Fillable Spousal Consent Form - Retirement Planners & Administrators printable pdf download

RETIREMENT PLAN

SPOUSAL CONSENT FORM FOR DISTRIBUTIONS

Use this form if your plan requires spousal consent for a distribution.

All 403(b) plans, and a small number of 401(k) plans, require this form.

Plan Name: ______________________________________________________________________________________

Employee Name: _________________________________________________________________________________

Last First M.I.

Social Security #: __________________________________________

CERTIFICATION FOR UNMARRIED PARTICIPANT

I certify that I am not legally married or that my total account balance is less than $5,000. I understand that a false statement by me

may cause the Plan legal damages, in which event I agree to be fully responsible for all such amounts and agree that this shall be

binding upon my heirs and my estate in the event of my death.

_____________________________________________

Signature of Unmarried Participant

CONSENT TO BE COMPLETED BY SPOUSE OF MARRIED PARTICIPANTS IF BENEFITS ARE NOT TO BE PAID IN

FORM OF A JOINT AND SURVIVOR ANNUITY.

I, _________________________________ (name of Participant’s spouse), am the spouse of ______________________________

(name of Participant). I understand that I have the right to have the plan named above pay my spouse’s retirement benefits in the

special Qualified Joint and Survivor Annuity payment form and I agree to give up that right. I understand that by signing this

agreement, I may receive less money than I may have received under the special Qualified Joint and Survivor Annuity payment form

and I may receive nothing after my spouse dies. I also understand that I cannot revoke this agreement once given.

I agree that my spouse can receive this withdrawal in a lump sum as described in the Payment and Mailing Information section of

the Rollover/Withdrawal Form. I understand that my spouse cannot choose a different form of payment unless I agree to the

change or unless the change is to the Qualified Joint and Survivor Annuity payment form. I understand that I do not have to sign

this agreement and I do so on a voluntary basis. I have read the information provided by the Plan Administrator with respect to my

rights to the Qualified Joint and Survivor Annuity for of payment.

Signature of Spouse:________________________________________ Date:__________________

Witnessed by Plan Administrator:________________________________

Date:__________________

OR WITNESSED BY NOTARY:

The spouse whose signature is above and who is known to me to be such spouse has affirmed such signature in my presence as his

or her free and voluntary act.

Given under my hand and notary seal this ______________ day of _______________________, _____.

Signature of Notary Public: ____________________________________

Date:__________________

Address:_________________________________________ State of:____________ County of:_______________

The date the commission of the Notary Public expires:_______________________________________

Spousal Consent Form - Retirement Planners & Administrators