Form Gp5479Us PDF Details

If you are like most people, when you think of tax forms, the first thing that comes to mind is a lot of paperwork and a complicated mess. However, with Form Gp5479Us, TaxACT has made the process easy and streamlined, so you can focus on what's important: your taxes. This comprehensive form is designed to help filers report all their income and deductions accurately. Plus, with TaxACT's user-friendly interface, you'll be able to complete your return quickly and easily.

This knowledge will allow you to understand better the details of the form gp5479us before you start filling it out.

QuestionAnswer
Form NameForm Gp5479Us
Form Length10 pages
Fillable?Yes
Fillable fields155
Avg. time to fill out33 min 34 sec
Other namesjohn hancock gp5536us, fill the john hancock withdrawal eligible for rollover form, john hasncock form gp5479us, john hancock withdrawal eligible for rollover form 2019

Form Preview Example

If you’re thinking about a cash distribution, know that taxes and penalties may apply. Visit www.JHCashOutCalculator.com to see how cashing out could affect your savings.

Includes: Withdrawal – Eligible for Rollover Form

Same goal. New choices.

Whether you’re changing jobs or retiring, it’s important to understand your options so you can make an informed decision about what to do with your retirement plan savings at John Hancock. Read more about your choices and next steps, then complete the attached form – or give us a call. We’re here to help.

You have two ways to take action:

Call John Hancock at 1-888-695-4472

Our Rollover Specialists will help answer questions about the options available to you:*

-Keep your money in the Plan

- Roll over to a John Hancock IRA - Roll over to another IRA

- Roll over to new employer-sponsored plan

-Take a cash distribution (see box at right)

We’ll introduce you to your plan’s financial representative if applicable

We’ll help you complete the process, including filling out any paperwork

Work with your financial representative or do-it-yourself

Review your options with your financial representative*

Fill out the attached Withdrawal – Eligible for Rollover Form

Return it based on the instructions provided to you by your plan administrator

Our Rollover Specialists are here to make your

transition a smooth one. Call us at 1-888-695-4472.

*Each distribution option has its own potential advantages, disadvantages and tax consequences. Anyone interested in these transactions or topics should seek advice based on his or her particular circumstances from independent professional advisors. There may be additional distribution options that are available only under your specific plan. Please check with your plan administrator for more information.

John Hancock Personal Financial Services, LLC, also referred to as “John Hancock”, is an affiliate of John Hancock Retirement Plan Services.

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

NOT FDIC INSURED | MAY LOSE VALUE | NOT BANK GUARANTEED

© 2019 All rights reserved.

GP5479US (2/2021)

G-P 37398-GE 01/19-37398

Reset Form

Withdrawal - Eligible for Rollover

Important Information about this Form

Your plan may require you to provide supporting documents or additional information before your request can be processed.

As the participant, you complete Sections 1 - 7 of this form and return it to your Plan Representative.

As the Plan Representative, you review Sections 1 - 7, and complete Sections 8 - 10 of this form.

If the participant address provided below is new or different than what is currently on record with John Hancock Retirement Plan Services, we will update our records accordingly. Ensure your next census submission includes revised employee information to avoid your file superseding the information supplied on this form.

A 1099R form will be issued for each distribution and loan default (if applicable) by January 31 of the following year.

This request is subject to the processing and procedure guidelines contained in John Hancock’s Administrative Guidelines for Financial Transactions (“AGFT”). The latest AGFT is available on the John Hancock plan sponsor website or you may contact your John Hancock representative for a copy.

All changes must be initialed in pen (including numbers crossed out or changed using correction fluid).

1. General Information

The Trustee of

{Contractholder_name}

Plan (“the Plan”)

{ContractNum2}

Contractholder Name

 

 

 

 

 

Contract Number

{Participant_name}

 

 

 

{SSN}

 

Participant Name as displayed on your Social Security Card (Last Name, First Name, Initial)

 

 

Participant Social Security Number (Full SSN Required)

 

 

 

 

Date

 

{ppt_address}

 

 

 

of Birth {DCCIASec3EffectiveDate}

Participant Address – Street Address

 

 

 

 

 

 

 

Participant

{PhoneNumber}

 

{ppt_cszip}

 

Phone No.

 

City, State, Zip Code, Country

2. What is the reason for your withdrawal? – Select ONE option only

It is the responsibility of the Plan Administrator, and not of John Hancock Retirement Plan Services, to ensure that the participant is permitted under the terms of the Plan to receive the distribution selected below.

TE

Termination date

RE

Retirement date

IR

Employee Money Transferred into Plan

DI

Disability

 

(Must complete Section 3B)

 

 

VC

Employee Voluntary Money

PD

Early/Pre-Retirement

 

(Must complete Section 3B)

 

(If permitted by the Plan)

Information about Deferred Distributions

Section 1102 of the Pension Protection Act of 2006 requires plans to notify participants that they have the right to defer distributions as well as the consequences of making that choice. The investment options available under your group annuity contract as well as the fees related to the investment options are part of this consideration.

For a description of the investment options available under your group annuity contract, including fees:

Log onto www.johnhancock.com/myplan.

Select: Your contract reports - Investments - Contract investment options and view Selected investment options only. Alternatively, participants may obtain this information by calling our toll free service line at 1-800-395-1113.

You should also review your plan's Summary Plan Description (SPD) which may contain special provisions that may materially affect your decision to defer a distribution. For a copy of the SPD, please contact your Plan Administrator.

GP5479US (2/2021)

Page 1 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

3. How much do you want to withdraw? Select ONE option only

If no option is selected a TOTAL withdrawal will be processed.

The amount or percentage below will be withdrawn as a gross withdrawal before income tax withholding.

A - Withdraw 100% of my vested account value

OR

B - Withdraw only a portion of the funds in my plan as follows - Tell us how much to withdraw from each eligible money type (Amount or Percentage). Completing the Investment Fund Code is not mandatory. If the Investment Fund Code is left blank, John Hancock Retirement Plan Services’ standard withdrawal order will be used.

Money Type

Investment Fund

Amount

 

Percentage

(Mandatory)

Code (Optional)

 

 

 

 

{PortionType1}

{PortionFund1}

${PortionAmt1}

OR

{PortionPct1}%

{PortionType2}

{PortionFund2}

${PortionAmt2}

{PortionPct2}%

 

{PortionType3}

{PortionFund3}

${PortionAmt3}

 

{PortionPct3}%

4. What do you want to do with your money?

Complete Section A if you wish to make your distribution payable to only a single destination. For multiple destinations, complete Section B.

A - Send my payment to ONE destination only - Select ONE option only.

Direct Rollover to an IRA or Roth IRA - Complete Section 5A or 5B

Direct Rollover to Employer Sponsored Qualified Plan - Complete Section 5C Payment Directly to Me - Complete Section 5D

Pay to the Plan Trustee for Deposit into the Plan’s Trust Account - A check will be mailed to the Trustee address on record with John Hancock Retirement Plan Services unless EFT instructions are provided in Section 5C. Taxes will not be withheld and a 1099R Form will not be issued. The Plan Trustee will be responsible for implementing the participant's direction and performing the applicable withholding and reporting obligations. Continue to Section 6.

Leave my money in the Plan. You may defer your distribution to a later date. Consult your Plan Administrator. Continue to Section 6.

OR

B - Send my payments to MULTIPLE destinations - If applicable, you may provide separate instructions for the taxable and non taxable money that make up your requested withdrawal.

IRC § 402(c)(2) will apply to any request withdrawing only a portion of the funds in your plan (Section 3B).

Payments directly to you will be deemed to come first from non-taxable amounts (from Non-Roth After-Tax contributions then Roth contributions followed by taxable amounts) in the following order: Non-Roth After-Tax earnings, Roth earnings and Pre-Tax accounts.

Payments directly to you will be processed first. Any remaining funds will be directly rolled over to the appropriate rollover vehicle indicated below.

Your withdrawal will be processed in accordance with the time frame described in our Administrative Guidelines.

GP5479US (2/2021)

Page 2 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

Split my payment - Select all the applicable options below and then complete the next Section.

{F34}

{F36}

{F45}

Pay directly to me $ {TaxDollar}

(Section 5D)

Pre-Tax and Non-Roth After-Tax:

 

 

{F37}

Non Taxable balance directly rolled over to:

 

 

{F38}

Traditional IRA

{F39}

Roth IRA

{F40}

Employer Sponsored Qualified Plan

 

 

(Section 5A)

 

(Section 5B)

 

(Section 5C)

{F41}

Taxable balance directly rolled over to:

 

 

 

{F42}

Traditional IRA

{F43}

Roth IRA

{F44}

Employer Sponsored Qualified Plan

 

 

(Section 5A)

 

(Section 5B)

 

(Section 5C)

Roth:

 

 

 

 

 

Directly rolled over to:

 

 

 

 

 

{F46}

Roth IRA

{F47}

A Designated Roth Account

 

 

(Section 5B)

 

in an Employer-Sponsored Qualified Plan

(Section 5C)

5. Where do you want your money sent?

Select and complete option(s) A, B, C, and/or D (as applicable)

Federal law requires that 20% of the taxable amount of an eligible rollover distribution be withheld, unless payment is directly rolled over to an eligible retirement plan. The amount withheld may not represent your entire tax bill. The rollover will be reported to the IRS and you are responsible for the payment of the income tax(es) that apply in connection with the rollover. Please refer to the Special Tax Notice provided by your Plan Administrator regarding these tax rules. Contact your tax advisor or Plan Administrator if you have any questions.

A - Traditional IRA

{F51} Direct Rollover to the following John Hancock product. Your funds will be transferred automatically by wire. You must provide the account number. For more information contact John Hancock at 1-888-695-4472.

Elect one:

{F49}

{F53}

{F52}

John Hancock Investments Rollover IRA

Account Number: {AccNum1}

 

 

 

John Hancock Managed IRA

Account Number: {AccNum2}

 

 

 

John Hancock GIFL Rollover Variable Annuity IRA

Account Number: {AccNumG1}

 

 

 

OR

 

 

 

{F55} Direct Rollover to another Financial Institution

Account Number: {AccNum3}

 

 

{RO_ Inst_Name}

 

 

 

 

Financial Institution Name

 

 

 

 

{RO_ Inst_Addr}

 

 

 

 

Financial Institution Address – Street, City, State, Zip Code, Country

 

 

 

Electronic Fund Transfer Information (REQUIRED)

You must provide electronic fund transfer information below, unless the financial institution requires a check be issued. Where a check is issued it will be mailed according to the standard mailing instructions on file with John Hancock Retirement Plan Services, as established by the Plan Trustee.

 

Expected Delivery: •

Checks: 7-10 business days • Direct Deposit: 2-3 business days • Wires: 1-2 business days

 

Electronic Fund Transfer Details

 

 

 

 

Direct Deposit

OR

Wire – Verify with receiving bank if they accept wires and/or charge a fee

 

Provide Domestic Bank details:

 

 

 

{BankName}

 

 

 

 

 

Bank Name

 

 

 

 

 

{BankABA}

 

 

{BankAcctNo}

 

 

Bank ABA/Routing (9 digits)

 

 

Bank Account No.

 

{F64}

For international banks, complete and attach the International Banking Instructions form.

GP5479US (2/2021)

 

 

 

Page 3 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

B - Roth IRA

{F62} Direct Rollover to the following John Hancock product. Your funds will be transferred automatically by wire. You must provide the account number. For more information contact John Hancock at 1-888-695-4472.

Elect one:

{F66}

{F68}

{F69}

John Hancock Investments Rollover IRA

Account Number: {AccNumR1}

 

 

 

John Hancock Managed IRA

Account Number: {AccNumR2}

 

 

 

John Hancock GIFL Rollover Variable Annuity IRA

Account Number: {AccNumRG1}

 

 

 

OR

 

 

 

{F72} Direct Rollover to another Financial Institution

Account Number: {AccNumR3}

 

 

{RO_ Inst_NameR}

 

 

 

 

Financial Institution Name

 

 

 

 

{RO_ Inst_AddrR}

 

 

 

 

Financial Institution Address – Street, City, State, Zip Code, Country

 

 

 

Electronic Fund Transfer Information (REQUIRED)

You must provide electronic fund transfer information below, unless the financial institution requires a check be issued. Where a check is issued it will be mailed according to the standard mailing instructions on file with John Hancock Retirement Plan Services, as established by the Plan Trustee.

Expected Delivery: •

Checks: 7-10 business days • Direct Deposit: 2-3 business days • Wires: 1-2 business days

Electronic Fund Transfer Details

 

 

 

Direct Deposit

OR

Wire – Verify with receiving bank if they accept wires and/or charge a fee

Provide Domestic Bank details:

 

 

{BankNameR}

 

 

 

 

Bank Name

 

 

 

 

{BankABAR}

 

 

{BankAcctNoR}

 

Bank ABA/Routing (9 digits)

 

 

Bank Account No.

{F82}

For international banks, complete and attach the International Banking Instructions form.

C - Employer Sponsored Qualified Plan

The Trustee of {Trustee_Name}

 

{PContractNum}

 

Plan Name

 

Plan Account Number

{RO_ Inst_NameEP}

 

 

Financial Institution Name

 

 

{RO_ Inst_AddrEP}

 

 

Financial Institution Address – Street, City, State, Zip Code, Country

 

 

GP5479US (2/2021)

Page 4 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

Electronic Fund Transfer Information (REQUIRED)

You must provide electronic fund transfer information below, unless the financial institution requires a check be issued. Where a check is issued it will be mailed according to the standard mailing instructions on file with John Hancock Retirement Plan Services, as established by the Plan Trustee.

Expected Delivery: •

Checks: 7-10 business days • Direct Deposit: 2-3 business days • Wires: 1-2 business days

Electronic Fund Transfer Details

 

 

 

Direct Deposit

OR

Wire – Verify with receiving bank if they accept wires and/or charge a fee

Provide Domestic Bank details:

 

 

{BankNameEP}

 

 

 

 

Bank Name

 

 

 

 

{BankABAEP}

 

 

{BankAcctNoEP}

 

Bank ABA/Routing (9 digits)

 

 

Bank Account No.

{F93}

For international banks, complete and attach the International Banking Instructions form.

D - Payment Directly to Me – All applicable taxes will be withheld

Federal Tax

A taxable distribution (and, if applicable, each outstanding loan balance) is subject to 20% mandatory minimum federal tax withholding for a U.S. person (including a U.S. resident alien).

To request a higher tax rate, specify a whole number above 20%: {TaxPercent} % (refer to DOL Field Assistance Bulletin 2004-02 for details).

OR {F96} I am neither a U.S. person nor a U.S. resident alien. Country of residence: {CountryRes}

Unless I have attached a completed IRS Form W-8BEN, withholding federal tax of 30% will apply.

GP5479US (2/2021)

Page 5 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

State Tax Withholding Instructions

State of

Enter state of residence at time of withdrawal if state tax withholding should be taken for a state

Residence

other than the state provided to us.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State of Residence

 

Options for State Tax Withholding

 

 

 

 

 

 

 

 

 

 

 

 

AR, DC, KS, MA, MD, ME, NC, NE,

You may not opt out. Since your distribution was subject to federal income tax, these states

OK, VA, VT

 

require mandatory state withholding based on the states’ applicable minimum requirements.

 

 

 

 

 

 

 

 

 

 

 

 

Generally, state tax withholding will be applied to your taxable distribution at the rate of

 

 

6.99%. However, if you elected a partial withdrawal, a flat dollar amount may be withheld

 

 

instead, but the amount must be calculated based on a completed CT-W4P form provided to

CT

 

the Plan Administrator. If no amount is indicated, 6.99% will be withheld.

 

 

{F100}

I elected a partial distribution on this form and provided a completed CT-W4P to my

 

 

 

Plan Administrator. The calculated amount to be withheld is: ${TaxDollar6}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State tax withholding will be applied to your taxable distribution unless one of the following

 

 

boxes is checked below:

 

 

 

 

 

{F98}

I elect to opt out of withholding. (This option is only available for residents of Michigan.)

MI, IA

 

{F99}

I am eligible to claim exemption of $ {TaxDollar2}

; withhold tax only on the

 

 

 

 

 

 

 

 

 

 

 

 

 

taxable, distributed amount that is in excess of the exempt amount.

 

 

If you check one of the boxes above, you are required to return a completed Form W-4P to

 

 

your Plan Administrator. Ensure that the election made above is consistent with the election

 

 

made on your completed Form W-4P.

 

 

 

 

 

 

 

 

 

 

CA, OR

 

You may opt out of the mandatory state withholding by checking here. {F101}

 

 

 

 

 

 

 

AL, CO, DE, GA, ID, IL, IN, KY, LA,

You may elect voluntary state income tax withholding by providing a percentage or whole

dollar amount to be applied for state tax withholding here. Some states mandate a minimum

MN, MO, MT, ND, NJ, NM, OH,

and/or maximum percentage.

 

 

 

SC, UT, WV, WI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

{TaxPercent2} % or $ {TaxDollar3}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Electronic Fund Transfer Information (REQUIRED)

You must provide electronic fund transfer information below, unless the financial institution requires a check be issued. Where a check is issued it will be mailed according to the standard mailing instructions on file with John Hancock Retirement Plan Services, as established by the Plan Trustee.

Expected Delivery: • Checks: 7-10 business days • Direct Deposit: 2-3 business days • Wires: 1-2 business days

Electronic Fund Transfer Details

 

 

 

Direct Deposit – My personal bank account is

Checking

OR

Savings

OR

 

 

 

Wire – Verify with receiving bank if they accept wires and/or charge a fee

Provide domestic bank details:

{BankName4}

Bank Name

{BankABA4}

 

{BankAcctNo4}

 

 

 

Bank ABA/Routing (9 digits)

 

Bank Account No.

{F111}For international banks, complete and attach the International Banking Instructions form.

6. Waiver of Waiting Period

In general, you have a right to a period of at least 30 days to consider the decision of whether to elect a withdrawal from the day that you receive the Special Tax Notice from your Plan Administrator. However, if your plan permits, you may elect to waive this 30-day waiting period and have your benefit paid earlier. To waive the waiting period, check below:

I wish to waive the 30-day waiting period

The information provided in this section shall not be maintained or acted upon by John Hancock Retirement Plan Services.

GP5479US (2/2021)

Page 6 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

7. Participant Signature

If my withdrawal is made from Funds with the Guaranteed Income feature, I acknowledge that I have read and reviewed the Guaranteed Income feature brochure and fully understand the consequences and impact that my withdrawal will have on my Benefit Base and other benefits provided by this feature. I understand that a brief outline of the terms and conditions governing my withdrawal is also contained in the summary entitled “Important Information about the Guaranteed Income Feature” which can be found on the John Hancock Retirement Plan Services participant website or obtained from my Plan Administrator.

John Hancock Retirement Plan Services may charge a fee for this withdrawal request. Other charges or fees may also apply. Please refer to your plan’s 404a-5 Plan & Investment Notice available on the participant website at www.johnhancock.com/myplan for further details.

For participants under a contract issued by John Hancock Life Insurance Company of New York, 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 any 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claims for each such violation. For all other states, civil penalties may apply.

Certification required of U.S. persons only (including U.S. citizens or U.S. resident aliens).

Under penalties of perjury, I certify that:

1.The number shown in Section 1 of this form is my correct taxpayer identification number, 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 (c) 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, including a U.S. resident alien (as defined in the IRS Form W-9 instructions).

Certification Instructions

You must check the box below if you have been notified by the IRS that you are currently subject to backup withholding because you failed to report all interest and dividends on your tax return.

{FCB1} I am subject to backup withholding as a result of a failure to report all interest and dividends.

Since the Plan is an account held in the United States, you are not required to provide a code indicating that you are exempt from FATCA reporting.

The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Please note that, by signing this form, you declare that you make the above certifications under penalties of perjury. Under penalties of perjury, I certify the above statements.

 

 

{FNamePrint}

 

{FSigDate}

Signature of Participant

 

Name - please print

 

Date

The following sections are to be completed by the Plan Representative.

8. Withdrawal Details

Has the final contribution been submitted for this participant?

If the final payroll for this participant has not been submitted

to John Hancock Retirement Plan Services, provide the final payroll ending date.

If a date is provided, John Hancock Retirement Plan Services will coordinate processing of this distribution with receipt of the final payroll to avoid additional contribution payouts that often remain uncashed.

Is the participant withdrawing In-Plan Roth Rollover (IRR) assets?

For a total withdrawal, we will report the original rollover amount processed as the amount allocable to IRR assets. For a partial withdrawal, provide the amount allocable to IRR assets $ {TaxDollar4}

Note: All Roth assets held by the participant would need to be taken into consideration when calculating the amount allocable to the IRR. If left blank, we will report the amount requested as being first allocable to the IRR assets.

GP5479US (2/2021)

Page 7 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

It is important that information on the allocable amount be provided to John Hancock Retirement Plan Services if this allocation order is not consistent with the terms of your Plan.

IRS Distribution Code

The applicable IRS distribution code will be based on the type of distribution and/or age of the participant.

If the early distribution exception code applies check here.

(Code 2 will be applied)

Code B will be included with the applicable code if the distribution includes Designated Roth contributions and the combination is valid.

Loans

If a loan is active at time of distribution (Termination, Retirement or Disability), we will apply the applicable age dependent loan distribution code.

Loans can only be rolled over to an employer sponsored qualified plan.

If the loan rollover code applies check here.

(Code G will be applied)

Vesting percentage(s)

Vesting is mandatory for partial and total termination, retirement, disability and total early/pre-retirement withdrawals.

The unvested money will be forfeited using instructions given in the Employer Unvested Money section below. For all other withdrawals vesting is not required.

% for ALL Employer money types

OR

Vesting varies by money type as indicated below

Money Type

%

 

 

ER Match

{VestPct}

Profit Sharing

{VestPct2}

Employer Unvested Money

Other ER Money

%

 

 

{PortionTypeER1}

{VestPct3}

{PortionTypeER2}

{VestPct4}

Other ER Money

%

 

 

{PortionTypeER3}

{VestPct5}

{PortionTypeER4}

{VestPct6}

If no box is selected below, direction for forfeitures previously provided to John Hancock will be applied to any unvested money in the participant’s account. If no direction for forfeitures has been provided and no box is selected below, any unvested money will remain in the participant’s account invested according to the current investment instructions.

If you determine the unvested portion of the account is not forfeitable, then you may wish to select leave in participant’s account as invested so that the participant continues to have the ability to direct the investment of the full balance of his/her account (including any unvested money).

Transfer to Cash Account

Pay outstanding John Hancock charges

Refund to Plan Trustee

Leave in Participant account and transfer to default fund

 

Leave in Participant account as invested

9. Third Party Administrator (TPA) Withdrawal Fee

${TaxDollar5}

OR

{TaxPercent4}%

 

 

 

 

 

Flat Fee Amount

 

Percentage of

 

 

 

Invested Balance

John Hancock Retirement Plan Services is not responsible for any uncollected fee amounts as a result of insufficient funds. These shortages will be reported on the transaction and summary confirmations.

No Fee will be applied if this section is not completed.

GP5479US (2/2021)

Page 8 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

10. Trustee/Authorized Signer Signature

If the participant fails to sign the Signature section, the Trustee/Authorized Signer below certifies, under penalties of perjury, that based on the plan sponsor's record, (i) the name shown on this form is the legal name of the participant; (ii) the number shown on this form is the correct taxpayer identification number (Social Security Number) of the participant; and, (iii) the participant is a U.S. person (including a U.S. resident alien) unless indicated otherwise above. I acknowledge that John Hancock Retirement Plan Services will rely on this certification in determining the tax withholding and reporting requirements applicable to the requested distribution and agree to hold John Hancock Retirement Plan Services harmless for any errors made in reliance upon this certification.

I hereby authorize John Hancock Retirement Plan Services to rely and act upon the instructions provided on this form. I understand that it is my responsibility to ensure that the withdrawal(s) requested herein are permitted by law and, if applicable, consistent with the terms of the Plan. If the amount withdrawn is paid directly to the Plan Trustee, I also agree and acknowledge that I am responsible for the proper handling of the funds in accordance with the requirements of the law.

I certify that all the above information is complete and correct, that the required participant elections and consent and, if applicable, spousal consent for married participants as required by IRC Sec. 417, have been properly obtained, and that the funds being withdrawn are not for the purpose of prohibited transactions as defined in IRC Sec. 4975. I also certify that all necessary and applicable information required to be furnished to the participant under IRC Sec. 417 and an explanation of the direct rollover option and related tax rules required by IRC Sec. 402 have been provided. I also certify that, if applicable, (i) the participant has waived the 30-day waiting period; and (ii) the Withholding Certificate for Pension or Annuity Payments (Form W-4P) for the states of Michigan and Iowa have been properly obtained, completed in accordance with Michigan and Iowa law, and that any amount exempt from state tax withholding described above accurately reflects such Withholding Certificate submitted by the participant.

In the event that the participant is under the age of 18, I certify that consent to this request has been obtained from the parent or legal guardian authorized to act on the participant's behalf.

I hereby direct John Hancock Retirement Plan Services to pay to the Third Party Administrator currently on record the above referenced fee (if applicable). I understand that this fee will be deducted from the participant's account balance at the time of the distribution using standard withdrawal protocol and will be held in the general business account of John Hancock Retirement Plan Services until paid to the Third Party Administrator. I hereby represent that this fee is in accordance with the fee schedule that has been approved by the plan's trustee or named fiduciary as reasonable and authorized under the terms of the plan.

On behalf of the Plan Sponsor, the Plan and its related trust, and the Plan Trustee or named Fiduciary, I further agree to indemnify and hold harmless John Hancock Retirement Plan Services, its employees, agents, directors, and officers from any liability, penalties, and taxes that may be incurred as a result of the requested distribution giving rise to one or more prohibited transactions or for implementing requests (including, if applicable, a direct rollover request) based solely on the instructions provided on this form, or if any of the certifications provided on this form are incorrect.

 

 

{FNamePrint}

 

{FSigDate}

Signature of Trustee/Authorized Signer

 

Name - please print

 

Date

GP5479US (2/2021)

Page 9 of 9

Group annuity contracts and recordkeeping agreements are issued by: John Hancock Life Insurance Company (U.S.A.) (“John Hancock USA”), Boston, MA (not licensed in New York) and John Hancock Life Insurance Company of New York (“John Hancock NY”), Valhalla, NY. Product features and availability may differ by state. John Hancock USA and John Hancock NY each make available a platform of investment alternatives to sponsors or administrators of retirement plans without regard to the individualized needs of any plan. Unless otherwise specifically stated in writing, John Hancock USA and John Hancock NY do not, and are not undertaking to, provide impartial investment advice or give advice in a fiduciary capacity.

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You have to write the information within the field The, Trustee, of, Contract, holder, Name Contract, Num, Contract, Number S, SN ppt, cs, zip, City, State, Zip, Code, Country DateofBirth, DC, CIA, Sec, Effective, Date Participant, Phone, No, Phone, Number FT, E, Termination, date, F, Termination, Date F, RE, Retirement, date, F, Retirement, Date IR, Employee, Money, Transferred, into, Plan Must, complete, Section, B FVC, Employee, Voluntary, Money Must, complete, Section, B F, DID, is, ability and Log, on, to, www, john, hancock, com, my, plan

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Note down the required information while you're on the Money, Type, Mandatory Investment, Fund, Code, Optional Amount, Percentage, Portion, Type Portion, Type Portion, Type Portion, Fund Portion, Fund Portion, Fund Portion, Amt Portion, Amt Portion, Amt Portion, Pct and Portion, Pct field.

Filling in gp5479us form step 3

The Section space is where both parties can indicate their rights and responsibilities.

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Finalize the form by reading the next fields: F, Pay, directly, tome Section, D Tax, Dollar F, Pre, Tax, and, Non, Roth, After, Tax F, Traditional, IRA FRoth, IRA, Section, B Section, A F, Employer, Sponsored, Qualified, Plan Section, C F, Taxable, balance, directly, rolled, over, to F, Traditional, IRA FRoth, IRA, Section, B Section, A F, Employer, Sponsored, Qualified, Plan and Section, C

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