Security Benefit Choice Annuity Application Issued by Security Benefit Life Insurance Company. Questions? Call our National Service Center at 1-800-888-2461. 1. Choose Type of Annuity Contract Please select the annuity type: Non-Qualified 408 IRA 408A Roth Other Initial Purchase Payment $ Annuity Start Date (Minimum NQ $5,000; Q $2,000) (mm/dd/yyyy) For IRAs only: Current Year $ Prior Year $ Rollover $ Transfer $ Initial Guarantee Period(s): minimum allocation per Guarantee Period is $1,000. % 1 Year % 2 Years % 3 Years % 4 Years % 5 Years % 6 Years % 7 Years % 8 Years % 9 Years % 10 Years % Other 2. Provide Annuitant Information Same as Owner Name of Annuitant Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Date of Birth (mm/dd/yyyy) Daytime Phone Number Home Phone Number 3. Provide Owner Information Name of Owner Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number Date of Birth (mm/dd/yyyy) 4. Provide Joint Owner Information Name of Joint Owner Male Female First MI Last Mailing Address Street Address City State ZIP Code Residential Address (if different from mailing address) Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number Date of Birth (mm/dd/yyyy) Please Continue 9499 (9-06) Choice 15-94993-00 2012/08/02 (1/4)
5. Provide Primary and Secondary Beneficiary(ies) For additional Primary Beneficiaries, please attach a separate list to the end of this application. 1. Primary Beneficiary Name Address (city, state, zip) Phone No. Social Security No. DOB (mm/dd/yyyy) Relationship to Contract Annuitant % of Benefit 2. 3. For additional Secondary Beneficiaries, please attach a separate list to the end of this application. 1. Secondary Beneficiary Name Address (city, state, zip) Phone No. Social Security No. DOB (mm/dd/yyyy) Relationship to Contract Annuitant % of Benefit 2. 3. 6. Provide Replacement Information Do you currently have any existing annuity or insurance policies? Yes No Does this proposed contract replace or change any existing annuity or insurance policy? Yes No If Yes, please list the company and policy number. Company Name Company Name Company Name Company Name Company Name Policy Number Policy Number Policy Number Policy Number Policy Number 7. Choose Systematic Payment of Interest Please select one: None Monthly Quarterly Semiannually Annually Tax Withholding? Yes No 8. Set Up Authorization for Automatic Deposits A voided check must be attached to the authorization. Use this form to direct the systematic payments directly to the clients checking or savings account. I hereby authorize Security Benefit to initiate credit entries to my: Savings Account Checking Account as indicated below. I also authorize the financial institution named below to credit the same to such account. Receipt by the bank of such credit entries shall be deemed receipt by me. I agree that any sum of money paid to the bank after my death shall be refunded to Security Benefit for distribution to the person(s), if any, entitled thereto under the terms of the contract. I hereby authorize the bank to make such refund from the account indicated. Financial Institution Name Mailing Address Street Address City State ZIP Code Transit Routing Number Bank Account Number Bank Account Name 9499 (9-06) Choice 15-94993-00 2012/08/02 (2/4)
State Fraud Disclosures Any person who, with intent to defraud or knowing that he/she is facilitating fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. This state fraud disclosure applies to all jurisdictions except KS, MN and the states listed below. AR Only Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. KY, NM, PA and WV Only Any person who, knowingly and with intent to defraud any Insurance Company or other person, files an application for insurance or statement of claim containing materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties. CO Only It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. CT Only Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud, as determined by a court of competent jurisdiction. D.C. Only WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. GA Only Any person who, with intent to defraud or knowingly that he/she is facilitating fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. MD Only Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. ME Only It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NJ Only Any person who includes any false and misleading information on an application for an insurance policy is subject to criminal and civil penalties. OK Only WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OR Only Any person who, with intent to defraud or knowing that he/she is facilitating fraud against an insurer, submits an application or files a claim containing a materially false or deceptive statement may be guilty of insurance fraud. RI Only Any Person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. TN and WA Only It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. TX Only Any person who, with intent to defraud or knowing that he/she is facilitating fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud, as determined by a court of competent jurisdiction. VA Only Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. VT Only Any person who knowingly presents a false or fraudulent claim for the payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. DE Residents please note: the contract issued based on this Application will be administered in adherence with Delaware s Civil Union and Equality Act of 2011. However, the Civil Union and Equality Act of 2011 does not supersede federal tax law and the Defense of Marriage Act which provide for disparate tax treatment between opposite-sex spouses and same-sex spouses and civil union partners. IL Residents please note: the contract issued based on this Application will be administered in adherence with Illinois Religious Freedom and Civil Union Act of 2011. 9499 (9-06) Choice 15-94993-00 2012/08/02 (3/4)
9. Incentives and Other Considerations Have you or the annuitant been offered any cash incentive or other consideration (such as free insurance) as an inducement to apply for this annuity contract? Yes No Does the owner have an insurable interest in the annuitant? Yes No 10. Provide Signature My signature below indicates that the information provided within the application is accurate and true, including my tax identification number. Tax Identification Number Certification Instructions: You must cross out item (2) in the below paragraph if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest or dividends on your tax return. For contributions to an individual retirement arrangement (IRA), and generally payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct Tax Identification Number. Under penalties of perjury I certify that (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends or the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person (as defined in the IRS Form W-9 instructions). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. x Signature of Owner Date (mm/dd/yyyy) Signed at (City/State) x x Signature of Joint Owner Date (mm/dd/yyyy) Signature of Annuitant Date (mm/dd/yyyy) Agent s Statement Will the Annuity being purchased replace any prior insurance or annuities of this or any other Company? No, to the best of my knowledge, this application is not involved in the replacement of any life insurance or annuity contract, as defined in applicable insurance department regulations. Yes. If yes, please comment below. I have complied with the requirements for disclosure and/or replacements. (Submit a copy of the Replacement Notice with this application and leave the applicant a copy of any written material presented to the applicant.) This application was completed and signed in my presence. Print Name of Agent Code x Signature of Agent Date (mm/dd/yyyy) Print Agency Name Important Information About Procedures for Purchasing a New Contract Code To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who purchases a contract. What this means to you: When you purchase a contract, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver s license or other identifying documents. Mailing Instructions Checks should be made payable to: Security Benefit Life Insurance Company P.O. Box 750497 Topeka, Kansas 66675-0497 Mail to: Security Benefit PO Box 750497 Topeka, KS 66675-0497 or Fax to: 1-785-368-1772 Visit us online at www.securitybenefit.com 9499 (9-06) Choice 15-94993-00 2012/08/02 (4/4)
SECURITY BENEFIT PRIVACY POLICY The privacy of Security Benefit s customers is of utmost importance to us. You provide nonpublic personal information ( NPI ) to us in the course of doing business. We treat this information as confidential and restrict access to it. We collect NPI about you from: (1) your requests for literature; (2) your applications and forms; (3) your financial advisor; and (4) your transactions with us. We do not sell information about current or former customers. We disclose information among our affiliates and to third parties as needed to process transactions or service your account. For example, we may contract with third parties to send you statements. Also, we disclose information as required or permitted by law. Except with regard to California residents, we also may disclose information to companies: (1) that help us sell our products; and (2) with whom we jointly offer products. When we contract with others, we will require them to adhere to our privacy standards. At Security Benefit, we restrict access to your NPI. Such information is given only to those who need it to provide products or services to you. We also maintain: (1) physical; (2) electronic; and (3) procedural safeguards to guard your NPI. This Privacy Policy applies to the following companies: Security Benefit Life Insurance Company, Security Benefit Corporation, Security Distributors, Inc., First Security Benefit Life Insurance and Annuity Company of New York, and Security Financial Resources, Inc. THIS PAGE IS NOT PART OF YOUR CONTRACT 7929S 22-79291-19 2012/02/27
Steps to Lock-In An Interest Rate Security Benefit Life Insurance Company (SBL) and First Security Benefit Life Insurance and Annuity Company of New York (FSBL) (referred to herein as Security Benefit ) offer a rate lock program that helps lock-in the current rate for 60 days while working through the paper process. Below are some questions and answers to help you take advantage of the rate lock. How do I lock the rate for my client? The rate lock is available for 60 days from date of the client signature on the application for new purchases. To ensure your client qualifies for the rate lock, you must meet all of the following requirements, including the In Good Order requirements. Use the check boxes below to ensure that your application submission meets the requirements. Security Benefit must receive all original paperwork within 5 business days of client signature in good order. Money transferring from another carrier must be received at Security Benefit within 60 days of client signature. Representatives should consider sending copies of original paperwork to your compliance staff for approval while sending originals to Security Benefit to meet the rate lock deadline. In Good Order Requirements: Fully completed Incoming Funds Request and/or application Original signed Incoming Funds Request including a signature guarantee if required by the transferring company State Replacement form and Sales Literature form if transfer is replacing an existing annuity Representatives may consider contacting transferring company to identify other additional requirements If you have questions or need assistance, please call our service center at 800-888-2461. The Premier Choice Annuity (Form FSB233 (12-02)) is a flexible purchase payment deferred annuity, and is issued by First Security Benefit Life Insurance and Annuity Company of New York, Rye Brook, New York. The Security Benefit Choice, Multi-Choice, and Select Annuities (Form 4585) are flexible purchase payment deferred annuities, issued by Security Benefit Life Insurance Company. Not available in all states. Security Benefit Life Insurance Company is not admitted in the state of New York and is not authorized to transact insurance business in New York. Annuities are not insured by the FDIC or otherwise insured or guaranteed by the Federal government or any of its agencies. They are not obligations of, or guaranteed by, any bank, savings and loan or credit union. To and Through Retirement 22-90190-00 2012/07/10
SM To and Through Retirement In Good Order Checklist To ensure your new business application will be complete and in good order, please provide Security Benefit the following listed documents. Make sure all parts are completed and each is signed or initialed in the appropriate places. Application Original, signed Incoming Funds Request form, including a signature guarantee if required by the transferring company Incoming Funds Transfer Form (if applicable) Annuity Comparison form (or state specific comparison form) State Replacement form and Sales Literature form if transfer is replacing an existing annuity Non-Resident form if the contract is signed in a state other than the one in which the applicant lives State specific forms (if applicable) NAIC Suitability in Annuity Transactions Model Regulation All Insurance Producers in states that have adopted the NAIC Model Regulation must complete product specific training before soliciting an annuity application. Security Benefit offers training online through RegEd (https://secure.reged.com). For business in states that have adopted this model, Security Benefit will not accept applications if you have not completed the training. If your state has adopted the model Regulation and you have taken your general 4-hour CE training from a company other than RegEd, please send a copy of your certificate from the training provider to Security Benefit, P.O. Box 750497, Topeka, KS 66675-0497. Anti-Money Laundering Training All Insurance Producers must complete Anti-Money Laundering (AML) training before soliciting an annuity application. If you have taken AML training, please send a copy of your certificate from the training provider to Security Benefit, P.O. Box 750497, Topeka, KS 66675-0497. If you have questions or need assistance, please call Security Benefit at 800-888-2461. 22-90280-00 2011/09/15
Choice Annuity Products Incoming Funds Request Questions? Call our National Service Center at 1-800-888-2461. Instructions Use this form to transfer funds from your current carrier to Security Benefit Life Insurance Company (SBL). Complete the entire form. Please type or print. 1. The Owner should complete this Incoming Funds Request form and any applicable state-required replacement forms. 2. Please contact your current carrier for any requirements it may have for transferring money to another company. 3. Obtain Signature Guarantee if required by your current carrier. 4. The documents mentioned above should be mailed to: Security Benefit P.O. Box 750497 Topeka, KS 66675-0497 5. Upon receiving this material Security Benefit will send an acceptance letter to the carrier. 6. If you are completing this form for a 403(b) or 403(b)(7) account/contract please contact your employer for any processing instructions the employer or third party administrator may require. Notice to Current Carrier Please make check(s) payable to Security Benefit for the benefit of the Owner listed on this form and mail to: Security Benefit P.O. Box 750500 Topeka, KS 66675-0500 1. Provide Security Benefit Account Information Application Attached or Contract Number Name of Owner First MI Last Mailing Address Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number Name of Joint Owner First MI Last Social Security Number/Tax I.D. Number Name of Annuitant/Participant (If different from Owner) First MI Last Social Security Number/Tax I.D. Number Please indicate the type of account you would like to transfer your funds to (check one). 403(b) TSA Roth 403(b) TSA Non-qualified Annuity Roth IRA Traditional IRA 7690 M 32-76901-13 2012/08/31 (1/4)
2. Provide Your Current Carrier Information Please fill out the name and contact information for your current carrier. Current Carrier s Name Mailing Address Street Address City State ZIP Code Phone Number Account Number for Current Carrier Please indicate the account type you have with your current carrier (check one). 401(a) 403(b)(7) Roth 403(b)(7) 457 Roth 403(b) TSA Non-qualified Annuity Non-qualified CD, Stock 1 Non-qualified Mutual Fund 1 Life Insurance SEP-IRA SIMPLE IRA Traditional IRA Roth IRA Roth 401(k) 403(b) TSA Other 401(k) 1 This transfer is a taxable event. Please indicate the investment type you have with your current carrier (check one). Annuity Bank CD Mutual Fund Life Policy Money Market Brokerage Account 401(k)/Pension Plan Other If this request involves your entire account balance, please check one of the following. My policy is: Enclosed Lost/destroyed 3. Set Up Transfer/Exchange/Rollover Option Please indicate one of the following. 1035 Exchange: I hereby make complete and absolute assignment and transfer all or the portion specified of my rights, title and interest of every nature and character in and to the Current Carrier Account in Section 2 to Security Benefit Life Insurance Company (SBL) in an exchange intended to qualify under Section 1035 of the Internal Revenue Code. I understand that by executing this assignment, I irrevocably waive all rights, claims and demands under the above policy for the portion specified. If you effect, or have effected, a partial exchange from a previously existing annuity contract with another carrier to an annuity contract with SBL under IRC Section 1035, any withdrawals from or changes in ownership to your SBL contract within 180 days of such partial exchange may have adverse tax consequences. Please consult your tax advisor. Exchange (exchange of 403(b)/403(b)(7) assets from one provider to another provider within your current employer s Plan) Rollover (not like-to-like, for example 457 to IRA, etc.) Transfer (like-to-like, for example, 457 to 457, IRA to IRA, prior employer 403(b) Plan to current employer 403(b) Plan) Please Transfer Immediately On date (transfer must occur within 30 calendar days from Date (mm/dd/yyyy) signing date and will be mailed two business days prior to date listed here) Amount Liquidate my entire Account: Estimated Value $ Liquidate a specified amount: Amount to Transfer $ or % Transfer over years Monthly Quarterly Semi-annually Annually Distribution Requirements (if applicable) I certify that applicable requirements have been met for distribution. Check all that apply: Age 59 1 /2 Disabled Severance from employment on Date (mm/dd/yyyy) 32-76901-13 2012/08/31 (2/4)
4. Required Minimum Distribution (if applicable) Current carrier should distribute my RMD to me prior to transferring/rolling over my account. Current carrier should proceed with the transfer/rollover because the requirements for the current year have been met. 5. Provide Investment Directions Please invest the funds (check one): As indicated on the enclosed application; or for an existing account, to the allocations on file. According to the Investment Allocations indicated below. Indicate whole percentages totaling 100%. The minimum allocation per guarantee period is $1000. Check with your representative as to which Guarantee Periods are available. % One Year Guarantee Period % Two Year Guarantee Period % Three Year Guarantee Period % Four Year Guarantee Period % Five Year Guarantee Period % Six Year Guarantee Period % Seven Year Guarantee Period % Eight Year Guarantee Period % Nine Year Guarantee Period % Ten Year Guarantee Period Must Total 100% 6. Provide Signatures As the Contractowner, I understand, acknowledge and certify that: I am responsible for tax consequences which could include the imposition of penalties, additional taxes and interest. Security Benefit assumes no responsibility or liability for any effects of this transaction. I am aware of my right to receive information regarding my current contract, including contract values. I certify that the information provided is correct and complete. x Signature of Owner Date (mm/dd/yyyy) Signature of Joint Owner Date (mm/dd/yyyy) x Signature of Plan Sponsor or Date (mm/dd/yyyy) Title Third Party Administrator (if applicable Please consult your financial representative or employer) x Signature of Representative Date (mm/dd/yyyy) Print Name of Representative Spousal Consent for Community Property States: If the owner/participant is a resident of AZ, CA, ID, LA, NM, NV, TX, WA or WI, spousal consent is required, unless the owner/participant has no legal spouse. x Signature of Spouse Date (mm/dd/yyyy) Please Continue 32-76901-13 2012/08/31 (3/4)
7. Obtain Signature Guarantee Please obtain a Signature Guarantee ONLY if required by your Current Carrier. You can obtain a Signature Guarantee from a bank, broker or other acceptable financial institution. A Notary Public cannot provide a Signature Guarantee. x Signature of Guarantor Date (mm/dd/yyyy) Title or Name of Institution Place Signature Guarantee Stamp Here 8. Security Benefit Acceptance To be completed by Security Benefit. Security Benefit hereby agrees to accept the transfer of the proceeds identified on this form. x Signature of Accepting Carrier Date (mm/dd/yyyy) Title Mail to: Security Benefit PO Box 750497 Topeka, KS 66675-0497 or Fax to: 1-785-368-1772 Visit us online at www.securitybenefit.com 32-76901-13 2012/08/31 (4/4)
Electronic Authorization Questions? Call our National Service Center at 1-800-888-2461. Instructions Use this form to activate electronic services. Transactions may be requested via telephone, Internet, or other electronic means by the Owner and/or servicing sales representative based on instructions of the Owner. Authorization must be on file with Security Benefit before we will activate electronic services. Please type or print. 1. Provide General Account Information Contract/Account Number Plan Number or Name (Applicable to Employer Retirement Plans only) Name of Owner/Participant First MI Last Mailing Address Street Address City State ZIP Code Social Security Number/Tax I.D. Number Daytime Phone Number Home Phone Number 2. Provide Signature I understand and agree to the terms set forth on this form. x x Signature of Owner/Participant Date (mm/dd/yyyy) Signature of Joint Owner (if applicable) Date (mm/dd/yyyy) x Signature of Representative (optional) Date (mm/dd/yyyy) Print Name of Representative Mail to: Security Benefit PO Box 750497 Topeka, KS 66675-0497 or Fax to: 1-785-368-1772 Visit us online at www.securitybenefit.com 7794 L (R5-06) 32-77941-12 (1/1)
Notice Regarding Replacement of Life Insurance and Annuities for the State of Pennsylvania You have indicated that you intend to replace existing life insurance or annuity coverage in connection with the purchase of our life insurance or annuity policy. As a result, we are required to send you this notice. Please read it carefully. Whether it is to your advantage to replace your existing insurance or annuity coverage, only you can decide. It is in your best interest, however, to have adequate information before a decision to replace your present coverage becomes final so that you may understand the essential features of the proposed policy and your existing insurance or annuity coverage. You may want to contact your existing life insurance or annuity company or its agent for additional information and advice or discuss your purchase with other advisors. Your existing company will provide this information to you. The information you receive should be of value to you in reaching a final decision. If either the proposed coverage or the existing coverage you intend to replace is participating, you should be aware that dividends may materially reduce the cost of insurance and are an important factor to consider. Dividends, however, are not guaranteed. You should recognize that a policy which has been in existence for a period of time may have certain advantages to you over a new policy. If the policy coverages are basically similar, the premiums for a new policy may be higher because rates increase as your age increases. Under your existing policy, the period of time during which the issuing company could contest the policy because of a material misrepresentation or omission concerning the medical information requested in your application, or deny coverage for death caused by suicide, may have expired or may expire earlier than it will under the proposed policy. Your existing policy may have options which are not available under the policy beings proposed to you or may not come into effect under the proposed policy until a later time during your life. Also, your proposed policy s cash values and dividends, if any, may grow slower initially because the company will incur the cost of issuing your new policy. On the other hand, the proposed policy may offer advantages which are more important to you. If you are considering borrowing against your existing policy to pay the premiums on the proposed policy, you should understand that in the event of your death, the amount of any unpaid loan, including unpaid interest, will be deducted from the benefits of your existing policy thereby reducing your total insurance coverage. After we have issued your policy, you will have 20 days from the date the new policy is received by you to notify us you are cancelling the policy issued on your application and you will receive back all payments you made to us. You are urged not to take action to terminate or alter your existing life insurance or annuity coverage until you have been issued the new policy, examined it and have found it acceptable to you. I have received and read a copy of this replacement notice. Applicant s Signature Agent s Signature Date Date Existing Policy # Mail to: Security Benefit PO Box 750497 Topeka, KS 66675-0497 National Service Center: 1-800-888-2461 www.securitybenefit.com 8074 PA (R9-05) 1st Copy Home Office - 2nd Copy Applicant - 3rd Copy Agent 32-80743-70 (1/1)
Commonwealth of Pennsylvania - Public School Employees' Retirement System PO Box 125 Harrisburg PA 17108-0125 Toll-Free: 1-888-773-7748 Web Address: www.psers.state.pa.us PSRS-1264 (02/2007) Authorization For Direct Rollover PSERS Health (Retirement) Insurance Program INSTRUCTIONS: You must complete Part A of the Authorization For Direct Rollover form and sign it. The financial institution you choose must complete Part B of this form with an authorized signature. Funds may be rolled to more than one institution and type of plan; however, a separate Authorization For Direct Rollover must be used for each institution and each plan type. Also, rollovers must be designated as going to an IRA or other eligible plan. The completed rollover form(s) should be submitted with your Application For Retirement. Member Information A Former Last Name (only if used in this System) Member Address Change Check here if new address Apt# or Suite Delivery Address City State & Zip Code Daytime Phone Member Name Evening Phone Social Security No. Gender Date of Birth I authorize the Public School Employees' Retirement System (PSERS) to directly roll over the following installment to the financial institution named in Part B. The amount to be rolled ove r is indicated on my Application For Retirement, Section 4, subsection C2 under "Directly Roll Over". Check one: Installment #1 Installment #2 Installment #3 Installment #4 I understand.... if my financial institution named in Part B will NOT accept a direct rollover because of the minimum threshold amount imposed by said financial institution, or if the distribution is less than $100.00, PSERS will make the payment to me minus 20 percent mandatory federal income tax.. if I decide to change the financial institution after PSERS has released my payment, it is my r esponsibility to transfer the funds from the financial institution named in Part B to the new financial institution. I certify that I am the primary beneficiary and/or sole owner of the eligible retirement plan into which this amount is being directly rolled over. I hereby affirm that the foregoing information is true and correct to the best of my knowledge and belief ; said affirmation is being made subject to the penalties prescribed by 18 Pa. C.S.A. Section 4904 (Unsworn Falsifications to Authorities). Member Signature (required) E-mail Address Date Authorization for Direct Rollover (Retirement) Page 1 of 2
PSERS will automatically include the member's name in the check address. If provided, depositor's account number appears on the check. B Financial Institution Information Depositor's Account Number Financial Institution Name Street Address Street Address Phone Number ( ) Ext. City State Zip Code + 4 Financial Institution Agreement: We certify that this account is an "Eligible Retirement Plan," cre ated or organized in the USA, as defined by the Internal Revenue Code (IRC Sections 401(a)(31)(D), 402(c)(8)(A) and (B)). We further certify that the named account holder is the primary beneficiary and/or sole owner of this "Eligible Retirement Plan." In which type of plan will the funds be placed? IRA (regular): taxfree or taxable funds Other: taxfree or taxable funds [401(a), 403(b), SEP or Safe Harbor 401(k)] Other: taxable funds only [Government 457(b)] Check this box only if this institution will not accept tax free funds. Check this box only if this account cannot accept additional monies after the initial rollover. Financial Institution Authorized Signature (required) Date Authorization for Direct Rollover (Retirement) Page 2 of 2