRA, but it cannot be rolled to an employer plan. If paid to an alternate payee, the choices are the same as the employee's options. Surviving spouses, alternate payees, or other beneficiaries are not subject to the additional 10% tax described in Section III above, even if they are younger than age 59-1/2. A surviving spouse, an alternate payee, or another beneficiary may be able to use the special tax treatment for lump-sum distributions. If payment is received because of the employee's death, the payment may be treated as a lump-sum distribution if the employee met the appropriate age requirements, whether or not the employee had 5 years of participation in the Plan. V. HOW TO OBTAIN ADDITIONAL INFORMATION:
This notice summarizes only the federal (not state or local) tax rules that might apply to the distribution or payment. The rules described above are complex and contain many conditions and exceptions that are not included in this notice. Therefore, it is advised that the recipient consult with a professional tax advisor before taking a distribution or payment from the Plan. Also, more specific information on the tax treatment of distributions or payments from qualified retirement plans can be found in IRS Publication 575, Pension and Annuity Income and IRS Publication 590, Individual Retirement Arrangements. These publications are available from the local IRS office or by calling 1-800-TAX-FORMS.
DIRECTIVE FOR BENEFIT PAYMENT FORM (DBPF) (Revised form September 2002) PLAN NAME PARTICIPANT NAME ADDRESS PHONE ( ) SOCIAL SECURITY NUMBER * * * * * * * * * * * * * * * * * * * * * * * * * * AMOUNT OF PAYMENT $ OR AMOUNT TO BE CALCULATED: YES OR NO REASON FOR PAYMENT: Check the appropriate reason and give the effective date of the event. [ ] RETIREMENT [ ] TERMINATION OF EMPLOYMENT [ ] DISABILITY [ ] PLAN TERMINATION [ ] DEATH [ ] OTHER * * * * * * * * * * IS THERE A CURRENT PARTICIPANT LOAN YOU HAVE MADE? [ ] YES [ ] NO * * * * * * * * * * UPON MY TERMINATION FROM EMPLOYMENT, I UNDERSTAND THAT, IF THE VALUE OF MY ACCOUNT IS LESS THAN $5,000, THE PLAN ADMINISTRATOR HAS THE OPTION BY LAW TO DISTRIBUTE THE AMOUNT WITH OR WITHOUT MY CONSENT; AND THAT IF I DO NOT RETURN THIS FORM WITHIN 30 DAYS, MY ACCOUNT WILL BE DISTRIBUTED, LESS 20% WHT. FEDERAL INCOME TAX LAW REQUIRES WITHHOLDING OF TAX FROM ANY PENSION DISTRIBUTION; HOWEVER, THE LAW PROVIDES THAT YOU CAN ELECT A DIRECT ROLLOVER OF A PORTION OR ALL OF YOUR VESTED INTEREST TO AN IRA OR ANOTHER EMPLOYER PLAN AND PAY TAX LATER ON THE ROLLED OVER PORTION WHEN YOU TAKE IT OUT OF THE IRA OR THE EMPLOYER PLAN. IF YOU CHOOSE TO BE PAID NOW IN A LUMP-SUM DISTRIBUTION, YOU WILL ONLY RECEIVE 80% OF YOUR VESTED ACCOUNT BALANCE BECAUSE 20% WILL BE AUTOMATICALLY WITHHELD AND PAID TO IRS AS WITHHELD TAXES (WHT). IF YOU CHOOSE A PORTION OF YOUR VESTED BALANCE TO BE PAID AS A LUMP SUM AND THE REMAINDER TO BE ROLLED TO AN IRA OR TO ANOTHER QUALIFIED PLAN, TAXES OF 20% WILL BE WITHHELD FROM THE LUMP SUM REQUESTED AND WILL BE PAID TO IRS. THE REMAINDER OF YOUR VESTED BALANCE WILL BE ROLLED TAX FREE TO THE IRA OR QUALIFIED PLAN. IF YOU CHOOSE TO BE PAID NOW BUT DECIDE ON A ROLLOVER WITHIN 60 DAYS, PLEASE SEE THE "SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS" ON THIS OPTION.
PLAN NAME PARTICIPANT NAME TYPE OF PAYMENT REQUESTED: [ ] IMMEDIATE LUMP SUM PAYMENT LESS 20% WITHHOLDING. [ ] PAYMENT OF $ LESS 20% WHT AND REMAINDER AS ROLLOVER. [ ] ROLLOVER PAYMENT ONLY. IF A ROLLOVER IS CHOSEN, YOU MUST PROVIDE THE FOLLOWING: Account Number of Rollover Plan or IRA: # Exact Name of Rollover Plan: Name of Institution receiving rollover: Mailing Address of Institution: Trustee's Name of Rollover Plan: Phone Number of Institution/Trustee: ( ) MARRIED: [ ] YES [ ] NO If yes, your spouse MUST SIGN the attached Spousal Consent to Distribution Form if your vested account balance is greater than $5,000. I CERTIFY THAT I HAVE RECEIVED A COPY OF THE "SPECIAL TAX NOTICE REGARDING DISTRIBUTION FROM A QUALIFIED RETIREMENT PLAN" AT LEAST 30 DAYS PRIOR TO THE DISTRIBUTION DATE OR THAT THE 30- DAY REQUIREMENT HAS BEEN WAIVED BY ME. THE INFORMATION CONTAINED ON THIS FORM IS COMPLETE AND ACCURATE. I FURTHER CERTIFY THAT NO INSOLVENCY OR BANKRUPTCY PROCEEDINGS ARE NOW AGAINST ANY OF THE UNDERSIGNED. I HEREBY AUTHORIZE THE PLAN ADMINISTRATOR TO ISSUE PAYMENT IN ACCORDANCE WITH SUCH INFORMATION. Participant s Signature Date Print Name of Participant DISTRIBUTION APPROVED BY: Plan Trustee/Plan Administrator s Signature Date
SPOUSAL CONSENT TO PLAN DISTRIBUTION PLAN NAME PARTICIPANT NAME REASON AND EFFECTIVE DATE OF TERMINATION OR REQUEST NOTE TO PARTICIPANT AND SPOUSE: PAYMENT OF INCOME TAX ON THIS DISTRIBUTION CAN BE DEFERRED IF THE DISTRIBUTABLE AMOUNT IS ROLLED INTO AN IRA ACCOUNT OR ANOTHER QUALIFIED PLAN. IF THE DISTRIBUTABLE AMOUNT IS NOT ROLLED AND THE PARTICIPANT IS UNDER AGE 59 1/2, 20% WITHHOLDING FOR INCOME TAX AND A POSSIBLE ADDITIONAL TEN (10%) PERCENT EXCISE TAX WILL BE DUE FOR THE TAXABLE YEAR IN WHICH DISTRIBUTION IS MADE. PLEASE REVIEW THE SPECIAL TAX NOTICE ATTACHED FOR THE VARIOUS OPTIONS AVAILABLE. I HEREBY CONSENT TO THE ELECTION BY MY SPOUSE OF THE FOLLOWING: [ ] IMMEDIATE LUMP-SUM DISTRIBUTION LESS 20% WITHHOLDING. [ ] IMMEDIATE PAYMENT OF $ LESS 20% WHT AND ROLLOVER OF THE REMAINDER TO AN IRA OR ANOTHER QUALIFIED PLAN. [ ] ROLLOVER OF ENTIRE VESTED BALANCE TO AN IRA OR ANOTHER QUALIFIED PLAN. Spouse s Signature Printed Name of Spouse Witness s Signature (Plan Representative or Notary Public) Printed Name of Witness SPOUSAL CONSENT ACCEPTED BY: Plan Trustee or Plan Sponsor (FAILURE TO PROVIDE APPROPRIATE SIGNATURES WILL CAUSE DELAY IN THE DISTRIBUTION)