Payment Election Form

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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
Name
Address
Address
City
State
Zip
City
State
Zip
Relationship
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

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