Form Hbp 026 – Fill Out and Use This PDF

SEAFARERS MONEY PURCHASE PENSION PLAN

5201 Auth Way, Camp Springs, Maryland, 20746

(800) 252-4674 or (301) 899-0675

APPLICATION FOR PENSION BENEFIT

This form is for pension benefits only. If you are applying for a death benefit, or if you are applying for either the In-Service Pension Benefit (age 70 or over) or the mandatory minimum distribution (over age 70 ½), you must use a different application form. Please call the Plan office to request the proper application form.

Please read this application carefully before answering any questions. Print your answers to all questions which apply to you. If any part of this application is not entirely clear, please contact the Plan office for assistance, at the above phone number between 9:00 a.m. and 5:00 p.m. EST, Monday through Friday.

I hereby make application for benefits from the Seafarers Money Purchase Pension Plan. I make the following statements and representations to the Trustees of the Fund with the knowledge that they will rely on this information in approving payment.

1)Participant’s Name _________________________________________________________________________________________

FIRST

MIDDLE INITIAL

LAST

2)Address _________________________________________________________________________________________________

	NUMBER AND STREET	CITY		STATE	ZIP CODE
3)	Social Security Number _________________________________		4)	Phone Number (	) _______________________

5)Date of Birth ____________/______/_______ (Submit birth certificate if monthly Joint and Survivor Benefit is Chosen)

6)	Marital Status:	[	] Single	[	] Married	[	] Divorced		[	] Widowed
				(Submit marriage certificate) (Submit Divorce Decree/QDRO)					(Submit Death Certificate)
7)	Spouse’s Name	_____________________________				Spouse’s Date of Birth		_____________________________
						(Submit birth certificate if monthly Joint and Survivor Benefit is chosen.)
8)	Union Affiliation	[	] SIU	[	] SMU	[ ] UIW	[ ] SEATU	[	] NMU	[ ] GLTD______

Type of Benefit - Please check Account(s) you wish to receive money from and indicate Date of Event.

9)	Employer Contribution Account [ ]
	a)	Choose Type: ______ Normal Retirement (Age 55 & over) ______________ Date of Retirement

- Proof of cessation of employment in the maritime industry required by signing Cessation of Employment declaration.

______ Total & Permanent Disability ___________ Date of Disability (Submit Social Security Disability Award)

-Proof of cessation of employment in the maritime industry required by signing Cessation of Employment declaration.

______ Withdrawal Benefit –

-Proof of cessation of employment in the maritime industry required by signing Cessation of Employment declaration.

-Must be out of the Industry for at least Twelve (12) Months.

b)Election of Benefit Form

-If your account balance is less than $5,000, it will be paid to you in one lump sum payment.

-If balance is $5,000 or more, you may elect the form of payment:

	Choose One:	______	One Lump Sum Payment (20% Federal Withholding Tax Applies)
		______	Ten (10) Equal Annual Payments
		______	Monthly Joint & 50% Survivor Benefit (payable for the joint lives of you and your spouse), in the
			amount of $ _________ per month, commencing on ____/	/	. And upon your death, your
			spouse will receive $ _______ per month, commencing the month following your death, during
			his/her lifetime. You and your spouse must submit a copy of birth certificates.
		______	Monthly Joint & 75% Survivor Benefit (payable for the joint lives of you and your spouse), in the
			amount of $ _________ per month, commencing on ____/	/	. And upon your death, your
			spouse will receive $ _______ per month, commencing the month following your death, during
			his/her lifetime. You and your spouse must submit a copy of birth certificates & marriage certificate.
		______	Direct Rollover to another Qualified Plan (You must provide Rollover information on next page
			along with a rollover authorization form signed by you and a representative of the company you are
			sending your money to.)
10)	Voluntary Contribution Account [ ]
	a)	______	Payout Benefit – Available once every 18 months.

b)Election of Benefit Form – It can be paid as follows:

Choose One: ______	One Lump Sum Payment
	of Voluntary Contribution Account Balance or a partial withdrawal from your Voluntary Contribution
	Account in the amount of $ ________________.
______	Ten (10) Equal Annual Payments
HBP 026 – 08/13

Seafarers Money Purchase Pension Plan

Application for Pension Benefit

Page 2 of 2

11)If You Choose a Rollover from Item #9, (on the other side of application), complete this item.

__________________________________________________________	(	)_______________________________
NAME OF BANK OR FINANCIAL INSTITUTION	PHONE NUMBER

______________________________________________________________________________________________________

STREET ADDRESS OF BANK OR FINANCIAL INSTITUTION

______________________________________________________________________________________________________

CITY, STATE, AND ZIP CODE OF BANK OR FINANCIAL INSTITUTION

_____________________________________________	____________________________________________
CONTACT/ACCOUNT REPRESENTATIVE	ACCOUNT NUMBER

Notice of Withholding – Any money paid directly to you from your Employer Contribution Account will be subjected to a mandatory 20% Federal Withholding Tax. The only exceptions to this law are payments over a period of at least 10 years in length or a rollover of the money to another Tax Deferred Qualified Retirement Plan.

12)Spousal Consent:

a.If you are single, check here ______.

b.If you are married, and you are applying for a benefit from your Employer Contribution account in the amount of $5,000 or more, or you are applying for a payout benefit from your Voluntary Contributions account, your spouse must complete the following:

I, _______________________________________, born ________________________, am aware that my spouse,

PRINT SPOUSE’S NAMEDATE OF BIRTH

_________________________________________, has applied for his/her pension benefit, and/or a payout benefit

PRINT MEMBER’S NAME

from his/her voluntary contribution account. I understand that my spouse may be able to receive his/her benefits in the form of a joint and survivor annuity. By signing this application, I consent to my spouse’s election regarding the form in which benefits

will be paid.

	__________________________________________	__________________________
	SPOUSE’S SIGNATURE	DATE SIGNED
13)	____________________________________________________	__________________________
	PARTICIPANT’S NAME	SOCIAL SECURITY NUMBER
14)	____________________________________________________	__________________________
	PARTICIPANT’S SIGNATURE	DATE SIGNED

15)NOTARIZATION: STATE OF __________________________, COUNTY OF: ______________________

I certify that on __________________, 20______, ____________________________		_________________________________
DATE	APPLICANT’S NAME	SPOUSE’S NAME (if applicable)

Personally came before me and acknowledged under oath, to my satisfaction that (he/she):

a)is named in and personally signed this document; and,

b)signed, sealed, and delivered this document as (his/her) act and deed.

________________________________________________________________

A NOTARY PUBLIC

HBP 026 – 08/13