Incoming Contract Exchange/direct Rollover
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4Incoming Contract Exchange/Direct Rollover
403(b) Plan
The Christian and Missionary Alliance Retirement Plan
95803-01
Participant Information
Last Name
First Name
MI
Social Security Number
Address - Number & Street
E-Mail Address
City
State
Zip Code
Mo
Day
Year
Female
Male
(
)
(
)
Home Phone
Work Phone
Date of Birth
Married
Unmarried
Payroll Information
Payroll Center Name
Payroll Center Number
Division Name
Division Number
Contract Exchange/Direct Rollover Information
Current Plan Administrator must authorize by signing in the Authorized Signature(s) section.
Previous Plan Administrator must authorize by signing in the Authorized Signature(s) section.
I am choosing a: (choose only one)
Contract Exchange from another investment provider under the Plan.
Direct Rollover from a:
401(a) plan
401(k) plan
Non-Roth $
(all contributions and earnings, excluding Roth contributions and earnings)
Roth $
(employee contributions and earnings)
403(b) plan
Non-Roth $
(all contributions and earnings, excluding Roth contributions and earnings)
Roth $
(employee contributions and earnings)
Direct Rollover from a Traditional IRA. (Non-deductible contributions/basis may not be rolled over.)
Previous Provider Information:
Company Name
Account Number
Mailing Address
(
)
City/State/Zip Code
Phone Number
Previous Provider must complete for contract exchanges:
Employer earnings: $
Employee earnings: $
Employer contributions: $
Employee contributions: $
Note: Unless otherwise indicated, all amounts received will be considered employee before-tax contributions and earnings.
NO_GRPG 41268/
YSAL
][
GWRS FRLCNT
06/03/16
95803-01
CHG NUPART
DOC ID: 435521698
)
][
)(
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