Form Dc 3679 1103 PDF Details

Transitioning between retirement plans can be a meticulous process, requiring detailed attention to ensure that assets are rolled over correctly and in compliance with regulatory standards. The State of Maryland Direct Rollover Request Form, known as DC 3679 1103, facilitates this transition for individuals aiming to transfer incoming assets to Nationwide Retirement Solutions. Designed to streamline the transfer of funds from one retirement plan to another, it covers an array of plan types including 457, 401(k), 403(b), and 401(a) plans, along with Traditional IRAs. Completing this form requires individuals to provide comprehensive information ranging from personal identification to detailed descriptions of the funds to be transferred. Moreover, it demands acknowledgment of certain IRS regulations regarding distributions prior to age 59 1/2, ensuring participants are aware of potential penalties and tax implications. By furnishing contact details, specifying the amount to rollover, and directing future investments, the form serves as a critical tool in safeguarding one's retirement savings during the transition. Nationwide Retirement Solutions, located in Dublin, Ohio, stipulates the form must be fully completed for the rollover request to be processed, highlighting the importance of accuracy and thoroughness in submissions.

QuestionAnswer
Form NameForm Dc 3679 1103
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesTRV02, Rowe, E-mail, FLV01

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State of Maryland Direct Rollover Request (For incoming assets only)

Please complete all sections of this form. All information on this document must be completed and returned to Nationwide Retirement Solutions in order to be processed. If you require assistance in completing this form or need additional information, please contact us at 1-877-628-2499.

Upon completion of this form, please return the signed document to: Nationwide Retirement Solutions

5900 Parkwood Drive, PW-04-10, Dublin, Ohio 43016

SECTION I: Participant Information

Name

Last

 

First

Middle

 

 

 

 

Current Address

Number and Street

 

Apt./Suite

 

 

 

 

 

City

 

 

State

Zip Code

 

 

 

 

State Agency:

 

Work Location:

 

SECTION II: Rollover/Transfer Funds From:

Social Security Number

Home Phone Number (Include Area Code)

Work Phone Number (Include Area Code)

E-mail Address:

Plan Type:

‰ 457 plan

‰ 401(k) plan ‰ 403(b) plan

‰ 401(a) plan

‰ Traditional IRA

‰ Other:

 

 

 

 

 

 

 

Amount to Rollover/Transfer:

‰ Total account balance ‰ Partial dollar

amount $

 

 

 

 

 

 

 

 

 

 

Carrier/Custodian Name

 

 

 

 

Account Number

 

 

 

 

 

 

 

Address

Number and Street

 

 

 

Contact Name

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

 

Telephone Number

If you are transferring from an employer sponsored eligible retirement plan [401(k), 403(b), 401(a), or 457], please complete the information below:

I have separated from service from my previous employer on ______________________(date).

Previous Employer’s Signature

 

 

Date

Phone Number

 

 

SECTION III: Rollover/Transfer Funds To:

 

 

 

 

 

 

Plan Type:

 

‰ 457 plan

‰ 401(k) plan

‰ 403(b) plan

 

 

 

 

 

Make check payable to: Nationwide Retirement Solutions, FBO (Participant Name, SS#)

 

 

 

 

Mail check to:

Nationwide Retirement Solutions, 5900 Parkwood Drive, PW-04-10., Dublin, Ohio 43016

 

 

 

 

 

 

 

 

 

SECTION IV: Investment Direction

 

 

 

 

 

 

‰ Credit my rollover/transfer according to the current allocation on file -OR-

‰ Credit my rollover/transfer as listed below:

 

 

FUND ID

INVESTMENT OPTION

 

 

ASSET CLASS

 

PERCENT

 

(MGG01)

Investment Contract Pool

 

 

Fixed Income

 

 

%

(FEV02)

Federated U.S. Gov’t Securities Fund: 2-5 years

 

Bond

 

 

%

(PMV06)

PIMCO Total Return Fund (Institutional Shares)

 

Bond

 

 

%

(FDV18)

Fidelity Puritan Fund

 

 

Balanced

 

 

%

(FLV01)

Scudder Flag Investors Value Builder Fund (Inst’l Class)

 

Balanced

 

 

%

(FDV19)

Fidelity Growth & Income Portfolio

 

Large Cap

 

 

%

(AFV24)

The Growth Fund of America (Class A)

 

Large Cap

 

 

%

(LMV01)

Legg Mason Value Trust Fund (Inst’l class)

 

Large Cap

 

 

%

(VGV10)

Vanguard Institutional Index Fund

 

Large Cap

 

 

%

(AFV07)

Washington Mutual Investors Fund

 

Large Cap

 

 

%

(IVV03)

INVESCO Dynamics

 

 

Mid Cap

 

 

%

(LAV01)

Lord Abbott Mid-Cap Value Fund (Class A)

 

Mid Cap

 

 

%

(DEV04)

Delaware Trend Fund (Inst’l class)

 

Small Cap

 

 

%

(TRV07)

T. Rowe Price Small Cap. Stock Fund

 

Small Cap

 

 

%

(AFV10)

EuroPacific Growth Fund

 

 

International

 

 

%

(TRV02)

T. Rowe Price International Stock Fund

 

International

 

 

%

(

)

Other __________________________________________

 

 

 

 

%

 

 

 

 

 

 

(MUST TOTAL 100%)

 

100

%

SECTION V: Authorization

Please be aware that due to Internal Revenue Service regulations, if you take a distribution prior to age 59 1/2 from your MSRP account there may be a 10% penalty imposed.

I acknowledge that I have received and read the fund prospectuses for the investment options I have elected above. I understand that my direct rollover will become subject to the terms and conditions of the plan.

I certify that I satisfy the requirements for making a tax-free rollover/transfer into an eligible retirement plan. Nationwide Retirement Solutions is entitled to rely fully on my certification. I expressly assume responsibility for tax consequences relating to this rollover/transfer, and I agree that Nationwide Retirement Solutions shall not be responsible for those tax consequences. Upon receipt, I hereby request my funds to be invested as directed on this form.

Nationwide Retirement Solutions hereby agrees to accept the direct rollover/transfer described herein and upon receipt will deposit the proceeds within 5 business days in the account established on behalf of the individual’s eligible employer.

Participant Signature

Date

Registered Principal Signature

Date

DC-3679-1103

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Filling out segment 1 in PW-04-10

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FDV, Legg Mason Value Trust Fund Instl, and Fixed Income inside PW-04-10

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