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Massachusetts Laborers’ Annuity

SECTION 3. Beneficiary

Please complete this portion of the application:

I hereby designate as my beneficiary to receive any benefits payable at my death from the Mass.

Laborers Annuity Fund:

Name:_______________________________ Social Sec. No.:_________________

Address: ___________________________________________________________

Date of Birth: _____________________ Relationship: ______________________

_____________________________________________________________________

Applicant Signature

Date

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INCOME TAX WITHHOLDING • If you have elected to have your retirement benefit distributed in

the form of a lump-sum or periodic payment for a period of less than 10 years, a 20% mandatory

Federal Income Tax withholding rule will apply. You may elect to have additional taxes withheld

below.

If you have elected to have your retirement benefit distributed in the form of an installment

distribution over 10 years or more, or a direct rollover to an Individual Retirement Account (IRA) or

another qualified retirement plan, the 20% mandatory Federal Income Tax withholding does not apply.

You may elect to have other applicable taxes withheld below.

You should also be aware that a 10% Federal Penalty Tax may apply for most distributions

made before attainment of age 59 1/2.

❏ No Federal Income Tax withheld

(Applies only to IRA Rollovers)

2. ❏ No State Income Tax withheld

3. ❏ 10% Federal Penalty Tax Withheld

4. ❏ __________% or $_________ State Income Tax withheld

5. ❏ __________% or $_________ Federal Income Tax withheld

Even if you elect not to have Federal Income Tax withheld, you are liable for payment of Federal

Income Tax on the taxable portion of your distribution or withdrawal. You may also be subject to

tax penalties under the estimated tax payment rates if your payments or estimated tax and

withholding, if any, are not adequate.

6. ❏ I am exempt from Massachusetts income tax withholding because my legal residence

(domicile) is elsewhere and the income being paid was not derived or connected with an

occupation, profession, trade or business carried on in Massachusetts.

Application For Alternate Payee Benefits Pursuant To A Qualified Domestic Relations Order - Massachusetts Laborers' Annuity Fund Page 3