Stable Value Account Group Annuity Withdrawal Form - Gemba Supplemental Retirement (Page 2 of 2) in pdf

Tax Withholding Instructions:

STATE Tax Withholding

FEDERAL Tax Withholding

Zero State Withholding

Zero Federal Withholding

27% of the Federal Tax Amount (VT)

10% Federal Withholding

4% State Withholding (GA, NC, VA)

___ % Federal Withholding

5% state Withholding (ME, DE, OK, IA, KS, AR, NE)

7.75% State Withholding (MD)

8% State Withholding ()R)

10% of the Federal Tax Amount (CA)

Even if you elect not to have income tax withheld, you are liable for payment of income tax on the taxable portion of your

distribution. You may also be subject to tax penalties under the estimated tax payment rules if your payments of estimated

tax and withholding, if any, are not accurate.

Important State Withholding Notice: If you state of residence is not listed, we cannot process state tax withholding on your

withdrawal. If you elect state tax withholding, the appropriate 4P Form for your state must be on file with GEBA or accompany this

withdrawal form in order to process your withdrawal with statte tax withholding. Please see your local state tax office or tax advisor for

forms.

Processing Information:

Withdrawals are processed according to the GEMBA annual contribution/withdrawal schedule. All withdrawal request forms must be

received in the GEMBA office before the close of business on the Friday prior to the desired withdrawal date. A complete withdrawal

form or written withdrawal request, including an original signature, must be received in order to process a withdrawal, no telephone or

email requests will be accepted. Distributions are prorated over all applicable Annuity accounts (SVA) and may not be specified from a

particular contract. All withdrawals are distributed by check and mailed from the custodian within 4 days of the withdrawal date,

therefore, they should arrive within 7-10 days, depending on the postal service. Once funds are requested of the custodian for the

benefit of the member, the withdrawal request is final and cannot be rescinded.

Applicable Penalties and Fees:

All withdrawals from a SVA (IRA and Group Annuity) are subject to a 5% withdrawal penalty UNLESS one of the following applies:

•

Member has attained age 59 ½

•

SVA has been open at least 5 years

•

Disability

•

Death

GEBA charges a $20 fee for each withdrawal. This fee is paid directly to PNC, custodian of the funds, to cover their $20 withdrawal

fee. We waive the fee for the following:

• Your Supplemental Retirement Plan assets exceed $500,000

• Your transfer funds from the SVA to the Variable Annuity Contract (VAC)

• You transfer funds from the SVA to the GEBA MAX Fixed Annuity

• You withdraw funds due to the IRS required minimum distribution (Traditional IRA only, one time a year only)

You withdraw funds due to the death or disability of the account holder.

•

Member Signature:

I hereby certify that I have read and understand the contents of this withdrawal request form, including information provided on

processing information and applicable fees.

Signature: ___________________________________________________________

Date: _________________________

GEMBA Authorized Signature: ____________________________________________

Date: _________________________

For Office Use Only:

Tax Code: ___________________ 5% Penalty ___________________ Processing Fee: ____________________

Notes:

Updated 5/16

Stable Value Account Group Annuity Withdrawal Form - Gemba Supplemental Retirement Page 2

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