Fillable Payment Election Form printable pdf download

Payment Election Form

Download a blank fillable Payment Election Form in PDF format just by clicking the "DOWNLOAD PDF" button.

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Complete Payment Election Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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S C R E E N A C T O R S G U I L D - P R O D U C E R S P E N S I O N & H E A L T H P L A N S

PAYMENT ELECTION FORM

I hereby elect to receive my pension in the form indicated below. I also understand that this election cannot be

revoked after I cash/deposit my first pension payment.

☐

Five Year Certain

-OR-

Ten Year Certain

Primary Beneficiary

Secondary Beneficiary

Name

Address

City

State

Zip

City

State

Zip

Relationship

-OR-

☐

Joint and Survivor With Pop-Up Option:

50% *

75%

100%

-OR-

☐

Joint and Survivor Without Pop-Up Option:

50% *

75%

100%

* 50% Joint and Survivor option is only available for your legal spouse or same sex domestic partner.

Contingent Annuitant, Spouse or Same Sex Domestic Partner Information:

Name

Social Security Number

Address

Date of Birth (Provide Proof)

City

State

Zip

Date of Marriage (Provide Recorded Marriage Certificate)

Spouse’s statement:

I hereby consent to my spouse’s Form of Pension Payment Election.

Spouse’s signature: _________________________________________________________ Social Security Number: _______________________________

Partial Lump Sum Payment

I understand that the partial lump sum is equal to twelve (12) times the monthly payment under the Five Year

Certain form of payment, and that all subsequent monthly payments shall be reduced to compensate for the

partial lump sum payment. I understand that after a partial lump sum payment has been made, the amount of

the partial lump sum will not be increased and an additional partial lump sum payment will not be payable as a

result of additional earnings credited either before or after the effective date of my Pension. I further understand

this election cannot be revoked after the partial lump sum payment or any subsequent monthly payment has

been deposited.

☐

I elect the partial lump sum payment

I elect a direct rollover of the partial lump sum payment

Spouse’s statement:

I hereby consent to my spouse’s election of the partial lump sum payment.

Spouse’s signature: _________________________________________________________ Social Security Number: _______________________________

Please sign and date:

Participant’s Name (please print) _____________________________________________ Social Security Number: _______________________________

Participant’s Signature: _____________________________________________________ Date: ________________________________________________

You must complete the 50% Joint and Survivor Option Rejection form if you have a legal spouse and did not elect the 50% Joint and Survivor Option.

M:\MasterForms\PayElec_Revised 06/03/11

Payment Election Form

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