Tiaa Cref Financial Statement PDF Details

Are you looking to get a loan or borrow money from a financial institution? if so, you will likely be required to fill out a Tiaa Cref Financial Statement Form. This form is used by the organization to collect information about your personal and financial situation. The information collected can be used to determine your creditworthiness and ability to repay any outstanding debts. The form is also used to determine the interest rate and loan amount that you may be eligible for. If you're new to the world of borrowing money or want to learn more about the Tiaa Cref Financial Statement Form, keep reading. In this post, we will provide an overview of what's included on the form and how it's used by lenders.

This page holds information about tiaa cref financial statement. It is suggested that you check out this material before you decide to begin working with the file.

QuestionAnswer
Form NameTiaa Cref Financial Statement
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other nameshow much is spousal support in ca, tiaa form f11380, tiaa financial statements, tiaa forms

Form Preview Example

ROLLOVER

FROM YOUR RETIREMENT INVESTMENTS

NEED HELP? 800-842-2252

Weekdays

8 a.m. – 10 p.m. (ET)

Saturday

9 a.m. – 6 p.m. (ET)

We will notify you of the rollover amount after we receive your completed forms. To avoid delays, be sure to complete all sections.

PLEASE NOTE: A rollover from your TIAA Traditional Account may not be available due to different plan rules and separate forms may be required. If you wish to make a rollover from your TIAA Traditional Account, please call us to obtain the correct form.

Federal or state taxes may apply for certain rollovers.

Tax information in this form is not intended as tax advice. If you have any questions about the impact of a requested rollover on your personal tax situation, you should consult a qualified tax adviser.

If you are paying off a loan (it is a taxable event), you must complete a cash withdrawal form before completing this rollover form.

Electronic Fund Transfers are not available for direct rollovers. We will send a check to the financial institution that you have designated on this rollover form.

Your account will be valued as of the date we receive this form in good order.

NOTE: If your rollover includes Roth 403(b)/401(k) contributions, they may be rolled over to another Roth 403(b)/401(k) that will accept them. They may also be rolled over to a Roth IRA.

If this plan is subject to ERISA, the spousal waiver section is only valid for 180 days from the date the Notary Public validates it. The signature on the withdrawal form is valid for 365 days.

Required Minimum Distribution (RMD): If you will be 70½ or older in this calendar year and you are separated from service, then the IRS requires that you receive your Required Minimum Distribution (RMD) amount prior to any rollover amount you request. If you have already satisfied your RMD for this calendar year, then you can continue with this rollover request. If you have not satisfied your RMD for this calendar year and you submit these rollover forms, then TIAA will pay your RMD amount for this calendar year prior to this rollover. TIAA will calculate your RMD amount using the IRS Uniform Life Expectancy table. Once the RMD amount is calculated, TIAA will pay this RMD amount out proportionately across all of your available funds. TIAA will send the RMD check to your address of record, withholding 10% for federal taxes and any applicable state taxes.

If you want different options, then you will need to call us to request cash forms to have your RMD amount satisfied and then you will need to submit a new set of rollover forms to TIAA.

NOTE: If this is a 403(b) plan and you have already satisfied your RMD for this calendar year with another 403(b) carrier, then you can attest to this in Step ONE and continue with your rollover request.

TAXCW/OTCPAYCSH F11380 (9/16)

ROLLOVER

FROM YOUR RETIREMENT INVESTMENTS

Page 1 of 10

Do you want to receive your money faster? Find out if you can request your rollover online - just log in to your account at TIAA.org, click on “Manage My Portfolio” and select “Rollover or Withdraw Money.” Some restrictions may apply.

Please print using black or dark blue ink.

IMPORTANT: A full Social Security Number/Taxpayer Identification Number is required to process your request.

If you claim residence AND citizenship outside the U.S., you must complete Form W-8BEN in addition to this form to certify your foreign tax status. To print the W-8BEN form, go to TIAA.org/forms, and scroll to Find tax forms.

1. PROVIDE YOUR INFORMATION

First Name

 

 

 

 

 

 

Middle Initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number/

 

 

 

 

 

 

 

 

Taxpayer Identification Number

Contact Telephone Number

Extension

 

 

 

 

 

 

 

 

 

 

State of Legal Residence

 

 

Citizenship (if not U.S.)

 

 

 

 

(if outside the U.S., write in Country of Residence)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*The Plan and Sub Plan Numbers should have been provided when you requested the form. If you don’t have them, please reference your quarterly statement.

2. PROVIDE YOUR CONTRACT NUMBERS

TIAA Number

   

Plan Number*

 

 

Sub Plan Number*

         

Plan Name

Was this contract issued as a result of a Divorce (Qualified Domestic Relations Order)?

Yes 

No

TAXCW/OTCPAYCSH F11380 (9/16)

ROLLOVER

FROM YOUR RETIREMENT INVESTMENTS

Page 2 of 10

3. ROTH ACCUMULATIONS

If you made Roth (After-Tax) contributions to the plan you are rolling funds from, please complete this section. If not, please move to next section.

Do you have ROTH accumulations?

Are you requesting ONLY non-Roth accumulations in this rollover?

OR

Yes 

Yes 

No

No

Are you requesting ONLY Roth accumulations in this rollover?

OR

Yes 

No

Are you requesting BOTH Roth and non-Roth accumulations in this rollover?

Yes 

No

NOTE: Satisfied means that you have already received your Required Minimum Distribution (RMD) check and have cashed it.

If you want different options, please call us.

4. REQUIRED MINIMUM DISTRIBUTION

If you will be 70½ or older in this calendar year and you are separated from service, then the IRS requires that you receive your Required Minimum Distribution (RMD) amount prior to any rollover amount you request. If you have already satisfied your RMD for this calendar year, then you can continue with this rollover request. If you have not satisfied your RMD for this calendar year and you submit these rollover forms, then TIAA will pay your RMD amount for this calendar year prior to this rollover. TIAA will calculate your RMD amount using the IRS Uniform Life Expectancy table. Once the RMD amount is calculated, TIAA will pay this RMD amount out proportionately across all of your available funds. TIAA will send the RMD check to your address of record, withholding 10% for federal taxes and any applicable state taxes. If this rollover is coming out of a 403(b) plan and you have already satisfied your RMD for this calendar year from another alternate carrier, please check the box below and continue to Section 5.

I attest that I have already satisfied my 403(b) Required Minimum Distribution (RMD) from another 403(b) carrier for this calendar year.

TAXCW/OTCPAYCSH F11380 (9/16)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ROLLOVER

 

 

 

 

 

 

 

 

 

FROM YOUR RETIREMENT INVESTMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 3 of 10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rollover amount will be

5. CHOOSE THE AMOUNT TO ROLL OVER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

based on the value of your

 

 

OPTION 1: Roll over entire amount available as allocated on file.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

investments on the day that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

your forms are received in

 

 

If you do not want these monies rolled over immediately, please specify a future date for TIAA to process

good order.

 

 

 

 

the request:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If no option is selected, or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

your allocation is invalid,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

your funds will be invested in

 

 

 

FUTURE DATE: Please roll over the funds on:

 

 

 

 

 

/

 

 

/

2

0

 

 

 

 

 

 

 

 

 

the default fund.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CREF has more than one

 

 

OPTION 2: Roll over a specific dollar amount.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

class which may vary by

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

plan. The class your funds

 

 

I want $

 

 

 

rolled over proportionately across all my available investments.

are in depends on your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Enter the dollar amount here and leave the specific investment section below blank.)

 

 

 

 

 

plan’s eligibility. If you have

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

questions about the CREF

 

 

OPTION 3: Roll over only a portion of account balance as indicated below.

 

 

 

 

 

classes, call us or visit

 

 

 

 

 

 

 

 

 

Indicate either the dollar amount or percentage from each account/fund. Percentages must be whole

TIAA.org.

 

 

IMPORTANT NOTE: If you

 

 

numbers.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

are currently subscribed to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percent of

the Custom Portfolio Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Investment Account/Fund Name

Rollover Amount

 

Fund Value

and you choose specific

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

funds, your account will be

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

subsequently rebalanced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

using your Custom Portfolio

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

Service instructions on file.

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you elect a systematic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

rollover, your last payment

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

may be less than your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

requested amount. The last

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

payment amount will be the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

balance left in your account

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

at the time that the last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

payment transaction occurs.

 

 

If you do not want these monies rolled over immediately, please specify a future date for TIAA to

You can choose to stop

 

 

 

 

process the request:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

systematic rollovers at any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date (mm/dd/yyyy)

 

 

 

 

 

time.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FUTURE DATE: Please roll over the funds on:

 

 

 

 

 

/

 

 

/

2

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPTION 4: Systematic Rollover

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The amount selected in Option 2 or Option 3 above will be the amount that we will setup as your

 

 

 

Systematic Rollover.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How often do you want to receive rollovers (choose one):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monthly 

 

Quarterly 

 

Semiannually 

 

 

Annually

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your payments will continue as above until there are no monies in designated funds. When do you want to start receiving rollovers?

If your plan is funded by a Transfer Payout Annuity (TPA), you may choose any date from the 5th to the 28th of the month. All others may choose any date from the 1st to the 28th.

(mm/dd/yyyy)

Start Date:

 

 

/

 

 

 

 

 

 

 

 

TAXCW/OTCPAYCSH

F11380 (9/16)

/

2 0

(mm/dd/yyyy)

Stop Date:

 

 

/

 

 

 

 

 

 

 

 

/

2 0

ROLLOVER

FROM YOUR RETIREMENT INVESTMENTS

Page 4 of 10

6. TELL US WHERE TO SEND YOUR ROLLOVER (CHOOSE ONE)

A. Roll over to another TIAA account.* (Also complete Section 6A)

OR

B. Roll over to another investment company.* (Also complete Section 6B)

Please tell us how to apply your after-tax monies.

Include in my rollover

Do not include in my rollover. TIAA will send me a check.

TAXCW/OTCPAYCSH

F11380 (9/16)

ROLLOVER

FROM YOUR RETIREMENT INVESTMENTS

Page 5 of 10

6A. ROLL OVER TO ANOTHER TIAA ACCOUNT

What type of account are you rolling over to? (Choose only one and provide account number.)

My existing employer’s plan.

TIAA Number

Plan Number

Plan Name

CREF Number

   

Sub Plan Number

 

   

My existing Roth or Traditional IRA (Please choose ONE of the following):

I already have my account number:

I opened my account within the last 30 days and do not yet have the account number to provide.

Do you want federal taxes withheld from the pretax amount you’re converting to a Roth IRA? If you don’t check a box, we’ll withhold 20% for federal taxes.

No, do not withhold federal taxes.

Yes, withhold

% (must be greater than 20%)

We will default to Allocations on File if no selection is made.

NOTE: If the amount you are rolling over includes funds currently invested in the TIAA Real Estate Account, please provide your investment allocations to the right.

A new Roth or Traditional IRA

Check here and attach enrollment form (call 800-842-2252 for form).

Another Tax-Deferred TIAA account

How would you like the funds allocated? (Choose only one)

Allocations on File (of the receiving plan).

Different Allocations – provide detail below.

Indicate either the dollar amount or percentage to each account/fund. Percentages must be whole numbers.

 

 

 

 

Percent of

Investment Account/Fund Name

Rollover Amount

 

Fund Value

 

 

 

 

 

 

 

 

 

$

 

OR

 

 

 

%

 

 

 

 

 

 

$

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

%

 

$

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

%

 

$

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

%

 

$

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

TAXCW/OTCPAYCSH F11380 (9/16)

 

ROLLOVER

 

FROM YOUR RETIREMENT INVESTMENTS

 

Page 6 of 10

 

 

The investment company

6B. ROLL OVER MY WITHDRAWAL TO ANOTHER INVESTMENT COMPANY

receiving your rollover must

What type of account are you rolling over to? (Choose only one)

complete the Investment

 

Company Information.

Traditional IRA (complete the Investment Company Information)

 

 

Roth IRA (complete the Investment Company Information)

 

Do you want federal taxes withheld from the pretax amount you’re converting to a Roth IRA? If you don’t

 

check a box, we’ll withhold 20% for federal taxes.

 

No, do not withhold federal taxes.

Yes, withhold

% (must be greater than 20%)

Other Plan (complete the Investment Company Information)

INVESTMENT COMPANY NAME

Investment Company Name

Address

City

 

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

Contact Telephone Number

 

Extension

 

Account Number

 

 

 

 

 

 

 

 

 

 

 

 

TAXCW/OTCPAYCSH

F11380 (9/16)

ROLLOVER

FROM YOUR RETIREMENT INVESTMENTS

Page 7 of 10

You must read, date and sign 7. YOUR AUTHORIZATION AND SIGNATURE

where indicated in order to

By signing below:

make a rollover.

 

Please sign your full legal name with suffix, if applicable, using blackor dark blue ink.

You authorize TIAA to make withdrawals from your account balances with TIAA, as stated in this form.

If you make a direct rollover into another employer’s plan, you understand your right to receive a distribution of these funds will be determined by the plan that is accepting the rollover and the funds in which your direct rollover are invested. You further understand that if you make a direct rollover to another employer’s plan that is subject to the Employee Retirement Income Security Act of 1974 (ERISA), spousal rights will apply to these funds and you may need a signed waiver from your spouse in order to receive a subsequent distribution of these funds.

For your protection, TIAA may require additional verification of your identity before accepting your transaction as in good order. You agree that your transaction will be valued as of the market close on the business

day that all of steps necessary to verify your identity and the transaction to be in good order have been completed. You also agree that in the event these steps are completed after the market close on a business day, then your transaction will be valued as of the market close on the next business day. The amount

of money that you receive will depend on the share or unit price on the day on which your transaction is deemed to be in good order. Due to market fluctuations, the price your shares or units ultimately receive could be less than the share or unit price when you initiated this transaction. It is also possible that if we are unable to reach you to verify this transaction it may result in the transaction being canceled.

Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); 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; and (4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Note: There are no FATCA code entries on this form, so please disregard item 4.

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

Your Signature

 

Today’s Date (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

2

0

 

 

TAXCW/OTCPAYCSH F11380 (9/16)

ROLLOVER

FROM YOUR RETIREMENT INVESTMENTS

Page 8 of 10

Unmarried Verification: If

8. UNMARRIED VERIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

you are unmarried, ONLY

 

I certify that I am not married AND no longer work for the employer that contributed to this plan.

 

complete Section 8.

 

Please sign using black or

Your Signature

 

Today’s Date (mm/dd/yyyy)

dark blue ink.

 

 

 

 

 

/

 

 

/

2

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that I am not married AND I am currently working for the employer that contributed to this plan.

 

 

 

 

Please sign below in the presence of the Plan Representative.

 

 

 

 

 

 

 

 

 

 

 

 

 

Your Signature

 

Today’s Date (mm/dd/yyyy)

 

 

 

 

 

 

/

 

 

/

2

0

 

 

 

 

PLAN REPRESENTATIVE CERTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

By signing, you certify that the participant is not married.

 

 

 

 

 

 

 

 

 

 

 

 

 

Plan Representative’s Signature

 

Today’s Date (mm/dd/yyyy)

/

Plan Representative’s Name (Please print)

Title

 

 

 

 

/

2 0

TAXCW/OTCPAYCSH F11380 (9/16)

ROLLOVER

FROM YOUR RETIREMENT INVESTMENTS

Page 9 of 10

To the participant: If you are

9. SPOUSE’S WAIVER OF SURVIVOR BENEFITS

married, ONLY your spouse

As the spouse of a participant in an employer-sponsored retirement plan, you have the right to receive a survivor

will need to complete

benefit of at least 50% of the participant’s (the account owner’s) accumulation if he or she dies before you

Section 9.

(referred to as a qualified joint and survivor annuity (“QJSA”)). The amount may be more, depending on the plan

Remember, spouse must

provisions. With this form, your spouse is requesting a distribution in a form other than the QJSA. Because this

sign and date this waiver on

means that the money used for the distribution will no longer be available to provide a QJSA survivor benefit to

or after the participant has

you, we must get your consent before completing the transaction. Please read and sign the statement below only

signed this form.

if you agree to the distribution in a form other than the QJSA. You do not have to sign this form. If you do not, you

 

 

will receive the QJSA survivor benefit described in the Explanation of the Qualified Joint and Survivor Annuity.

 

Important: You must have your signature witnessed by a Notary Public OR the contributing employer’s Plan

 

Representative. And you must sign and date this waiver on or after your spouse has signed the distribution form.

 

By signing I confirm that I have read and understand the Explanation of the Qualified Joint and Survivor

Please sign using black or

Annuity, which includes information about the QJSA and the requirements for spousal consent. I hereby agree

to this distribution and understand that the amount to be distributed will not be available as a QJSA survivor

dark blue ink.

benefit. I also understand that this waiver applies to this request only; it does not apply to future requests.

 

 

First Name

 

Last Name

 

 

 

 

 

 

 

 

 

 

This section must be completed by either a Notary Public or Plan Representative. If you reside outside the U.S., then

you need to go to a U.S. Embassy/U.S. Consulate or U.S. Bank Branch to obtain a Notary Public’s signature.

Signature

 

Today’s Date (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

2

0

 

 

NOTARY PUBLIC CERTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notary Expiration

 

 

 

 

State

 

County

 

Date (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

/

 

 

/

2

0

 

 

On the date noted below the subscriber known to me to be the person described in and who executed the foregoing instrument and he/she acknowledged to me that he/she executed the same.

Notary Public’s Signature

Today’s Date (mm/dd/yyyy)

Please contact your benefits office to complete the Plan Representative Certification instead of a Notary Public

FOR NOTARY PUBLICS IN MA

Indicate the type of identification:

Valid federal or state ID

Testimony of a credible witness

Personal knowledge of the subscriber

PLAN REPRESENTATIVE CERTIFICATION

By signing, you are certifying you witnessed the spouse’s signature.

Plan Representative’s Signature

/

 

 

/

2

0

 

 

In this space, the Notary Public must provide his/her notarial number and the date the appointment expires. Provide the notarial seal if outside New York state.

Today’s Date (mm/dd/yyyy)

Certification.

/

 

 

/

2

0

 

 

Plan Representative’s Name (Please print)

 

Title

 

 

 

 

 

 

TAXCW/OTCPAYCSH F11380 (9/16)

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