Distributions Details

When you leave a job, whether it's voluntarily or involuntarily, you have the option to take your money out of your company's 401k. The Transamerica 401K Withdrawal Form is the document you need to complete in order to take money out of your account. There are a few things you need to know before completing the form, so be sure to read this guide first. In particular, there are tax implications to consider, so make sure you understand them before finalizing your decision. Whatever you decide, make sure you talk with a financial advisor or accountant beforehand to get their advice.

The table has got specifics of the transamerica 401k withdrawal. You can look at it just before writing the gaps.

QuestionAnswer
Form NameTransamerica 401K Withdrawal
Form Length28 pages
Fillable?No
Fillable fields0
Avg. time to fill out7 min
Other names

Form Preview Example

Distribution Request Form

READ THE ATTACHED IRS SPECIAL TAX NOTICE: IF YOUR PLAN ALLOWS FOR AN ANNUITY OPTION, READ THE WRITTEN EXPLANATION OF QUALIFIED JOINT AND 50% CONTINGENT SURVIVOR ANNUITY FORM OF BENEFIT BEFORE COMPLETING THIS FORM.

Please note: Do not use this form for:

(1)

Death Benefit Claim

 

(2)

Required Minimum Distribution

 

(3)

Hardship Withdrawal Request

INSTRUCTIONS AND INFORMATION FOR COMPLETING THIS FORM

This Form Must Be Completed And Signed By You (And Your Spouse If You Are Married And Your Plan Allows For Annuities) And The Plan Administrator, Trustee Or An Authorized Signer. If any information is missing or incomplete, you may be required to complete a new form or provide additional information before the distribution can be processed.

PARTICIPANT INSTRUCTIONS

1.Complete Sections A-H. If you do not have a Roth 401(k) Account, skip Section D. If you are married and your plan allows for annuities, complete Section H, Spousal Consent.

2.Your signature is required in Section I.

3.Submit this form to your Employer for signature and processing. DoUnot mailUthis form directly to the Processing Center listed at the end of this form.

EMPLOYER INSTRUCTIONS

1.Complete Section J.

2.Your signature is required in Section J.

3.Submit this form to the Processing Center

SECTION A. Participant Information — Please print

Company/Employer Name

 

Contract Number

 

 

 

Social Security No.

– –

Last Name

Date of Birth (mmddyyyy)

– –

Date of Hire (mmddyyyy)

 

E-mail Address

 

 

 

 

 

 

First Name/Middle Initial

Street Address/Apt. No.

 

 

 

 

 

 

Phone No.

 

 

Ext. (if any)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip Code

 

Marital Status

 

 

 

 

 

 

 

 

 

 

 

 

Married

Not Married

 

 

 

 

 

 

 

 

 

 

 

 

 

MAIL DELIVERY OF DISTRIBUTIONS

If no address is provided in Section A, the address on file will be used to process this request. All checks will be sent via First Class Mail unless the Overnight Mail box is checked below.

Send check overnight mail and deduct $25.00 from the check for express charges. $50.00 will be deducted when two checks are required. (Example: One check sent to a rollover institution and one check to the participant). Please note: A street address must be provided.

Based on plan provisions, a distribution fee may be assessed at the time of processing. Please check with your Plan Administrator for any questions as to if a distribution fee may apply to your request.

SECTION B. Reason For Distribution Request — Must be completed OR skip this section if your employer checked off “plan termination” in Section J

Check the appropriate box below:

Termination of employment

Age 59 1P /P R2R (if allowed by the Plan)

In-service (if allowed by the Plan) Retirement

Disability as determined by the Plan’s fiduciary

Withdrawal of After-Tax Contributions (if allowed by the Plan)

Withdrawal of Rollover contributions (if allowed by the Plan)

Payment to alternate payee under QDRO (Only Applies to Divorce Proceedings)

Alternate Payee’s SSN #

Name

– –

January 2014

Page 1 of 28

Distribution Request Form - CSC

SECTION C. Form of Payment For Traditional 401(k) Account - Only choose one of the three options

²Option 1 (Rollover) - I am requesting a Direct Rollover of

all or a

partial amount of my Traditional 401(k) account.

¹Partial amount to be rolled over: $___________________

Direct Rollover to: (Select Only One)

_____ AN IRA OFFERED THROUGH Transamerica (Minimum rollover amount is $5,000). If you are interested in the Rollover IRA option

through Transamerica, call (866) 691-0030 to learn more and to establish an account. An IRA account number is required before the rollover can be processed.

_____ AN ELIGIBLE RETIREMENT PLAN (401(a), 401(k), 403(b), and Governmental 457)

_____ AN IRA

 

NEW ACCOUNT INFORMATION:

MAILING ADDRESS:

 

 

 

 

 

 

 

 

 

IRA Account Number (Required) / Plan Name

Name of Trustee or Custodian for the New Plan or IRA

 

 

 

 

 

 

 

 

 

Make Check Payable To:

Address – Number & Street

 

 

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

²Option 2 (Combination) - I am requesting a distribution of my Traditional 401(k) account to be paid partially to me and partially as a Direct Rollover.

I understand that the portion payable to me may be subject to 20% federal income tax withholding.

Distribute __________% of my Traditional 401(k) account:

____________% of the above paid directly to me, and

____________% of the above applied to the Direct Rollover Account indicated below.

The above two percentages must equal 100%

Direct Rollover to: (Select Only One)

_____ AN IRA OFFERED THROUGH Transamerica (Minimum rollover amount is $5,000). If you are interested in the Rollover IRA option

through Transamerica, call (866) 691-0030 to learn more and to establish an account. An IRA account number is required before the rollover can be processed.

_____ AN ELIGIBLE RETIREMENT PLAN (401(a), 401(k), 403(b), and Governmental 457)

_____ AN IRA

NEW ACCOUNT INFORMATION:

MAILING ADDRESS:

IRA Account Number (Required) / Plan Name

Name of Trustee or Custodian for the New Plan or IRA

Make Check Payable To:

Address – Number & Street

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Option 3 (Cash) - I am requesting a distribution of

all or a

partial amount of my Traditional 401(k) account. I am not electing a Direct

Rollover of any portion of the distribution. I understand the check will be made payable to me and that the portion payable to me may be subject to 20% federal income tax withholding.

¹Partial amount to be paid directly to me: $_____________

¹Actual Value of the distribution may vary based on the final market closing price at the time the distribution is processed, and any applicable processing fees.

PARTIAL DISTRIBUTION AMOUNTS -I understand that if I choose a partial amount in the options above, I am responsible for ensuring that partial distributions are completed by the shorter of my life expectancy or 15 years after the first partial distribution is made to me, as required by the Plan. I also understand that if I choose this option I may lose favorable tax treatment on my distributions

²DIRECT ROLLOVER

In a Direct Rollover, an eligible rollover distribution is paid from your retirement plan directly to an IRA or your new Employer's 401(a), 401(k), 403(b) or governmental 457 Plan. An IRS Form 1099-R will still be completed and submitted to the IRS; however, no federal or state income tax is withheld from amounts directly rolled over. The Direct Rollover check will be made payable to the IRA/plan trustee or custodian for the benefit of the participant or alternate payee unless otherwise indicated above.

January 2014

Page 2 of 28

Distribution Request Form - CSC

SECTION D. Form of Payment For A Roth 401(k) Account – Complete only if your plan allows for Roth Contributions. Only choose one of the three options

²Option 1 (Rollover) - I am requesting a Direct Rollover of

all or a

partial amount of my Roth 401(k) account.

¹Partial amount to be rolled over: $___________________

Direct Rollover to: (Select Only One)

_____A ROTH IRA OFFERED THROUGH Transamerica. (Minimum rollover amount is $5,000.) If you are interested in the Rollover IRA

option through Transamerica, call (866) 691-0030 to learn more and to establish an account. An IRA account number is required before the rollover can be processed.

______A DESIGNATED ROTH ACCOUNT (401(k) or 403(b)) OR ROTH IRA

NEW ACCOUNT INFORMATION:

MAILING ADDRESS:

 

 

Roth IRA Account Number (Required) / Plan Name

Name of Trustee or Custodian for the New Roth 401(k) or Roth IRA

Make Check Payable To:

Address – Number & Street

City

State

Zip Code

²Option 2 (Combination) - I am requesting a distribution of my Roth 401(k) account to be paid partially to me and partially as a Direct Rollover.

I understand that the portion payable to me may be subject to 20% federal income tax withholding.

Distribute __________% of my Roth 401(k) account:

____________% of the above paid directly to me, and

____________% of the above applied to the Direct Rollover Account indicated below.

The above two percentages must equal 100%

Direct Rollover to: (Select Only One)

_____ A ROTH IRA OFFERED THROUGH Transamerica. (Minimum rollover amount is $5,000.) If you are interested in the Rollover IRA

option through Transamerica, call (866) 691-0030 to learn more and to establish an account. An IRA account is required before the rollover can be processed.

_____ A DESIGNATED ROTH ACCOUNT (401(k) or 403(b)) OR ROTH IRA

NEW ACCOUNT INFORMATION:

MAILING ADDRESS:

IRA Account Number (Required) / Plan Name

Name of Trustee or Custodian for the New Plan or IRA

Make Check Payable To:

Address – Number & Street

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

Option 3 (Cash) - I am requesting a distribution of

all or a

partial amount of my Roth 401(k) account. I am not electing a Direct Rollover of

any portion of the distribution. I understand the check will be made payable to me and that the portion payable to me may be subject to 20% federal income tax withholding.

¹Partial amount to be paid directly to me: $___________

¹Actual Value of the distribution may vary based on the final market closing price at the time the distribution is processed, and any applicable processing fees.

DISTRIBUTION AMOUNTS -I understand that if I choose a partial amount in the options above, I am responsible for ensuring that partial distributions are completed by the shorter of my life expectancy or 15 years after the first partial distribution is made to me, as required by the Plan. I also understand that if I choose this option I may lose favorable tax treatment on my distributions

²DIRECT ROLLOVER

In a Direct Rollover, an eligible rollover distribution is paid from your retirement plan directly to an IRA or your new Employer's 401(a), 401(k), 403(b) or governmental 457 Plan. An IRS Form 1099-R will still be completed and submitted to the IRS; however, no federal or state income tax is withheld from amounts directly rolled over. The Direct Rollover check will be made payable to the IRA/plan trustee or custodian for the benefit of the participant or alternate payee unless otherwise indicated above.

For participants required to take a minimum distribution during the current year that was not satisfied, please note the following: Your required minimum distribution (RMD) for the current year will need to be completed and made payable to you prior to the processing of your direct rollover request.

January 2014

Page 3 of 28

Distribution Request Form - CSC

SECTION E. Annuity Request (Not applicable to vested account under $5000 or if your plan does not offer annuities)

Skip this section if you made an election in Section C or D.

By selecting this option your entire account balance will be distributed in order to purchase the annuity

Annuity: If the plan offers annuities as a form of benefit payment, I elect payment as a monthly annuity with payments to commence ___________________.

Upon my death, my spouse’s payments should be _____% (from 50% to 100%) of my payments. My spouse’s date of birth is _________________. Such

annuity will be a Joint and Contingent Survivor Annuity if I am married and a Single Life Annuity if I am not married. I also understand that if I am married, my spouse need not consent to this election if I choose a Qualified Joint and Contingent Survivor Annuity (“QJSA”).

SECTION F. Outstanding Loan Payoff Instructions — Skip this section if you do not have an outstanding loan or are requesting an In-Service Withdrawal, Withdrawal of After Tax Contributions, 591/2 Withdrawal or a QDRO.

One of the following will occur if you have an outstanding loan amount and your reason for a distribution request in Section B is for Termination of Employment, Disability or a Retirement Benefit.

Your Loan will be considered paid in full if you have submitted your payment for the outstanding loan amount to your employer or have attached a money order or cashier’s check to this form.

Your outstanding loan balance will default and become taxable to you if Transamerica receives this form and your payment has not been received and processed.

SECTION G. Income Tax Withholding

The income tax withholding requirements vary depending on whether or not the distribution requested is an eligible rollover distribution. Please see the attached Special Tax Notice for the definition of eligible rollover distribution and a detailed explanation of the federal income tax withholding rules. If you request a Direct Rollover, no federal income tax will be withheld from the amount directly rolled over.

FEDERAL INCOME TAX

Eligible Rollover Distributions:

If you request a Direct Rollover, no federal income tax will be withheld from the amount directly rolled over.

If you request any portion that is an Eligible Rollover Distribution and payable to you: 20% mandatory federal income tax withholding will apply if the taxable amount of the distribution is more than $200 unless paid over 10 or more years.

STATE INCOME TAX

If your address of record is within a mandatory withholding state, state taxes will be withheld from your distribution in accordance with the respective state rules. Other states allow an independent election and in these states, state tax will be withheld unless you elect otherwise. If your state does not allow withholding, no state tax can be withheld. Please consult a tax advisor or Transamerica if you have questions regarding state tax withholding.

Do not withhold state income tax (ONLY IF INDEPENDENT ELECTION IS PERMITTED).

Withhold state income tax:__________% (If your state requires a greater withholding percentage than what you have indicated, the mandatory state

tax will apply).

SECTION H. Spousal Consent

Check with your Employer/Plan Administrator or Summary Plan Description to determine whether your plan is subject to spousal consent requirements. If spousal consent is required, complete this section. If your plan is not subject to spousal consent requirements, skip to Section I. Please note: You must have your spouse’s signature notarized or have a plan representative witness your spouse’s signature if your vested account balance is greater than $5,000 and your plan provides for joint and survivor annuities. However, if your vested account balance is less than $5,000 spousal consent is not required.

Spousal Consent

I, the undersigned spouse of the participant, have read the “Special Tax Notice Regarding Payments From Qualified Plans” provided to me and understand the effects of the waiver. I understand that federal law requires that the retirement benefit of my spouse must be paid under a Qualified Joint and Survivor Annuity Form as described in the attached “Special Tax Notice Regarding Payments From Qualified Plans,” unless I consent otherwise in writing to another benefit form. I hereby consent to the waiver of the annuity and consent to the form of benefit elected by my spouse.

Signature of Participant’s Spouse:

 

Date:

Statement of Plan Representative or Notary Public

The spouse whose signature I have witnessed is known to me and signed this form in my presence.

 

Plan Representative:

 

Date:

Notary Public Signature:

 

Date:

PLACE SEAL HERE (if applicable)

January 2014

Page 4 of 28

Distribution Request Form - CSC

SECTION I. Participant Signature

My signature acknowledges that I have read, understand and agree to all the terms of this Distribution Request form, and affirm that all information that I have provided is true and correct. Further, I acknowledge that I have received the “Special Tax Notice Regarding Payments From Qualified Plans” and other required notices. The above information is true and correct to the best of my knowledge. I further understand that I may revoke this election at any time prior to the distribution taking place.

Signature of Participant

Date

PARTICIPANT: RETURN COMPLETED FORM TO YOUR PLAN ADMINISTRATOR FOR PROCESSING

Section J. For Completion by Plan Administrator, Trustee Or Authorized Signer Only

Plan Name

Contract Number

Sub ID/Division # (if applicable)

Participant’s SSN #

– –

Participant’s Termination Date (if applicable):

– –

The Participant is entitled to a vested benefit of% of company matching contributions.

The Participant is entitled to a vested benefit of _______________________% of profit sharing contributions.

The Number of hours worked in the Plan Year of Termination: __________________

Please refer to your Plan Document for the vesting schedule. If this information is not provided, the distribution will be processed with the data in Transamerica’s recordkeeping system.

Is payment of this benefit subject to Plan Termination?

No

Yes

By signing below, I hereby authorize Transamerica to process the distribution described in this form. This request is in compliance with plan provisions.

If spousal consent is not provided, then in accordance with the terms and provisions of the plan and under the current law, spousal consent is not required for payment of the requested benefit.

If this request is for a disability distribution, I certify that the participant meets the requirements of Section 72(m)(7).

Only submit this form after final contributions and loan repayments have been processed for termination distributions

Once this form has been completed with all of the necessary information and required signatures, please forward to the Processing Center. This form cannot be processed without the Plan Administrator, Trustee or Authorized Signer’s signature.

Be sure to keep a copy for your records.

By: Signature of Plan Administrator, Trustee or Authorized Signer

 

Date

 

 

 

Print Name of Plan Administrator, Trustee or Authorized Signer

 

Date

FOR PLAN ADMINISTRATOR USE ONLY - MAIL TO: 8488 Shepherd Farm Drive, West Chester, OH 45069,Fax #: (877) 449-4443

January 2014

Page 5 of 28

Distribution Request Form - CSC

SPECIAL TAX NOTICE

REGARDING PAYMENTS FROM QUALIFIED PLANS

YOUR ROLLOVER OPTIONS

You are receiving this notice because all or a portion of a payment you are receiving from your Employer’s plan (the "Plan") is eligible to be rolled over to an IRA, a Roth IRA, an employer plan, or a designated Roth account in an employer plan. This notice is intended to help you decide whether to do a rollover.

This notice describes the rollover rules that apply to two types of payments that you may be eligible to receive from the Plan: payments that are from a designated Roth account and payments that are not from a designated Roth account. A designated Roth account is a type of account with special tax rules that is available in some employer plans. If you are eligible to receive payments from the Plan that are from a designated Roth account and payments that are not from such an account, the Plan administrator or the payor will tell you the amount that is being paid from each account.

Rules that apply to most payments from a plan are described in the "General Information About Rollovers" section. In addition, additional rules that apply to most payments from a designated Roth account are described in the "General Information About Rollovers From A Designated Roth Account" section. Special rules that only apply in certain circumstances are described in the "Special Rules and Options" section.

Your Right to Waive the 30-Day Notice Period

Generally, neither a Direct Rollover nor a payment can be made from the plan until at least 30 days after your receipt of this notice. Thus, after receiving this notice, you have at least 30 days to consider whether or not to have your withdrawal directly rolled over. If you do not wish to wait until this 30-day notice period ends before your election is processed, you may waive the notice period by making an affirmative election indicating whether or not you wish to make a Direct Rollover. Your withdrawal will then be processed in accordance with your election as soon as practical after it is received by the Plan Administrator.

GENERAL INFORMATION ABOUT ROLLOVERS

How can a rollover affect my taxes?

You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59 1/2 and do not do a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59 1/2 (or if an exception applies).

Where may I roll over the payment?

You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the IRA or employer plan.

January 2014

Page 6 of 28

Distribution Request Form - CSC

How do I do a rollover?

There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.

If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRA sponsor or the administrator of the employer plan for information on how to do a direct rollover.

If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are under age 59 1/2 (unless an exception applies).

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:

Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

Required minimum distributions after age 70 1/2 (or after death)

Hardship distributions

ESOP dividends

Corrective distributions of contributions that exceed tax law limitations

Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends)

Cost of life insurance paid by the Plan

Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment

Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax consequences if you roll over a distribution of S corporation stock to an IRA).

The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.

If I don't do a rollover, will I have to pay the 10% additional income tax on early distributions?

If you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the payment not rolled over.

The 10% additional income tax does not apply to the following payments from the Plan:

Payments made after you separate from service if you will be at least age 55 in the year of the separation

Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety employee and you are at least age 50 in the year of the separation

Payments made due to disability

Payments after your death

Payments of ESOP dividends

Corrective distributions of contributions that exceed tax law limitations

Cost of life insurance paid by the Plan

Payments made directly to the government to satisfy a federal tax levy

Payments made under a qualified domestic relations order (QDRO)

Payments up to the amount of your deductible medical expenses

Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days

Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution.

January 2014

Page 7 of 28

Distribution Request Form - CSC

If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?

If you receive a payment from an IRA when you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions from the IRA, unless an exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same as the exceptions listed above for early distributions from a plan. However, there are a few differences for payments from an IRA, including:

There is no exception for payments after separation from service that are made after age 55.

The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).

The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service.

There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and (3) payments after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment compensation but for self-employed status).

Will I owe State income taxes?

This notice does not describe any State or local income tax rules (including withholding rules).

January 2014

Page 8 of 28

Distribution Request Form - CSC

GENERAL INFORMATION ABOUT ROLLOVERS

FROM A DESIGNATED ROTH ACCOUNT

How can a rollover affect my taxes?

After-tax contributions included in a payment from a designated Roth account are not taxed, but earnings might be taxed. The tax treatment of earnings included in the payment depends on whether the payment is a qualified distribution. If a payment is only part of your designated Roth account, the payment will include an allocable portion of the earnings in your designated Roth account.

If the payment from the Plan is not a qualified distribution and you do not do a rollover to a Roth IRA or a designated Roth account in an employer plan, you will be taxed on the earnings in the payment. If you are under age 59 1/2, a 10% additional income tax on early distributions will also apply to the earnings (unless an exception applies). However, if you do a rollover, you will not have to pay taxes currently on the earnings and you will not have to pay taxes later on payments that are qualified distributions.

If the payment from the Plan is a qualified distribution, you will not be taxed on any part of the payment even if you do not do a rollover. If you do a rollover, you will not be taxed on the amount you roll over and any earnings on the amount you roll over will not be taxed if paid later in a qualified distribution.

A qualified distribution from a designated Roth account in the Plan is a payment made after you are age 59 1/2 (or after your death or disability) and after you have had a designated Roth account in the Plan for at least 5 years. In applying the 5-year rule, you count from January 1 of the year your first contribution was made to the designated Roth account. However, if you did a direct rollover to a designated Roth account in the Plan from a designated Roth account in another employer plan, your participation will count from January 1 of the year your first contribution was made to the designated Roth account in the Plan or, if earlier, to the designated Roth account in the other employer plan.

Where may I roll over the payment?

You may roll over the payment to either a Roth IRA (a Roth individual retirement account or Roth individual retirement annuity) or a designated Roth account in an employer plan (a tax-qualified plan or section 403(b) plan) that will accept the rollover. The rules of the Roth IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the Roth IRA or employer plan (for example, no spousal consent rules apply to Roth IRAs and Roth IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the Roth IRA or the designated Roth account in the employer plan. In general, these tax rules are similar to those described elsewhere in this notice, but differences include:

If you do a rollover to a Roth IRA, all of your Roth IRAs will be considered for purposes of determining whether you have satisfied the 5-year rule (counting from January 1 of the year for which your first contribution was made to any of your Roth IRAs).

If you do a rollover to a Roth IRA, you will not be required to take a distribution from the Roth IRA during your lifetime and you must keep track of the aggregate amount of the after-tax contributions in all of your Roth IRAs (in order to determine your taxable income for later Roth IRA payments that are not qualified distributions).

Eligible rollover distributions from a Roth IRA can only be rolled over to another Roth IRA.

January 2014

Page 9 of 28

Distribution Request Form - CSC

How do I do a rollover?

There are two ways to do a rollover. You can either do a direct rollover or a 60-day rollover.

If you do a direct rollover, the Plan will make the payment directly to your Roth IRA or designated Roth account in an employer plan. You should contact the Roth IRA sponsor or the administrator of the employer plan for information on how to do a direct rollover.

If you do not do a direct rollover, you may still do a rollover by making a deposit within 60 days into a Roth IRA, whether the payment is a qualified or nonqualified distribution. In addition, you can do a rollover by making a deposit within 60 days into a designated Roth account in an employer plan if the payment is a nonqualified distribution and the rollover does not exceed the amount of the earnings in the payment. You cannot do a 60-day rollover to an employer plan of any part of a qualified distribution. If you receive a distribution that is a nonqualified distribution and you do not roll over an amount at least equal to the earnings allocable to the distribution, you will be taxed on the amount of those earnings not rolled over, including the 10% additional income tax on early distributions if you are under age 59 1/2 (unless an exception applies).

If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable portion of the earnings in your designated Roth account.

If you do not do a direct rollover and the payment is not a qualified distribution, the Plan is required to withhold 20% of the earnings for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover to a Roth IRA, you must use other funds to make up for the 20% withheld.

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:

Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

Required minimum distributions after age 70 1/2 (or after death)

Hardship distributions

ESOP dividends

Corrective distributions of contributions that exceed tax law limitations

Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends)

Cost of life insurance paid by the Plan

Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment

Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax consequences if S corporation stock is held by an IRA).

The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.

January 2014

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Distribution Request Form - CSC

If I don't do a rollover, will I have to pay the 10% additional income tax on early distributions?

If a payment is not a qualified distribution and you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions with respect to the earnings allocated to the payment that you do not roll over (including amounts withheld for income tax), unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the earnings not rolled over.

The 10% additional income tax does not apply to the following payments from the Plan:

Payments made after you separate from service if you will be at least age 55 in the year of the separation

Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

Payments made due to disability

Payments after your death

Payments of ESOP dividends

Corrective distributions of contributions that exceed tax law limitations

Cost of life insurance paid by the Plan

Payments made directly to the government to satisfy a federal tax levy

Payments made under a qualified domestic relations order (QDRO)

Payments up to the amount of your deductible medical expenses

Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days

Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution.

If I do a rollover to a Roth IRA, will the 10% additional income tax apply to early distributions from the IRA?

If you receive a payment from a Roth IRA when you are under age 59 1/2, you will have to pay the 10% additional income tax on early distributions on the earnings paid from the Roth IRA, unless an exception applies or the payment is a qualified distribution. In general, the exceptions to the 10% additional income tax for early distributions from a Roth IRA listed above are the same as the exceptions for early distributions from a plan. However, there are a few differences for payments from a Roth IRA, including:

There is no special exception for payments after separation from service.

The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to a Roth IRA of a spouse or former spouse).

The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service.

There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and (3) payments after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment compensation but for self-employed status).

Will I owe State income taxes?

This notice does not describe any State or local income tax rules (including withholding rules).

January 2014

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Distribution Request Form - CSC

SPECIAL RULES AND OPTIONS

If your payment includes after-tax contributions (other than payments from a designated Roth account)

After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax contributions is generally included in the payment. If you have pre-1987 after-tax contributions maintained in a separate account, a special rule may apply to determine whether the after-tax contributions are included in a payment.

You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable portion of the after-tax contributions. If you do a 60-day rollover to an IRA of only a portion of the payment made to you, the after-tax contributions are treated as rolled over last. For example, assume you are receiving a complete distribution of your benefit which totals $12,000, of which $2,000 is after-tax contributions. In this case, if you roll over $10,000 to an IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is treated as being after-tax contributions.

You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled over.

If you miss the 60-day rollover deadline

Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).

If your payment includes employer stock that you do not roll over

If you do not do a rollover, or if you receive a distribution from a designated Roth account that is not a qualified distribution and you do not roll it over, you can apply a special rule to payments of employer stock (or other employer securities) that are paid in a lump sum after separation from service (or after age 59 1/2, disability, or the participant's death). Under the special rule, the net unrealized appreciation on the stock included in the earnings in the payment will not be taxed when distributed to you from the Plan and will be taxed at capital gain rates when you sell the stock. If you do a rollover for a payment that includes employer stock, or if you receive a distribution from a designated Roth account and you do a rollover to a Roth IRA for a nonqualified distribution that includes employer stock (for example, by selling the stock and rolling over the proceeds within 60 days of the distribution), you will not have any taxable income and the special rule relating to the distributed employer stock will not apply to any subsequent payments from the IRA, Roth IRA, or employer plan, as applicable. Net unrealized appreciation is generally the increase in the value of the employer stock after it was acquired by the Plan. The Plan administrator can tell you the amount of any net unrealized appreciation.

If you receive a payment from a designated Roth account that is a qualified distribution that includes employer stock and you do not roll it over, your basis in the stock (used to determine gain or loss when you later sell the stock) will equal the fair market value of the stock at the time of the payment from the Plan.

If you have an outstanding loan that is being offset

If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The loan offset amount is treated as a distribution to you at the time of the offset and, if the distribution is a nonqualified distribution, the earnings in the loan offset will be taxed (including the 10% additional income tax on early distributions, unless an exception applies) unless you do a 60-day rollover in the amount of the earnings in the loan offset to an IRA, Roth IRA, employer plan, or designated Roth account in an employer plan, as applicable.

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If you were born on or before January 1, 1936

If you were born on or before January 1, 1936, and receive a lump sum distribution (or you receive a distribution from a designated Roth account that is not a qualified distribution) that you do not roll over, special rules for calculating the amount of the tax on the earnings in the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.

If your payment is from a governmental section 457(b) plan

If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice generally apply, allowing you to roll over the payment to an IRA or an employer plan that accepts rollovers. One difference is that, if you do not do a rollover, you will not have to pay the 10% additional income tax on early distributions from the Plan even if you are under age 59 1/2 (unless the payment is from a separate account holding rollover contributions that were made to the Plan from a tax-qualified plan, a section 403(b) plan, or an IRA). However, if you do a rollover to an IRA or to an employer plan that is not a governmental section 457(b) plan, a later distribution made before age 59 1/2 will be subject to the 10% additional income tax on early distributions (unless an exception applies). Other differences are that you cannot do a rollover if the payment is due to an "unforeseeable emergency" and the special rules under "If your payment includes employer stock that you do not roll over" and "If you were born on or before January 1, 1936" do not apply.

If are an eligible retired public safety officer (and, for those who receive distributions from a designated Roth account, you receive a nonqualified distribution), and your pension payment is used to pay for health coverage or qualified long-term care insurance

If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal retirement age, you can exclude from your taxable income nonqualified distributions paid directly as premiums to an accident or health plan (or a qualified long-term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or ambulance crew.

If you roll over your payment to a Roth IRA (applicable to payments that do NOT come from designated Roth accounts only)

You can roll over a payment from the Plan made before January 1, 2010 to a Roth IRA only if your modified adjusted gross income is not more than $100,000 for the year the payment is made to you and, if married, you file a joint return. These limitations do not apply to payments made to you from the Plan after 2009. If you wish to roll over the payment to a Roth IRA, but you are not eligible to do a rollover to a Roth IRA until after 2009, you can do a rollover to a traditional IRA and then, after 2009, elect to convert the traditional IRA into a Roth IRA.

If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax amounts) will be taxed. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within 5 years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that are rolled over to a Roth IRA, the taxable amount can be spread over a 2-year period starting in 2011.

If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a payment made after you are age 59 1/2 (or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent of earnings after the rollover, including the 10% additional income tax on early distributions (unless an exception applies). You do not have to take required minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).

You may also roll over a payment from the Plan to a designated Roth account in an employer plan.

January 2014

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Distribution Request Form - CSC

If you complete an in-plan roll over to a designated Roth account in your plan (applicable to payments that do NOT come from designated Roth accounts only)

If you roll over a payment to a designated Roth account in the plan, the amount of the payment rolled over (reduced by any after-tax amounts directly rolled over) will be taxed. However, the 10% additional tax on early distributions will not apply (unless you take the amount rolled over out of the designated Roth account within the 5-year period that begins on January 1 of the year of the rollover). For payments from the plan in 2010 that are rolled over to a designated Roth account in the plan (and that are not distributed from that account until after 2011), the taxable amount of the rollover will be taxed half in 2011 and half in 2012, unless you elect to be taxed in 2010.

If you roll over the payment to a designated Roth account in the plan, later payments from the designated Roth account that are qualified distributions will not be taxed (including earnings after the rollover). A qualified distribution from a designated Roth account is a payment made both after you attain age 59½ (or after your death or disability) and after you have had a designated Roth account in the plan for a period of at least 5 years. The 5-year period described in the preceding sentence begins on January 1 of the year your first contribution was made to the designated Roth account. However, if you made a direct rollover to a designated Roth account in the plan from a designated Roth account in a plan of another employer, the 5-year period begins on January 1 of the year your first contribution was made to the designated Roth account in the plan or, if earlier, to the designated Roth account in the plan of the other employer. Payments from the designated Roth account that are not qualified distributions will be taxed to the extent allocable to earnings after the rollover, including the 10% additional tax on early distributions (unless an exception applies).

If you are not a plan participant

Payments after death of the participant. If you receive a distribution after the participant's death that you do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this notice. However, the 10% additional income tax on early distributions and the special rules for public safety officers do not apply, and the special rule described under the section "If were born on or before January 1, 1936" applies only if the participant was born on or before January 1, 1936. Also, if you receive a distribution from a designated Roth account, whether the payment is a qualified distribution generally depends on when the participant first made a contribution to the designated Roth account in the Plan.

If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the same rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA (or a Roth IRA, if the distribution is from a designated Roth account), you may treat the IRA as your own or as an inherited IRA.

An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59 1/2 will be subject to the 10% additional income tax on early distributions (unless an exception applies) and required minimum distributions from your IRA do not have to start until after you are age 70 1/2.

If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional income tax on early distributions. However, if the participant had started taking required minimum distributions, you will have to receive required minimum distributions from the inherited IRA. If the participant had not started taking required minimum distributions from the Plan, you will not have to start receiving required minimum distributions from the inherited IRA until the year the participant would have been age 70 1/2.

If you receive a distribution from a designated Roth account, a Roth IRA you treat as your own is treated like any other Roth IRA of yours, so that you will not have to receive any required minimum distributions during your lifetime and earnings paid to you in a nonqualified distribution before you are age 59 1/2 will be subject to the 10% additional income tax on early distributions (unless an exception applies).

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Distribution Request Form - CSC

If you receive a distribution from a designated Roth account, and you treat the Roth IRA as an inherited Roth IRA, payments from the Roth IRA will not be subject to the 10% additional income tax on early distributions. An inherited Roth IRA is subject to required minimum distributions. If the participant had started taking required minimum distributions from the Plan, you will have to receive required minimum distributions from the inherited Roth IRA. If the participant had not started taking required minimum distributions, you will not have to start receiving required minimum distributions from the inherited Roth IRA until the year the participant would have been age 70 1/2.

If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the participant's death and you are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA (or an inherited Roth IRA if the distribution is from a designated Roth account). Payments from the inherited IRA or inherited Roth IRA (even if made in a nonqualified distribution) will not be subject to the 10% additional income tax on early distributions. You will have to receive required minimum distributions from the inherited IRA.

Payments under a qualified domestic relations order. If you are the spouse or a former spouse of the participant who receives a payment from the Plan under a qualified domestic relations order (QDRO), you generally have the same options the participant would have (for example, you may roll over the payment as described in this notice). Payments under the QDRO will not be subject to the 10% additional income tax on early distributions.

If you are a nonresident alien

If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan is generally required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a 60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.

Other special rules

If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in the series (unless you make a different choice for later payments).

If your payments (not including payments from a designated Roth account in the Plan) for the year are less than $200, the Plan is not required to allow you to do a direct rollover and is not required to withhold for federal income taxes. Further, if your payments from a designated Roth account in the Plan for the year are less than $200, the Plan is not required to allow you to do a direct rollover and is not required to withhold for federal income taxes. However, you may do a 60-day rollover.

Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a designated Roth account in the Plan) will be directly rolled over to an IRA chosen by the Plan administrator or the payor. Further, unless you elect otherwise, a mandatory cashout from the designated Roth account in the Plan of more than $1,000 will be directly rolled over to a Roth IRA chosen by the Plan administrator or the payor. A mandatory cashout is a payment from a plan to a participant made before age 62 (or normal retirement age, if later) and without consent, where the participant's benefit does not exceed $5,000 (not including any amounts held under the plan as a result of a prior rollover made to the plan).

You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces' Tax Guide.

FOR MORE INFORMATION

You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can find more detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590, Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from a local IRS office, on the web at www.irs.gov, or by calling 1-800-TAX-FORM.

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Distribution Request Form - CSC

IF YOUR PLAN DOES NOT PROVIDE

FOR ANNUITY PAYMENTS,

PLEASE STOP HERE.

IF YOUR PLAN DOES PROVIDE

FOR ANNUITY PAYMENTS,

PLEASE CONTINUE WITH THE

REMAINDER OF THIS PACKAGE.

January 2014

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Distribution Request Form - CSC

WRITTEN EXPLANATION OF

QUALIFIED JOINT AND 50% CONTINGENT SURVIVOR ANNUITY FORM OF BENEFIT

This information only applies to retirement plans subject to the joint and survivor annuity requirements. To confirm if your plan is subject to these requirements, please refer to your Summary Plan Description or contact your Plan Administrator.

If, after receiving this Explanation, you elect an optional form of distribution and your spouse, if any, consents to that form, your distribution may be made less than 30 days from the date this Explanation was given to you. However, your distribution may not be made before the end of the seventh (7th) day after the date this Explanation was provided to you.

Terms and Conditions of the Form of Distribution

If your total vested benefit is:

Your general payment options are

Timing of your requested distribution:

 

(referred to as “optional forms of

 

 

benefit”):

 

 

$5,000 or less

Single Lump Sum

As soon as administratively possible

 

 

 

 

More than $5,000

Single Lump Sum

As soon as administratively possible

 

Monthly Annuity

Deferred to a later date (only if you are requesting a

 

Installment Payments

distribution due to termination of employment)

A monthly annuity will be purchased from Transamerica Life Insurance Company or another insurance company with payments to commence on a date determined by you and the insurance company. Your benefit distribution, your age, your spouse’s age (if you are married), the survivor portion you elect for your spouse (if you are married), the number of guaranteed or installment payments you elect and the date distributions are to commence will determine the amount of your monthly annuity.

Following is a description of the optional forms of benefit generally available under the Plan:

Form of benefit:

Available to Unmarried

Available to Married

Participants

Participants

 

 

 

Yes

Single Lump Sum – a single cash payment

Yes

(requires spousal

 

 

consent)

Single Life Annuity – a life annuity, with monthly payments payable during your

Yes

Yes

lifetime. Payments will stop at your death.

(automatic form of benefit)

(requires spousal

 

 

consent)

Life Annuity with payments for 60 months certain – a life annuity, with monthly

 

Yes

payments payable during your lifetime but in no event payable for less than

Yes

(requires spousal

60 months.

 

consent)

Life Annuity with payments for 120 months certain – a life annuity, with monthly

 

Yes

payments payable during your lifetime but in no event payable for less than

Yes

(requires spousal

120 months.

 

consent)

Life Annuity with payments for 180 months certain – a life annuity, with monthly

 

Yes

payments payable during your lifetime but in no event payable for less than

Yes

(requires spousal

180 months.

 

consent)

Installment Payments – monthly payments for a period not exceeding the

Yes

Yes

(requires spousal

shorter of 15 years or your life expectancy.

 

 

consent)

 

 

Qualified Joint & 50% Contingent Survivor Annuity – monthly payments for

 

 

your lifetime plus, after your death, if your spouse is still living, monthly

 

Yes

payments to your spouse for his/her lifetime equal to 50% of the amount that

No

(automatic form of

you received while you both were living. If your spouse pre-deceases you,

 

benefit)

your monthly payments will not change. All payments will stop when both you

 

 

and your spouse die.

 

 

Qualified Joint & 100% Contingent Survivor Annuity – monthly payments for

 

 

your lifetime plus, after your death, if your spouse is still living, the same

 

 

amount of monthly payments to your spouse for his/her lifetime. If your

No

Yes

spouse pre-deceases you, your monthly payments will not change. All

 

 

payments will stop when both you and your spouse die.

 

 

In order to estimate the amount of the monthly annuity or installments that can be purchased by your requested distribution amount, please refer to the following attachments titled “How to Estimate Your Immediate Monthly Annuity or Installment Payment Worksheet” and “How to Estimate Your Deferred Monthly Annuity or Installment Payment Worksheet.” The monthly payments and installments calculated on the worksheets are only

January 2014

Page 17 of 28

Distribution Request Form - CSC

estimates. If you are considering a monthly annuity or installments and you want to know what the actual payment is under any optional form of benefit available to you, please contact your Plan Administrator.

Waiver of the Joint & 50% Contingent Survivor Annuity Form of Distribution

During the 180-day period ending on your annuity starting date (the first day of the first period for which an amount is payable as an annuity or, in the case of benefits not payable as an annuity, the first day on which all events have occurred which entitle you to benefits), you (with your spouse’s consent) may elect to waive (and therefore elect another form of payment) the Qualified Joint and 50% Contingent Survivor Annuity an unlimited number of times.

During the same 180-day period, you are permitted to revoke a previous waiver of the Qualified Joint and 50% Contingent Survivor Annuity an unlimited number of times.

Your election to waive the Qualified Joint and 50% Contingent Survivor Annuity will not be effective unless your spouse consents in writing to the waiver. The written consent must be made at the time of your waiver election and must acknowledge the effect of the election. In addition, your spouse’s written consent must be witnessed by a Plan Representative (who cannot be you) or a notary public. See Section J of the Distribution Request Form.

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Distribution Request Form - CSC

Step 1:

Go to the Annuity

Purchase Rate

("APR") Table and find

your current age.

HOW TO ESTIMATE YOUR IMMEDIATE MONTHLY ANNUITY OR INSTALLMENT PAYMENT WORKSHEET

Step 2 for Single Life Annuity:

Step 3 for Joint & Survivor Annuity:

Step 4 for installment payments:

 

 

Find the APRs under (i) the Joint & 100%

 

Go to the Annuity Purchase Rate ("APR") Table

Find the APR factor under the

 

Contingent Survivor Annuity and (ii) the

 

and find the installment factor under the 10-Year

Single Life Annuity column for

 

Joint & 50% Contingent Survivor

 

Installment column (there is only one number in

your current age.

 

Annuity columns for your current age.

 

this column).

Step 5:

FOR ANNUITY PAYMENTS: Divide your

current vested account balance by the APRs

from Steps 2 and 3.FOR INSTALLMENT PAYMENTS: Multiply your current vested account balance by the applicable interest rate factor from Step 4 and divide by the number of monthly installments.

EXAMPLE:

Suppose you are married and you and your spouse are both age 45 now.

 

 

 

Also suppose your current vested account balance is $35,000. (Please contact your Plan Administrator if you need help determining your vested account balance.)

 

 

 

 

 

 

 

(a)

 

(b)

(c)

(d)

 

Optional Form of

 

Applicable APR factor from Step 2

 

 

 

Benefit

 

or Step 3

Applicable installment factor from Step 4

Amount of Immediate Distribution Equivalent to Vested Account Balance

 

Single Lump Sum

 

N/A

N/A

current vested account balance = $35,000

Single Life Annuity

 

264.75 (from Step 2)

N/A

$35,000 divided by col. (b) =

$132

Joint & 100%

 

 

 

 

 

Contingent Survivor

 

 

 

 

 

Annuity

 

292.25 (from Step 3 (i))

N/A

$35,000 divided by col. (b) =

$120

Joint & 50%

 

 

 

 

 

Contingent Survivor

 

 

 

 

 

Annuity

 

278.50 (from Step 3 (ii))

N/A

$35,000 divided by col. (b) =

$126

120 monthly

 

 

 

 

 

installments

 

N/A

104.02

$35,000 divided by col. (c) =

$336

 

 

 

 

 

 

 

 

 

 

 

 

January 2014

Page 19 of 28

Distribution Request Form - CSC

YOUR WORKSHEET (fill in the blanks):

Your current age:

_________

 

 

 

Your current vested account balance:

$______________________

 

 

 

 

 

 

(a)

(b)

(c)

(d)

 

Optional Form of

Applicable APR factor from Step 2

 

 

 

Benefit

or Step 3

Applicable installment factor from Step 4

Amount of Immediate Distribution Equivalent to Vested Account Balance

 

Single Lump Sum

N/A

N/A

current vested account balance = $ ___________

Single Life Annuity

__ __ __.__ __ (from Step 2)

N/A

current vested account balance divided by col. (b) =

$ ______

Joint & 100%

 

 

 

 

Contingent Survivor

 

 

 

 

Annuity

__ __ __.__ __ (from Step 3(i))

N/A

current vested account balance divided by col. (b) =

$ ______

Joint & 50%

 

 

 

 

Contingent Survivor

 

 

 

 

Annuity

__ __ __.__ __ (from Step 3(ii))

N/A

current vested account balance divided by col. (b) =

$ ______

120 monthly

 

 

 

 

installments

N/A

104.02

current vested account balance divided by col. (c) =

$ ______

 

 

 

 

 

 

 

 

 

 

The APR and interest factors used in the above example and worksheet are only for estimating the monthly annuity that might be purchased from an insurance company and the installment payments. The actual amount of monthly annuity purchased from an insurance company and your installment payments may be higher or lower. Please contact your Plan Administrator before you make your benefit election if you are interested in the annuity or installment option. Your Plan Administrator will provide you with the actual amount of your monthly installment or annuity as obtained from an insurance company. Also, please contact your Plan Administrator if you would like information applicable to your individual situation, e.g. if you would like APR factors based on your spouse's actual age.

January 2014

Page 20 of 28

Distribution Request Form - CSC

HOW TO ESTIMATE YOUR DEFERRED MONTHLY ANNUITY OR INSTALLMENT PAYMENT WORKSHEET

Step 1:

Estimate your vested

account balance at your

deferred age by

multiplying your current vested account balance by the Deferred Interest Factor from the Interest Factor Table for the number of years you want to defer your payment.

Step 2:

Go to the

Annuity

Purchase

Rate ("APR") Table and find your deferred age.

Step 3 for Single Life Annuity:

Find the APR factor under the Single Life Annuity column for your deferred age.

Step 4 for Joint & Survivor Annuity:

Find the APRs under

(i)the Joint & 100% Contingent Survivor Annuity and (ii) the

Joint & 50%

Contingent Survivor Annuity columns for your deferred age.

Step 5 for installment payments:

Go to the Annuity Purchase Rate

("APR") Table and find the installment factor under the 10-Year Installment column (there is only one number in this column).

Step 6:

FOR ANNUITY PAYMENTS: Divide your deferred vested account balance by the APRs from Steps 3 and 4.

FOR INSTALLMENT PAYMENTS: Divide your deferred vested account balance by the APR from Step 5.

EXAMPLE:

Suppose you are married, you and your spouse are both age 45 now and you are deferring receipt of your distribution until age 65 (number of years you want to defer payment = 20).

 

 

Also suppose your current vested account balance is $35,000. (Please contact your Plan Administrator if you need help determining your current vested account balance.)

 

 

 

 

 

 

 

 

(a)

 

(b)

(c)

(d)

(e)

 

 

 

Applicable

 

 

 

 

 

 

interest factor

Applicable APR factor from Step 3 or

Applicable installment

 

 

Optional Form of Benefit

 

from Step 1

Step 4

factor from Step 5

Amount of Deferred Distribution Equivalent to Current Vested Account Balance

Single Lump Sum

 

3.2071

N/A

N/A

$35,000 multiplied by col. (b) =

$112,249

Single Life Annuity

 

3.2071

171.66 (from Step 3)

N/A

$35,000 multiplied by col. (b) then divided by col. (c) =

$654

Joint & 100%

 

 

 

 

 

 

Contingent Survivor

 

 

 

 

 

 

Annuity

 

3.2071

206.77 (from Step 4(i))

N/A

$35,000 multiplied by col. (b) then divided by col. (c) =

$543

Joint & 50% Contingent

 

 

 

 

 

 

Survivor Annuity

 

3.2071

189.22 (from Step 4(ii))

N/A

$35,000 multiplied by col. (b) then divided by col. (c) =

$593

120 monthly

 

 

 

 

 

 

installments

 

3.2071

N/A

104.02

$35,000 multiplied by col. (b) then divided by col. (d) =

$1,079

 

 

 

 

 

 

 

 

 

 

 

 

 

 

January 2014

Page 21 of 28

Distribution Request Form - CSC

YOUR WORKSHEET (fill in the blanks):

Your current age:

_________

Your deferred age (the age at which you want to start taking your distributions): _________

 

 

Your current vested account balance:

$______________________

 

 

 

 

 

 

(a)

(b)

(c)

(d)

(e)

 

Applicable

 

 

 

 

interest factor

Applicable APR factor from Step 3 or

Applicable interest

 

Optional Form of Benefit

from Step 1

Step 4

factor from Step 5

Amount of Deferred Distribution Equivalent to Current Vested Account Balance

Single Lump Sum

 

N/A

N/A

current vested account balance multiplied by col. (b) = $ _____________

Single Life Annuity

 

__ __ __.__ __ (from Step 3)

N/A

current vested account balance multiplied by col. (b) then divided by col. (c) = $_____

Joint & 100%

 

 

 

 

Contingent Survivor

 

 

 

 

Annuity

 

__ __ __.__ __ (from Step 4(i))

N/A

current vested account balance multiplied by col. (b) then divided by col. (c) = $_____

Joint & 50% Contingent

 

 

 

 

Survivor Annuity

 

__ __ __.__ __ (from Step 4(ii))

N/A

current vested account balance multiplied by col. (b) then divided by col. (c) = $_____

120 monthly

 

 

 

 

installments

 

N/A

104.02

current vested account balance multiplied by col. (b) then divided by col. (d) = $______

 

 

 

 

 

 

 

 

 

 

The APR and interest factors used in the above example and worksheet are only for estimating the monthly annuity that might be purchased from an insurance company and the installment payments. The actual amount of monthly annuity purchased from an insurance company and your installment payments may be higher or lower. Please contact your Plan Administrator before you make your benefit election if you are interested in the annuity or installment option. Your Plan Administrator will provide you with the actual amount of your monthly installment or annuity as obtained from an insurance company. Also, please contact your Plan Administrator if you would like information applicable to your individual situation, e.g. if you would like APR factors based on your spouse's actual age.

January 2014

Page 22 of 28

Distribution Request Form - CSC

QJSA ADDITIONAL INFORMATION

With the attached worksheets and enclosed tables, you and your spouse, if applicable, should be able to compare the financial effect of electing different optional forms of benefit generally

available under the Plan. If you would like to be provided with the financial effect of any other optional form Plan Administrator.

The APR and interest factors used in these examples and worksheets are only for estimating the monthly annuity that might be purchased from an insurance company and the installment payments. The actual amount of monthly annuity purchased from an insurance company and your installment payments may be higher or lower. If you are interested in the annuity or installment payment option, or if you would like information specific to you and your spouse's situation, please contact your Plan Administrator before you make your benefit election.

Your Plan Administrator will provide you with the actual amount of your monthly installment or annuity as obtained from an insurance company.

If you have any questions regarding your specific situation or if you need help in completing these worksheets, please contact your Plan Administrator. Please note that these worksheets are based on certain interest and mortality assumptions which may not apply to you.

January 2014

Page 23 of 28

Distribution Request Form - CSC

EXPLANATION OF PRE-RETIREMENT SURVIVOR ANNUITY

If you are married, the law provides (unless you elect otherwise) that the death benefits be paid to your spouse in the form of a Pre-Retirement Survivor Annuity. Under this Pre-Retirement Survivor Annuity, payments will be made each month for your spouse’s lifetime. Your spouse may have the option of electing a different form of payment prior to the date that benefits are scheduled to begin. A description of the amount and the eligibility requirements for this benefit is contained in the Summary Plan Description. If you do not have a copy of this informative booklet, you should request a copy from your Employer.

If you are not married, you can designate whomever you wish to be the beneficiary of this death benefit. If you get married, however, this designation will become invalid and your spouse will become the beneficiary unless you file a new beneficiary designation form approved by your spouse as described below.

You and your spouse can elect, at any time, not to be covered by the Pre-Retirement Survivor Annuity. That is, you can designate a person other than your spouse to be the beneficiary of your death benefit. This election will not be valid, however, without your spouse’s written consent. Your spouse’s written consent must either be witnessed by a Plan Representative or a Notary Public. In addition, if your election is made before you are age 35; the election becomes invalid on the first day of the Plan Year in which you reach age 35. If you and your spouse do not make a new election after you have attained age 35, your spouse will automatically become your beneficiary.

If you elect to waive the Pre-Retirement Survivor Annuity, such waiver will only apply to your spouse who consented to that waiver. If you later remarry (following a divorce or the death of your current spouse), your election will become invalid and your new spouse will be your beneficiary unless you make a new election consented by your new spouse.

If you elect not to be covered by the Pre-Retirement Survivor Annuity, you may later revoke the election. You do not need your spouse’s consent to do this. If you revoke your election, you will once again be covered by the Pre-Retirement Survivor Annuity and your spouse will be your beneficiary.

The examples below compare benefits under the qualified Pre-Retirement Survivor Annuity and other forms of distribution. The examples are based on specific assumptions and certain interest rates and mortality rates. The amounts shown are used to illustrate the differences between the various options. The values may be different in your case. Assume a participant dies at age 45 with a vested account balance of $35,000 and has a spouse of the same age.

 

Benefit to Spouse

Type of Immediate Distribution

After Participant Dies

Single Lump Sum

$

35,000

Single Life Annuity

$

132 per month

120 Monthly Installments

$

336 per month

A monthly annuity will be purchased from Transamerica Life Insurance Company or another insurance company with payments to commence on a date determined by you and the insurance company. The amount of the monthly annuity depends upon the value of your vested account balance, your spouse’s age and the date distributions commence.

In order to estimate the amount of monthly annuity or installments that can be purchased by your vested account balance on your spouse’s behalf, please refer to the attachment titled “Qualified Pre-Retirement Survivor Annuity or Installment Payment Worksheet”. The monthly annuity and installments calculated on the worksheet are only estimates. If you are considering retaining the Pre-Retirement Survivor Annuity or if your spouse is considering electing installment payments in place of the Pre-Retirement Survivor Annuity, and you want to know what the actual payment would be, please contact your Plan Administrator.

It is important that you and your spouse understand your rights and obligations concerning your death benefit. Please contact your Plan Administrator if you have any questions. Also, because a spouse has certain rights to the death benefit, you should immediately inform your Plan Administrator of any change in your marital status.

January 2014

Page 24 of 28

Distribution Request Form - CSC

QUALIFIED PRE-RETIREMENT SURVIVOR ANNUITY OR INSTALLMENT PAYMENT WORKSHEET

Step 1:

Go to the Annuity

Purchase Rate ("APR")

Table and find your spouse's current age.

Step 2 for Single Life Annuity:

Find the APR factor under the Single Life Annuity column for your spouse's current age.

Step 3 for installment payments:

Go to the Annuity Purchase Rate ("APR") Table and find the installment factor under the 10-Year Installment column (there is only one number in this column).

Step 4:

FOR ANNUITY PAYMENTS: Divide your current vested account balance

by the APR from Step 2.FOR INSTALLMENT PAYMENTS: Multiply your current vested account balance by the applicable interest rate factor from Step 3 and divide by the number of monthly installments.

EXAMPLE:

Suppose you are married and you and your spouse are both age 45 now.

 

 

 

Also suppose your current vested account balance is $35,000.

 

 

 

(Please contact your Plan Administrator if you need help determining your vested account balance.)

 

 

 

 

 

 

 

(a)

(b)

(c)

(d)

 

 

Applicable APR factor from

 

Amount of Immediate Distribution Equivalent to Vested Account

Optional Form of Benefit

Step 2

Applicable installment factor from Step 3

Balance

 

Single Lump Sum

N/A

N/A

current vested account balance = $35,000

Single Life Annuity

264.75

N/A

$35,000 divided by col. (b) =

$132

120 monthly installments

N/A

104.02

$35,000 divided by col. (c) =

$336

YOUR WORKSHEET (fill in the blanks):

Your spouse's current age:

_________

 

 

Your current vested account balance:

$______________________

 

 

 

 

(a)

(b)

(c)

(d)

 

Applicable APR factor from

 

Amount of Immediate Distribution Equivalent to Vested Account

Optional Form of Benefit

Step 2

Applicable installment factor from Step 3

Balance

Single Lump Sum

N/A

N/A

current vested account balance = $ ___________

Single Life Annuity

__ __ __.__ __ (from Step 2)

N/A

current vested account balance divided by col. (b) = $ ______

120 monthly installments

N/A

104.02

current vested account balance divided by col. (c) = $ ______

The APR and interest factors used in the above example and worksheet are only for estimating the monthly annuity that might be purchased from an insurance company and the installment payments. The actual amount of monthly annuity purchased from an insurance company and installment payments may be higher or lower. Please contact your Plan Administrator for the actual amount that

may be paid to your spouse in annuity or installment forms of benefit. Also, please contact Plan Administrator if you need information applicable to your individual situation, e.g. if your spouse's current age is not shown on the attached Annuity Purchase Rate Table.

January 2014

Page 25 of 28

Distribution Request Form - CSC

QPSA ADDITIONAL INFORMATION

With the attached worksheet and the enclosed tables, you and your spouse should be able to compare the financial effect of electing different optional forms of benefit generally available under the Plan. If you would like to be provided with the financial effect of any other optional form of benefit available to you under the Plan, please contact your Plan Administrator.

The APR and interest factors used in this example and worksheet are only for estimating the monthly annuity that might be purchased from an insurance company and the installment payments. The actual amount of monthly annuity purchased from an insurance company and your spouse's installment payments may be higher or lower. Please contact your Plan Administrator for the actual amount that may be paid

to your spouse in the annuity or installment forms of benefit.

In addition, if the current age of your spouse is not shown on the enclosed annuity factor table, please contact your Plan Administrator and the appropriate annuity factors will be provided for your individual situation.

If you and your spouse have any questions regarding your specific situation or if you need help in completing this worksheet, please contact your Plan Administrator. Please note that this worksheet is based on certain interest and mortality assumptions which may not apply to your specific situation.

January 2014

Page 26 of 28

Distribution Request Form - CSC

 

 

 

ANNUITY PURCHASE RATES

 

 

 

 

ANNUITY PURCHASE RATE

 

 

 

TO BE USED TO ESTIMATE YOUR MONTHLY ANNUITY

 

 

 

TO BE USED TO ESTIMATE

 

 

 

 

 

 

 

 

YOUR INSTALLMENT PAYMENTS

(The following rates are based on an assumed interest rate of 3% per year and the 1983 GAM Male Mortality Table, projected to 2007 with Scale H, 1 year

(The following rate is based on an assumed

 

 

setback for Participant, 1 year setback for Contingent Annuitant)

 

 

 

interest rate of 3% per year)

 

Single

Joint & 100%

Joint & 50%

 

Single

Joint & 100%

Joint & 50%

 

10-Year

Your

Life

Contingent

Contingent

Your

Life

Contingent

Contingent

Your

Monthly

Age

Annuity

Survivor Annuity

Survivor Annuity

Age

Annuity

Survivor Annuity

Survivor Annuity

Age

Installment

25

325.33

342.84

334.09

53

231.25

262.81

247.03

Any age

104.02

26

323.04

340.94

331.99

54

226.71

258.70

242.71

 

 

27

320.69

338.99

329.84

55

222.10

254.49

238.30

 

 

28

318.27

336.98

327.63

56

217.42

250.19

233.80

 

 

29

315.78

334.92

325.35

57

212.66

245.78

229.22

 

 

30

313.22

332.79

323.01

58

207.81

241.26

224.54

 

 

31

310.59

330.60

320.60

59

202.88

236.64

219.76

 

 

32

307.88

328.35

318.11

60

197.87

231.92

214.89

 

 

33

305.09

326..03

315.56

61

192.77

227.09

209.93

 

 

34

302.23

323.64

312.93

62

187.58

222.15

204.87

 

 

35

299.28

321.17

310.23

63

182.33

217.12

199.72

 

 

36

296.24

318.64

307.44

64

177.02

211.99

194.50

 

 

37

293.11

316.03

304.57

65

171.66

206.77

189.22

 

 

38

289.88

313.35

301.61

66

166.28

201.47

183.87

 

 

39

286.55

310.58

298.57

67

160.87

196.09

178.48

 

 

40

283.14

307.74

295.44

68

155.47

190.66

173.07

 

 

41

279.64

304.81

292.22

69

150.09

185.18

167.63

 

 

42

276.05

301.80

288.92

70

144.75

179.66

162.20

 

 

43

272.37

298.70

285.53

71

139.46

174.11

156.79

 

 

44

268.60

295.52

282.06

72

134.22

168.55

151.39

 

 

45

264.75

292.25

278.50

73

129.04

162.96

146.00

 

 

46

260.83

288.89

274.86

74

123.91

157.37

140.64

 

 

47

256.82

285.44

271.13

75

118.80

151.75

135.27

 

 

48

252.75

281.90

267.33

76

113.73

146.12

129.92

 

 

49

248.60

278.27

263.44

77

108.72

140.49

124.60

 

 

50

244.38

274.55

259.46

78

103.77

134.89

119.33

 

 

51

240.08

270.73

255.41

79

98.92

129.32

114.12

 

 

52

235.70

266.82

251.26

80

94.16

123.81

108.98

 

 

Actuarial Assumptions:

Assumed Interest Rate: 3% per year

Mortality Table: 1983 GAM-Male projected to 2007 using Scale H, (-1,-1)

Spouse assumed to be the same age as the participant

NOTE: The above Assumed Interest Rate and Mortality Table are representative of the interest rate and mortality table used to purchase an annuity from Transamerica Life Insurance Company for calendar year 2007.

January 2014

Page 27 of 28

Distribution Request Form - CSC

ASSUMED 6% ANNUAL INTEREST RATE FACTOR TABLE

TO BE USED TO ESTIMATE YOUR DEFERRED MONTHLY ANNUITY AND/OR DEFERRED INSTALLMENT PAYMENTS

ASSUMING A 6% ANNUAL INTEREST RATE

Period of

 

Period of

 

Deferment

 

Deferment

 

(number of years

Deferred

(number of years

Deferred

from today to the

Interest Factor

from today to the

Interest Factor

date you want

(assuming a

date you want

(assuming a

to begin receiving

6% annual

to begin receiving

6% annual

payments)

interest rate)

payments)

interest rate)

1

1.0600

26

4.5494

2

1.1236

27

4.8223

3

1.1910

28

5.1117

4

1.2625

29

5.4184

5

1.3382

30

5.7435

6

1.4185

31

6.0881

7

1.5036

32

6.4534

8

1.5938

33

6.8406

9

1.6895

34

7.2510

10

1.7908

35

7.6861

11

1.8983

36

8.1473

12

2.0122

37

8.6361

13

2.1329

38

9.1543

14

2.2609

39

9.7035

15

2.3966

40

10.2857

16

2.5404

41

10.9029

17

2.6928

42

11.5570

18

2.8543

43

12.2505

19

3.0256

44

12.9855

20

3.2071

45

13.7646

21

3.3996

46

14.5905

22

3.6035

47

15.4659

23

3.8197

48

16.3939

24

4.0489

49

17.3775

25

4.2919

50

18.4202

January 2014

Page 28 of 28

Distribution Request Form - CSC