Form Std Fspsrv - Separation From Employment Withdrawal Request 401(A) Plan (Page 8 of 14) in pdf

100% Withdrawal With A Portion Payable to Me and the Remaining Balance as a Direct Rollover

I would enter the requested amount to be paid to me and the remaining balance will be withdrawn as a direct rollover.

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If I select the Net Amount box, the actual withdrawal amount will be greater than the withdrawal amount received to account for applicable income

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taxes and fees.

If I select the Gross Amount box, applicable income taxes and fees will be withheld from the gross amount, resulting in an amount less than the

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requested amount. If both or neither check box is marked, the request will be processed as a Gross Amount.

An eligible rollover withdrawal may be paid directly to Roth IRA. Mandatory Federal and State Income Tax withholding does not apply to this type of

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rollover. However, this withdrawal is subject to Federal and State Income Tax withholding and I am responsible for making tax payments. The taxable

withdrawal will be reported on IRS Form 1099-R. Making an estimated tax payment to the IRS and an appropriate state authority at the time of this

rollover may be one of the options to cover this tax liability. Where I deem appropriate, I will seek a consultation with my tax advisor.

The rollover may not be completed if the acceptance letter and the form provide conflicting information. I may be contacted to provide additional

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information.

Required Minimum Distributions are not eligible for rollover.

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After-tax contributions in a 401(a) or 401(k) Plan may be rolled into another 401(a), 401(k) or 403(b) Plan which agreed to separately account

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for amounts transferred, or Traditional IRA or Roth IRA. After-tax contributions in a 401(a) or 401(k) Plan, however, may not be rolled over to a

Governmental 457(b) Plan. If I have after-tax contributions in my account and I elect a direct rollover to a Governmental 457(b) Plan, the cost basis of

the after-tax contributions will be distributed to me and the investment earnings on the after-tax contributions will be included in the rollover amount.

Rollover to an IRA or an Eligible Retirement Plan as a One-time Withdrawal

It is my responsibility to determine if the IRA or an eligible retirement plan accepts eligible rollover withdrawals.

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I would check this box to have my withdrawal sent to an IRA or an eligible retirement plan or New Employer’s Plan and enter the requested amount.

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The withdrawal will be prorated against all of my available investment options and all available contribution sources as allowed by IRS regulations.

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An eligible rollover withdrawal may be paid directly to a Roth IRA. Mandatory Federal and State Income Tax withholding does not apply to this type of

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rollover. However, this withdrawal is subject to Federal and State Income Tax withholding and I am responsible for making tax payments. The taxable

withdrawal will be reported on IRS Form 1099-R. Making an estimated tax payment to the IRS and an appropriate state authority at the time of this

rollover may be one of the options to cover this tax liability. Where I deem appropriate, I will seek a consultation with my tax advisor.

It is my responsibility to make sure that the eligible retirement plan provides for a designated Roth account and can accept Roth rollovers.

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The rollover may not be completed if the acceptance letter and the form provide conflicting information. I may be contacted to provide additional

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information.

I must complete the Required Minimum Distribution information if I am age 70½ or older and I am requesting a 100% withdrawal as a direct rollover

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unless I have already satisfied my required minimum distribution for the year.

Required Minimum Distributions are not eligible for rollover.

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After-tax contributions in a 401(a) or 401(k) Plan may be rolled into another 401(a), 401(k) or 403(b) Plan which agreed to separately account

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for amounts transferred, or Traditional IRA or Roth IRA. After-tax contributions in a 401(a) or 401(k) Plan, however, may not be rolled over to a

Governmental 457(b) Plan. If I have after-tax contributions in my account and I elect a direct rollover to a Governmental 457(b) Plan, the cost basis of

the after-tax contributions will be distributed to me and the investment earnings on the after-tax contributions will be included in the rollover amount.

Periodic Installment Payments

If I am requesting to establish a new periodic installment payment, I would check the box before “I am requesting to establish a new Periodic Installment

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Payment.” I would then fill in the First Payment Processing Date, Frequency and Payment Type. See Periodic Installment Payment Options below

for explanation of the options available.

If I have an existing periodic installment payment and I would like to change the frequency or payment date, I would check the box before “I am making

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a change to an existing Periodic Installment Payment.” I would then fill in the information that I want changed.

If my request is to establish a new periodic installment payment but I would also like to take a one-time partial withdrawal, I would check the box before

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“I am also requesting a one-time withdrawal...” and enter the dollar amount or percentage on the line provided. I would then fill in the First Payment

Processing Date, Frequency and Payment Type. See Periodic Installment Payment Options below for explanation of the options available.

If I select the Net Amount box, the actual withdrawal amount will be greater than the withdrawal amount received to account for applicable income

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taxes and fees.

If I select the Gross Amount box, applicable income taxes and fees will be withheld from the gross amount, resulting in an amount less than the

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requested amount. If both or neither check box is marked, the request will be processed as a Gross Amount.

Periodic Installment Payment Options

First Payment Processing Date

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I must select a First Payment Processing Date. The First Payment Processing Date is the date the funds will be withdrawn from my account.

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I may choose any day between the 1st and the 28th for my First Payment Processing Date. If my chosen date falls on a non-business day (weekend,

holiday, etc.) then my payment will distribute on the next available business day.

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Allow 5-10 business days from the First Payment Processing Date to receive the withdrawal.

Frequency

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I must select the frequency of my payment from the available options.

Payment Type

Amount Certain

(Gross Amount Only)

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I would select this option if I wish to receive specific dollar amount payments on an installment basis.

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The payments will continue until my account balance is zero.

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The number of payments I receive will vary depending on the performance of my underlying investment options.

Period Certain

(Specific Number of Years)

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I would select this option if I wish to receive a set number of periodic installment payments.

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Payment amounts will depend on the account value, which may fluctuate depending upon my chosen investments’ performance, the number of

years I elect to receive payments and the frequency chosen.

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The payment amount will be calculated by dividing my current vested account balance by the number of remaining payments and is recalculated

each time a payment is distributed; therefore, the amount of each payment typically differs. For example, if the payout is to be annually for 4 years,

the initial payout amount will be equal to ¼ of my account balance. The second payment will be

of my balance. The third payment will be ½ and

the final payment will be the remainder of the account balance, resulting in a zero account balance.

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STD FSPSRV

07/31/17

98721-01