Ohio Details

Did you know that if you are a business owner who wants to appoint a representative to act on your behalf with the DC Department of Consumer and Regulatory Affairs, you need to file Form Dc 4212 1211? This is a requirement for all businesses, whether you are new or existing. You must file this form any time you want to name or change your designated representative. Failing to do so may result in penalties and fines. Let's take a closer look at what this form is and what it entails. For more information on this form or how to file it, please visit our website or contact us today.

Here is the information about the file you were in search of to fill in. It can show you how much time you will need to complete form dc 4212 1211, what parts you will have to fill in, etc.

QuestionAnswer
Form NameForm Dc 4212 1211
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names

Form Preview Example

MARYLAND SUPPLEMENTAL RETIREMENT PLAN

BENEFICIARY or ALTERNATE PAYEE CLAIM FORM

Section 1 – Participant Information

Beneficiary Claim (check one below)

OR

Alternate Payee Claim (Domestic Relations Order) (check one below)

Spouse

 

Ex-Spouse

 

 

Non-Spouse

 

Other

 

 

Participant’s Name ________________________________________________

Social Security # ______________________

 

Claimant’s Name __________________________________________________

Social Security # ______________________

Date of Birth: ________

Mailing Address __________________________________________________________________________________________________________________

Number and Street

 

 

 

 

____________________________________________________________________________________

________________

__________________

City

 

 

State

Zip Code

Section 2 – Select Beneficiary(ies)

Check here if this is a change of beneficiary. (Beneficiaries listed below replace any prior designation)

 

 

Beneficiary Name(s)

Split %

Relationship

Social Security Number

Date of Birth

Primary

Contingent

______________________

_______

_____________

_____________________

____________

Primary

Contingent

______________________

_______

_____________

_____________________

____________

Primary

Contingent

______________________

_______

_____________

_____________________

____________

If additional space for beneficiaries is required, attach additional sheets and mark this box:

Section 3 – Payout Options

If this request is a beneficiary claim, submit a certified copy of the death certificate with this form. If the claimant is a minor, legal guardianship papers must also be included. If there are multiple claimants, each must complete a copy of this form and all documents must be submitted at the same time. Descriptions of the payout options are on the back of this form. Not all options are available for non-spousal beneficiaries. For more information, please contact us at 1-800-545-4730.

Select Plan Type: 457(b) Plan 401(a) Plan 401(k) Plan 403(b) Plan

(All funds will be withdrawn on a pro-rated basis across all accounts within the plan selected.)

Select an option:

LUMP SUM: (If you are a Spousal Beneficiary or Ex-Spousal Alternate Payee, complete the Eligible Rollover Distribution Section)

1. Partial Lump Sum in the amount of $_______________________.

2. Lump Sum for the entire account balance.

SYSTEMATIC WITHDRAWAL: All funds will be withdrawn on a prorated basis across all investment options.

Frequency:

Monthly

Quarterly

Semi-Annually

Annually

1. Designated Amount of $_______________

IfyouareaSpousalBeneficiaryoranEx-SpousalAlternatePayeeandthepaymentsareexpectedtolastlessthan10years,completeSection4below.

2. Designated Period of ______________ years (1-30)

IfyouareaSpousalBeneficiaryoranEx-SpousalAlternatePayeeandthepaymentsarelessthan10years,completeSection4below.

3. Required Minimum Distribution (Must be at least age 70 1/2. This option is not eligible for rollover.) See back of form for additional details.

PURCHASED ANNUITIES (Your election of a purchased annuity is irrevocable.)

 

 

*Attach proof of date of birth for Life Annuity and Life Income

 

 

Frequency:

Monthly

Quarterly

Semi-Annually

Annually

1.

Single Life Annuity (No Beneficiary)*

 

Circle One: NATIONWIDE or METROPOLITAN

2.

Life Income with Payments Certain*

 

Circle One: NATIONWIDE or METROPOLITAN

5 yrs certain 10 yrs certain 15 yrs certain

20 yrs certain

25 yrs certain

30 yrs certain

3.

Fixed Designated Period of ________________ years (3-20)

Circle One: NATIONWIDE or METROPOLITAN

4.

Designated Amount of $______________.

 

Circle One: NATIONWIDE or METROPOLITAN

5.Joint and Survivor*

 

 

Circle One: NATIONWIDE or METROPOLITAN

50%

66 2/3% 75%

100%

 

 

 

Survivor__________________________________________________

Social Security Number__________________

Mailing Address____________________________________________

Date of Birth___________________________

City, State, & Zip Code_______________________________________

Contact Phone Number__________________

Section 4 – ELIGIBLE ROLLOVER DISTRIBUTION

This option is available only to Spousal Beneficiaries and Ex-Spousal Alternate Payees.

Complete only if you have elected a lump sum distribution or a systematic withdrawal that is reasonably expected to last less than 10 years.

If no election is made, box #1 below will apply.

1. Pay directly to me. I understand 20% of the taxable amount of the eligible rollover distribution will be withheld for federal income taxes.

2. Direct Rollover:

Important Note - A Letter of Acceptance from the new carrier (financial institution) is required and MUST accompany this form to process your rollover request.

I wish to have 100% of the eligible rollover distribution directly rolled over to the eligible retirement plan or IRA designated below.

I wish to have $_______________ (at least $500) directly rolled over to the eligible retirement plan or IRA designated below, and leave $______________ in the account.

Pay remaining portion directly to me.

I understand 20% of the taxable portion of the distribution paid to me will be withheld for federal income taxes.

Direct rollover plan designation (select one only):

TO ANOTHER ELIGIBLE RETIREMENT PLAN:

Caution: You are advised to verify that the Plan will accept this direct rollover.

Name of Plan: ________________________________________________________________

Address: ____________________________________________City: ____________________State: ______Zip: ______________

TO AN IRA*

Name of financial institution:______________________________________________Account #______________________________

Address: ____________________________________________City: ____________________State: ______Zip: ______________

*You must establish an IRA account at your financial institution prior to our sending the distribution. An account number and forward- ing instructions must be submitted with this form in order to process the direct rollover to an IRA.

Section 5 – Authorization

I certify that I have received and read the “Special Tax Notice Regarding Plan Payments”. If I elect to receive this distribution before the end of the 30- day minimum notice period, my signature on this election shall constitute a waiver of my rights to the 30-day notice requirement.

Federal income tax will be withheld from your payments as required by the Internal Revenue Code. You must submit a W-4P with this request and payments will be reported on a 1099-R Form. State taxes will be withheld where applicable.

Participant Signature: _______________________________________________

Date: ______________________

IF YOU HAVE ANY QUESTIONS CONCERNING THIS FORM, PLEASE CONTACT US AT 1-800-545-4730.

Original & Copy 1: NRS

Copy 2: Participant

Nationwide Retirement Solutions • PO Box 182797 • Columbus, Ohio 43218 • 1-877-677-3678

DC-4212-1211

PAYOUT OPTION DESCRIPTIONS

PARTIAL LUMP SUM PAYMENT: This option provides for a single payment in the amount requested (minimum of $25.00) from the value of your account.

LUMP SUM PAYMENT: This option provides for the payment of the full value of your account in a single payment.

SYSTEMATIC WITHDRAWAL OPTIONS: Your account is maintained on the Administrator’s Accumulation System and continues to earn either recurrent interest in the fixed return or fund investment performance if in the variable return option, throughout the payout period. You will continue to receive quarterly statements. In the event of your death prior to the exhaustion of your account, upon the claim, the beneficiary will receive payments until the account is exhausted or a lump sum payment of the remaining account balance. All funds are withdrawn on a prorated basis.

DESIGNATED AMOUNT: This option provides for payments of the designated amount (minimum of $25.00) until your account is exhausted. The final payment will be the balance of your account. Please indicate the amount to be paid, your beneficiaries, their rela- tionships to you, their Social Security numbers, and their birth dates.

Exchanges are permitted, subject to annual exchange limitations.

For example:

Participant dies prior to the exhaustion of the account.

––Upon their claim, the beneficiary receives payments until the account is exhausted or a lump sum payment of the remaining account balance.

DESIGNATED PERIOD: This option allows you to choose the number of years you will receive payments. Your payment may fluctuate if some or all of your money is invested in Mutual Fund Options. Please indicate the amount to be paid, your beneficiaries, their relationships to you, their Social Security numbers, and their birth dates.

Exchanges are permitted, subject to annual exchange limitations.

For example:

Participant dies prior to the exhaustion of the account.

––Upon their claim, the beneficiary receives payments until the account is exhausted or a lump sum payment of the remaining account balance.

REQUIRED MINIMUM DISTRIBUTION: A minimum distribution of your account is required to begin when you attain age 70 1/2. This payment option will only pay the minimum that is required to be paid to you each year. The amount that is required to be distributed will be calculated for each distribution year in accordance with regulations under Section 401(a)(9) of the Internal Revenue Code. The Required Minimum Distribution (RMD) will usually be different for each year because of the changes in your account balance and the change in your life expectan- cy. This payment option is not available unless you have attained age 70 1/2 and your account cannot be rolled over to another

eligible retirement plan or IRA. Please indicate the amount to be paid, your beneficiaries, their relationships to you, their Social Security numbers, and their birth dates

For example:

Participant dies prior to the exhaustion of the account.

–– Beneficiary receives payments until the account is exhausted or a lump sum payment of the remaining account balance.

PURCHASED ANNUITY OPTIONS: Your account is removed from the Administrator’s Accumulation System and your account balance is used to purchase an annuity contract that you select. Purchase rates are subject to change monthly. However, once you have purchased an annuity, the benefit amount will remain the same for the life of the annuity. You will receive an annuity certificate stating the terms of the con- tract. You will no longer receive quarterly statements.

SINGLE LIFE ANNUITY: This option provides equal payments over your lifetime. At the participant’s death, payments will stop. There is no named beneficiary. Attach proof of date of birth.

For example:

Annuitant dies after two payments are made - no death benefit payable.

LIFE INCOME WITH PAYMENTS CERTAIN: This option provides payments for your lifetime. If you die before the selected number of guaranteed payments has been made, payments will continue to your named beneficiary until the total number of guaranteed payments (5, 10, 15, 20, 25, or 30 years) has been made to you and your beneficiary. If you die after the guaranteed number of payments has been made, no death benefit is payable. Please select a guaranteed period and indicate your beneficiaries, their relationships to you, their Social Security numbers and their birth date and attach proof of your date of birth.

For example:

20 Years Certain – Annuitant dies in the 5th year.

–– Beneficiary receives 15 years of monthly payments or an adjusted lump sum payment.

JOINT & SURVIVOR: This option provides payments for you and your survivor for your lifetimes. Upon your death, payments will contin- ue to survivor, if he or she is living. No other beneficiaries are permitted under this option. Payments to the survivor may be a percentage (50%, 66 2/3%, 75% 100%) of the original amount. Please name your survivor, the survivor’s relationship to you, the survivor’s Social Security number, and the survivor’s birth date.

For example:

Annuitant dies and survivor is still living.

––Survivor receives the monthly benefit for as long as they live at 50%, 66 2/3%, 75%, or 100% of the original amount. Annuitant dies and survivor is also deceased.

––No death benefit, once the annuitant and the survivor are deceased the annuity is over.

FIXED DESIGNATED PERIOD: This option provides for payments for the number of years chosen. You may select any whole number of years between 3 and 20, inclusive. If you should die before the end of the period, payments will continue to the beneficiary. Please indi- cate the number of years to be paid, your beneficiaries, their relationships to you, their Social Security numbers, and their birth dates.

For example:

Annuitant dies prior to the end of the designated number of years.

–– Beneficiary receives payments to the end of the designated period or an adjusted lump sum payment.

DESIGNATED AMOUNT: This option provides for payments of a specified dollar amount. The length of the payout is determined by the account value and a set purchase rate. If you should die before the annuity is exhausted, your beneficiary could either continue the pay- out or receive the remaining lump sum.

For example:

Annuitant dies before all annuity payments are received.

–– Beneficiary receives payments to end of annuity amount or adjusted lump sum.

Nationwide Retirement Solutions • PO Box 182797 • Columbus, Ohio 43218 • 1-877-677-3678

DC-4212-1211

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .