APPLICATION FOR SURVIVORS BENEFITS

APPLICATION FOR SURVIVORS BENEFITS ALL APPLICATIONS FOR SURVIVORS BENEFITS SHOULD BE SENT TO: UMWA Health and Retirement Funds 2121 K Street, NW Suite 350 Washington, DC 20037-1879 1-800-291-1425 Fax: 202-521-2353 E-mail: Pension@umwafunds.org

SURVIVORS BENEFIT APPLICATION SURVIVING SPOUSE BENEFIT, JOINT AND SURVIVOR ANNUITY, PRE-RETIREMENT SURVIVOR ANNUITY, OR WIDOW S PENSION A monthly pension will be paid to the eligible spouse of a deceased mine worker who was eligible for or receiving a pension at the time of death, or to the eligible spouse of a participant who was service-eligible, but not yet old enough to receive a pension and who had completed at least one hour of service on or after August 23, 1984, and died after October 1, 1984. DEATH BENEFIT A lump sum death benefit will be paid upon the death of a mine worker who was receiving a pension at the time of his death. No death benefit is payable if the mine worker was receiving a deferred vested pension based on less than twenty years of service or any pension based, in part, upon non-classified service. The Trust Fund that provides the death benefit is determined by the health benefit plan (if any), the pension type the mine worker was receiving and the signatory status of the last coal employer. 1950 PENSIONERS In general, if the mine worker was receiving health benefits from the Combined Benefit Fund, a lump sum death benefit of $5,000 will be paid to the widow or other eligible surviving dependents. If there are no eligible surviving dependents, a lump sum payment of $4,000 will be made to the estate of the pensioner. If the mine worker was not receiving health benefits from the Combined Benefit Fund, and dies on or after January 1, 2007, a death benefit in the amount of $8,500 will be paid to the widow or other eligible surviving dependents. If there are no eligible surviving dependents, a lump sum payment of $7,000 will be made to the estate of the deceased pensioner. For such pensioners who are not Combined Fund beneficiaries, and who die on or after July 1, 2013, a death benefit of $10,000 will be paid to the eligible surviving spouse or dependents, or a death benefit of $8,500 will be paid to the deceased s estate. 1974 PENSIONERS If the mine worker was receiving health benefits from the Combined Benefit Fund, a lump sum death benefit will be paid to the beneficiary named by the pensioner. If the named beneficiary is an eligible dependent, the death benefit will be $5,000. The death benefit for any other named beneficiary will be $4,000. If the mine worker was not receiving health benefits from the Combined Benefit Fund, a death benefit will be paid to the beneficiary named by the mine worker. The amount of the death benefit is determined by the mine worker s date of death and the relationship of the named beneficiary. If the mine worker died on or after January 1, 2007, and the named beneficiary is an eligible dependent, the death benefit will be $8,500. The death benefit for any other named beneficiary will be $7,000. If such mine worker dies on or after July 1, 2013, and the beneficiary is an eligible dependent, the death benefit will be $10,000. The death benefit for any other named beneficiary will be $8,500. HEALTH BENEFITS If the last signatory employer for whom the pensioner worked is still in business and providing coverage at the time of the pensioner s death, health benefits will be provided by the Employer. Health benefits may be provided to the eligible survivors of a deceased pensioner who retired from a signatory Employer that is no longer in business and meets certain criteria. A widow who receives the surviving spouse benefit may continue receiving health benefits unless she remarries. As long as the widow remains eligible, the pensioner s surviving unmarried dependent children may receive health benefits until they attain the age of twenty-two. If no widow survives the pensioner, the dependent children may receive health benefits for twenty-two months after the pensioner s death or until they attain twenty-two years of age, whichever comes first. Disabled surviving dependent children of all ages may receive health benefits as long as the widow remains eligible. If the Funds are providing health benefits coverage at the time of the pensioner s death, such coverage will continue for the eligible surviving spouse and dependents as long as eligibility requirements are met. 2

Survivors Benefits Application Checklist All applicants must remember to: Attach a copy of the mine worker s death certificate. Attach marriage certificate (if the spouse is applying). If applying as a Representative of the Estate, please attach a copy of the paperwork appointing you as such. If a divorced spouse is applying, attach a copy of the Divorce Decree and any Qualified Domestic Relations Order, if applicable. If applying for a death benefit as the Contingent Beneficiary, please attach the death certificate of the primary beneficiary. Make sure you sign the application on page 6 when complete, and any other shaded areas that are applicable to you. Please mail or fax your completed application and all attachments to the address/fax number on the cover. 3

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Check the type of benefit you are applying for: DEATH SURVIVING SPOUSE PENSION (widow/widower) SURVIVING SPOUSE PENSION (former spouse) Application for Survivors Benefits Please be sure to attach copies of any relevant documents requested in each section of the application below. Information About the Deceased Mine Worker Name (Last, First, Middle) Social Security Number Address Date of Birth City State Zip Date of Death (Attach Death Certificate) Information About the Applicant Name (Last, First, Middle) Social Security Number/EIN Address Area Code and Telephone Number ( ) City State Zip If surviving spouse, how long have you lived at this address? E-mail Address Alternate Area Code and Phone Number Relationship to the Mine Worker ( ) If you are filing as a legal representative of the deceased s estate, attach a copy of the document appointing you to your position. Surviving Spouse Information (attach copy of marriage certificate) Date of Birth Date of Marriage Were you married to the deceased mine worker at the time of death? YES NO Were you living with the deceased If no, how did marriage end? When (Month, Day, Year) Where (Name of City and State) If you were not living with the mine mine worker at the time of death? YES NO worker, please explain why. If no, was the mine worker providing financial support? YES NO Are you employed? YES NO If yes, give the following information: Name of Employer Date of Employment Gross Monthly Earnings 5

Information About The Deceased s Marriage(s) Answer this item ONLY if the deceased had other marriages, including common law marriages. (If none, write NONE. ) Please provide actual dates, if known. If dates are approximate, please circle them. Spouses s Name (Including maiden name) When (Month, Day, and Year) Where (Name of City and State) How Marriage Ended When (Month, Day, and Year) Where (Name of City and State) Legal Marriage Spouse s date of birth If spouse deceased, give date of death Common Law Marriage (or age) Spouse s Social Security Number (If none or unknown, so indicate) Spouses s Name (Including maiden name) When (Month, Day, and Year) Where (Name of City and State) How Marriage Ended When (Month, Day, and Year) Where (Name of City and State) Legal Marriage Spouse s date of birth If spouse deceased, give date of death Common Law Marriage (or age) Spouse s Social Security Number (If none or unknown, so indicate) Spouses s Name (Including maiden name) When (Month, Day, and Year) Where (Name of City and State) How Marriage Ended When (Month, Day, and Year) Where (Name of City and State) Legal Marriage Spouse s date of birth If spouse deceased, give date of death Common Law Marriage (or age) Spouse s Social Security Number (If none or unknown, so indicate) If necessary, attach a separate sheet of paper with this same information about any other marriages of the deceased. 6

Information About Surviving Dependents Other Than Spouse Gross Monthly Status Earnings Social (Student, From Relationship Security Date Enrolled in Name of Dependent Working, etc.) Employment to Deceased Number of Birth Medicare If any of the surviving dependents listed above do not live with the surviving spouse, list their names and the names and addresses of the people with whom they live: Yes Yes Yes No No No Caretaker/Responsible Party Name For (dependent name): Address Telephone Number: ( ) City State Zip E-mail Address: Alternate Phone Number: ( ) Complete this section only if you are the Power of Attorney/Legal Guardian Name (Last, First, Middle) Telephone Number ( ) Address City State Zip If you are filing as the Power of Attorney/Legal Guardian for the applicant, please include a copy of the legal document naming you as such. Applicant s Certification I certify that all of the information on this application is true and correct. I understand that if any of the information is false, and that if I then receive benefits because of false information, I shall have to repay the benefits to the Funds. I also understand that if I have deliberately given false information, the Funds may take legal action against me. APPLICANT S SIGNATURE DATE Please be sure to sign above to avoid any unnecessary delays in processing. Thank you. 7

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Complete this form only if you are applying for a Surviving Spouse Pension Federal Income Tax Withholding Election Applicant s Name Last First MI Applicant s SSN/EIN Whether or not federal income tax will be withheld from your pension check is your decision. Please read the two choices listed below and indicate your decision by checking only one box (A or B). A. I DO NOT WANT TO HAVE FEDERAL INCOME TAX WITHHELD FROM MY MONTHLY PENSION CHECK. B. I WANT TO HAVE FEDERAL INCOME TAX WITHHELD FROM MY MONTHLY PENSION CHECK ON THE FOLLOWING BASIS (Please check only one box, then enter the number of exemptions you claim for tax purposes.) MARRIED SINGLE NUMBER OF EXEMPTIONS Also, I want to have the following amount withheld from my monthly pension check in addition to the amount calculated using the number of exemptions listed above: $. MINE WORKER S SOCIAL SECURITY NUMBER SPOUSE OR ALTERNATE PAYEE S SOCIAL SECURITY NUMBER APPLICANT S SIGNATURE DATE 9

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Complete this form only if you are applying for a Surviving Spouse Pension Enrollment for Pension Payment by Electronic Funds Transfer I authorize the UMWA 1974 Pension Plan and the financial institution listed below to deposit my pension payment electronically into my account each month. If monies to which I am not entitled are deposited into my account, I authorize the Plan to direct my financial institution to return said funds. This authority will remain in effect until I have cancelled it in writing. Name Financial Institution Payee Social Security Number Branch Address Mine Worker SSN (if different than Payee SSN above) Payee Address: ( ) (Area Code) Phone Number Signature Date City, State, Zip City State Zip Checking Savings (Check one type of account) Account Number ( ) Bank Phone Number Transit Routing Number (ABA*) ATTACH VOIDED PERSONAL CHECK OR DEPOSIT SLIP HERE 11

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Complete this form only if you are applying for a Death Benefit and are the Estate or an Organization UMWA Pension Trust DEATH BENEFIT TAX ELECTION FOR ESTATE OR ORGANIZATION Federal law requires a benefit distribution from the UMWA 1950 or 1974 Pension Trust to be treated as taxable income to you. We must, therefore, report the payment to the Internal Revenue Service (IRS) on Form 1099-R. We are required to withhold 10% of a death benefit distribution unless you inform us that you do not wish to have any amount withheld. The amount withheld will be sent to the IRS and a Form 1099-R will be issued to you at the beginning of next year to reflect the amount that was withheld. If you do not wish to have any amount withheld, you must complete and sign the form below. Your Name (last, first, middle initial) OR Name of Organization Address (street number and name) Mine Worker s Social Security Number City, State, Zip Code Your Telephone Number Income Tax Withholding Check one: I elect to have 10% federal income tax withheld from my benefit payment. I elect not to have federal income tax withheld from my benefit payment. I understand that if I elect to have federal income tax withheld, I am still liable for the payment of federal income tax on any taxable portion of my distribution and that, regardless of my election, I may still be responsible for estimated tax payments if any amount withheld is not sufficient to meet federal income tax obligations. Signature Date PLEASE RETURN THIS FORM IN THE ENCLOSED ENVELOPE 13

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Complete this form only if you are applying for a Death Benefit and are the Surviving Spouse or another named beneficiary (NOT the Estate or an Organization). If the pensioner was receiving Combined Fund Health Benefits, do not complete this form. Please refer to all the following pages for detailed information concerning your election. UMWA Pension Trust DEATH BENEFIT DISTRIBUTION ELECTION FOR INDIVIDUAL PAYEE A. Your Name (last, first, middle initial) Mine Worker Social Security Number Address (street number and name) Beneficiary s Social Security Number City, State, Zip Code Your Telephone Number ( ) B. Income Tax Withholding I have read the Special Tax Notice Regarding Death Benefit Payments and elect to have my distribution paid as follows: (PLEASE CHECK ONLY ONE BOX) 1. I request that a check for the appropriate death benefit amount be made payable to me and sent to the address shown above. I understand that this election reflects the mandatory 20 percent federal income tax withholding which the UMWA Health and Retirement Funds will forward to the Internal Revenue Service. 2. I request that the Trust transfer my death benefit directly to an individual retirement arrangement (IRA). (If you choose this option, please complete section C below.) 3. I request that the Trust transfer a portion of the death benefit payable to me directly to an IRA and that the remainder be made payable to me. The portion of the distribution that is to be made as a direct rollover is $. This check is to be made payable to the trustee of the IRA. I understand that the remainder of the distribution that is payable to me is subject to mandatory 20 percent federal income tax withholding which the UMWA Health and Retirement Funds will forward to the Internal Revenue Service. (If you choose this option, please complete section C below.) Signature Date If you checked box B2 or B3, you must complete this section of the form. C. Rollover Information Name of IRA Name of Financial Institution Account Number Street Address Telephone Number of Financial Institution ( ) City, State, Zip Code 15

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The following pages apply only to individual named beneficiaries, Surviving Spouses, and Former Spouses (alternate payees under a QDRO*) applying for a Death Benefit UMWA Pension Trust DEATH BENEFIT DISTRIBUTION REQUEST Dear Applicant: If the deceased mine worker did not have health benefits under the Combined Benefit Fund, you may be eligible for a death benefit payable from the United Mine Workers of America ( UMWA ) 1974 Pension Trust. Federal law requires us to withhold federal income tax before the death benefit is paid unless you elect to have the death benefit transferred directly to an individual retirement arrangement ( IRA ). An IRA may be either an individual retirement account or an individual retirement annuity. The attached Special Tax Notice explains in detail your options regarding payment of the death benefit and the federal income tax consequences of those options. The two choices available to you are summarized below. However, please carefully review the attached materials for additional information and examples. Your tax advisor may also be able to give you advice. OPTION 1 DISTRIBUTION PAYMENT DIRECTLY TO YOU. If you select this option, we will make the check payable directly to you. However, we are required by law to withhold 20% of that check as mandatory federal income tax withholding. The amount withheld will be paid to the Internal Revenue Service ( IRS ) and reported on IRS Form 1099-R at the end of the year. Depending on your particular tax situation, you may be able to obtain a tax refund from the IRS for some or all of the amount withheld. However, to obtain any refund that might be due, you must file a federal income tax return for the applicable year. After you receive the death benefit, you may still decide to roll over (transfer) to an IRA all or a portion of the death benefit you receive within 60 days. To do so, you must comply with the requirements described in the enclosed Special Tax Notice. OPTION 2 DIRECT ROLLOVER OF ALL OR A PORTION OF THE DEATH BENEFIT. If you select this option, you can request that we transfer some or all of the death benefit directly to the trustee of an IRA set up in your name. The trustee of an IRA is usually a bank or other financial institution. The check will be made payable to [Your Bank], as trustee of the IRA of [Your Name]. If you are a nonspouse beneficiary, the IRA must be set up in your name as beneficiary of the deceased. If you request that the entire death benefit be directly rolled over to an IRA, nothing will be withheld. If you request that only a portion of the death benefit be directly rolled over to an IRA, and a portion paid directly to you, we will be required by law to withhold 20% of the amount that is paid directly to you and report the amount withheld to the IRS as discussed in Option 1, above. *** Please consider your options and return the election form included in this application on page 13. You must affirmatively elect the direct rollover option for the death benefit by completing and returning the election form if you want to avoid the 20% mandatory withholding rules. If you are determined to be eligible for a death benefit and you do not elect a direct rollover within 60 days of the date your application is received, we will automatically distribute your benefits directly to you, less the 20% Federal withholding tax. Please return this form with your completed death benefit application. As soon as we receive your properly completed form and application, we will begin processing the death benefit. If you wish to revoke your election you must do so in writing prior to the distribution of the benefit. If you have difficulty filling out the form, please contact the Funds Call Center at 1-800-291-1425 for assistance. SPECIAL TAX NOTICE REGARDING DEATH BENEFIT PAYMENTS This notice contains important information you will need before you decide how to receive a one-time death benefit from the United Mine Workers of America 1974 Pension Trust ( Trust ). *Qualified Domestic Relations Order 17

SUMMARY If you are claiming entitlement to a death benefit as a surviving spouse (or as a former spouse who has previously been identified as an alternate payee for the death benefit on a qualified domestic relations order), or as a designated beneficiary who is not the surviving spouse ( nonspouse beneficiary ) then the rollover rules set forth in this notice apply to you. If you are one of these types of beneficiaries, then payment of a death benefit from the Trusts can be taken in either of two ways. You can have all or any portion of the death benefit either (1) PAID IN A DIRECT ROLLOVER or (2) PAID TO YOU. A direct rollover is a payment of the death benefit to an individual retirement arrangement ( IRA ) if you are a surviving spouse, or a nonspouse beneficiary, or to an IRA or your qualified employer plan if you are an alternate payee under a qualified domestic relations order. This choice will affect the tax you owe. If you choose a DIRECT ROLLOVER Your payment will not be taxed in the current year and no income tax will be withheld. Your payment will be made directly to your IRA or, if applicable, your Employer Plan. Your payment will be taxed later when you take it out of the IRA, or, if applicable, your Employer Plan. If you choose to have your Plan benefits PAID TO YOU You will receive only 80% of the payment, because the Plan administrator is required to withhold 20% of the payment and send it to the IRS as income tax withholding to be credited against your taxes. Your payment will be taxed in the current year unless you roll it over. You can roll over the payment to your IRA or, if applicable, your Employer Plan, within 60 days of receiving the payment. The amount rolled over will not be taxed until you take it out of the IRA. If you want to roll over 100% of the payment to an IRA or an employer plan, if applicable, you must find other money to replace the 20% that was withheld. If you rollover only the 80% that you received, you will be taxed on the 20% that was withheld and that is not rolled over. MORE INFORMATION I. PAYMENTS THAT CAN AND CANNOT BE ROLLED OVER........................... 18 II. DIRECT ROLLOVER......................................................... 19 III. PAYMENT PAID TO YOU...................................................... 19 IV. SURVIVING SPOUSES, ALTERNATE PAYEES AND OTHER BENEFICIARIES............ 20 V. HOW TO OBTAIN ADDITIONAL INFORMATION................................... 20 I. PAYMENTS THAT CAN AND CANNOT BE ROLLED OVER A benefit is eligible for rollover to an IRA (or an IRA or another employer plan in the case of former spouses who are alternate payees under qualified domestic relations orders) if it meets the requirements of an eligible rollover distribution. A death benefit from the Plan is an eligible rollover distribution if the death benefit is payable to either (i) the surviving spouse of the deceased pensioner, or (ii) a former spouse who has been identified as an alternate payee pursuant to a qualified domestic relations order in connection with a divorce from the deceased pensioner, or (iii) a nonspouse individual beneficiary. Any payments other than the one-time death benefit may not be rolled over into an IRA or an employer plan. Therefore, any monthly benefits you receive from the Plan are not eligible rollover distributions. 18

II. DIRECT ROLLOVER You can choose a direct rollover of all or any portion of your death benefit payment that is an eligible rollover distribution, as described above. In a direct rollover, the eligible rollover distribution is paid directly from the Plan to an IRA or employer plan. If you choose a direct rollover, you are not taxed on a payment until you later take it out of the IRA or employer plan. Direct Rollover to an IRA. You can open an IRA to receive direct rollover. (The term IRA, as used in this Notice, includes individual retirement accounts and individual retirement annuities.) If you choose to have your death benefit payment made directly to an IRA, contact an IRA sponsor (usually a financial institution) to find out how to have your payment made in a direct rollover to an IRA at that institution. If you are unsure of how to invest your money, you can temporarily establish an IRA to receive the payment. However, in choosing an IRA, you may wish to consider whether the IRA you choose will allow you to move all or a part of your payment to another IRA at a later date, without penalties or other limitations. If you are a nonspouse beneficiary, the IRA must be in your name as beneficiary of the deceased. See IRS Publication 590, Individual Retirement Arrangements, for more information on IRAs (including limits on how often you can roll over between IRAs) (Call 1-800-829-3676). Direct Rollover to a Plan. If you are an alternate payee under a qualified domestic relations order with respect to the death benefit and are employed by an employer that has a plan, and you want a direct rollover to that plan, ask the administrator of that plan whether it will accept your rollover. If your employer s plan does not accept a rollover, you can choose a direct rollover to an IRA. III. PAYMENT PAID TO YOU If you have the death benefit payment made to you, it is subject to 20% income tax withholding. The payment is taxed in the year you receive it unless, within 60 days, you roll it over to an IRA. Mandatory Income Tax Withholding. If any portion of the payment to you is an eligible rollover distribution, the Plan is required by law to withhold 20% of that amount. The withheld amount is sent to the IRS as income tax withholding. For example, if your death benefit is $8,500, only $6,800 would be paid to you because the Plan must withhold $1,700 as income tax. However, when you prepare your income tax return for the year, you will report the full $8,500 as a payment from the Plan.You will report the $1,700 as tax withheld, and it will be credited against any income tax you owe for the year. Voluntary Withholding. If any portion of your payment is not an eligible rollover distribution but is taxable, the mandatory withholding rules described above do not apply. In this case, you may elect not to have withholding apply to that portion. To elect out of withholding, ask the Plan administrator for the election form and related information. Sixty-Day Rollover Option. If the death benefit is paid to you directly, you can still decide to roll over all or part of the net proceeds to an IRA or, if applicable, another employer plan. If you decide to roll over, you must make the rollover within 60 days after you receive the payment. The portion of your payment that is rolled over will not be taxed until you take it out of the IRA or employer plan. You can roll over up to 100% of the death benefit, including an amount equal to the 20% that was withheld. If you choose to roll over 100%, you must find other money within the 60-day period to contribute to the IRA or employer plan to replace the 20% that was withheld. On the other hand, if you roll over only the 80% that you received, you will be taxed on the 20% that was withheld. Example. Your death benefit is $8,500, and you choose to have it paid to you. You will receive $6,800, and $1,700 will be sent to the IRS as income tax withholding. Within 60 days after receiving the $6,800, you may roll over the entire $8,500 to an IRA. To do this, you roll over the $6,800 you received from the Plan, and you will have to find $1,700 from other sources (your savings, a loan, etc.) In this case, the entire $8,500 is not taxed until you take it out of the IRA. If you roll over the entire $8,500, when you file your income tax return you may get a refund of the $1,700 withheld. If, on the other hand, you roll over only $6,800, the $1,700 you did not roll over is taxed in the year it was withheld. When you file your income tax return you may get a refund of part of the $1,700 withheld. (However, any refund is likely to be larger if you roll over the entire $8,500.) Additional 10% Tax If You Are Under Age 59 1/2. If you receive a payment before you reach age 59 1/2 and you do not roll it over, then, in addition to the regular income tax you may have to pay an extra tax equal to 10% of the taxable portion of the payment. The additional 10% does not apply to your payment if it is (1) paid to you because you separate from service with your employer during or after the year you reach age 55, (2) paid because you retire due to disability, (3) paid to you as equal (or almost equal) payments over your life or life expectancy (or you and your 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. 19

Special Tax Treatment. If your eligible rollover distribution is not rolled over, it will be taxed in the year you receive 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 your entire balance under the Plan (and certain other similar plans of the Employer) that is payable to you because you have reached age 59 1/2 or have separated from service with your employer (or, in the case of a self employed individual, because you have reached age 59 1/2 or have become disabled), or the participant has died and you are the beneficiary under the Plan. For a payment to qualify as a lump sum distribution, you must have been a participant in the Plan for at least 5 years. The special tax treatment for lump sum distributions is described below. Five Year Averaging. If you receive a lump sum distribution after you are age 59 1/2, you 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 you owe because it treats the payment much as if it were paid over 5 years. Ten Year Averaging If You Were Born Before January 1, 1936. If you receive a lump sum distribution and you were born before January 1, 1936, you 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 you owe. Capital Gain Treatment If You Were Born Before January 1, 1936. In addition, if you receive a lump sum distribution and you were born before January l, 1936, you can make a one-time election to have the part of your payment that is attributable to your pre-1974 participation in the Plan (if any) taxed as long-term capital gain at a rate of 20%. There are other limits on the special tax treatment for lump sum distributions. For example, you can generally elect this special tax treatment only once in your lifetime, and the election applies to all lump sum distributions that you receive in that same year. If you have previously rolled over a payment from the Plan (or certain other similar plans of the employer), you cannot use this special tax treatment for later payments from the Plan. If you roll over your payment to an IRA, you will not be able to use this special tax treatment for later payments from the IRA. Also, if you roll over only a portion of your payment to an IRA, this special tax treatment is not available for the rest of the payment. Additional restrictions are described in IRS Form 4972, which has more information on lump sum distributions and how you elect the special tax treatment. 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, and to individual nonspouse beneficiaries.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. If you are a surviving spouse or a nonspouse beneficiary, you may choose to have an eligible rollover distribution paid in a direct rollover to an IRA or paid to you. If you have the payment paid to you, you can keep it or roll it over yourself to an IRA, but you cannot roll it over to an employer plan. If you are an alternate payee, you have the same choices as the employee. Thus, you can have the payment paid as a direct rollover or paid to you. If you have it paid to you, you can keep it or roll it over yourself to an IRA or to another employer plan that accepts rollovers. If an estate or an organization is named as the beneficiary of the death benefit, you CANNOT choose a direct rollover, and you CANNOT roll over the payment yourself. If you are a surviving spouse, an alternate payee, or another beneficiary, your payment is not subject to the additional 10% tax described in section III above, even if you are younger than age 59 1/2. If you are a surviving spouse, an alternate payee, or another beneficiary you may be able to use the special tax treatment for lump sum distributions. If you receive a payment because of the employee s death, you may be able to treat the payment 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 your payment.) The rules described above are complex and contain many conditions and exceptions that are not included in this notice. Therefore, you may want to consult with a professional tax advisor before you take a payment of death benefits from the Plan. Also, you can find more specific information on the tax treatment of payments from qualified retirement plans in IRS Publication 575, Pension and Annuity Income, and IRS Publication 590, Individual Retirement Arrangements. These publications are available from your local IRS office or by calling 1-800-TAX-FORM (1-800-829-3676). (Rev. 10/12)