Application For Rollover Form
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1
2Application for Rollover Form
Synergy Services 401(k) Plan
#808477
See reverse for instructions on completing this form
PARTICIPANT INFORMATION
Participant Name (please print)
Social Security Number
Phone Number
ROLLOVER CONTRIBUTION INFORMATION
See your Summary Plan Description or Plan Administrator for your plan’s rollover provisions. I request the Plan Administrator to
accept my rollover, based on the following information. The Plan Administrator reserves the right to require additional evidence
that my distribution is from a qualified retirement plan, a tax sheltered annuity, a governmental 457 plan, or an IRA, as allowed
by the Plan.
Name of distributing plan or IRA custodian:__________________________________________________________________
The requested rollover represents:
a.
An eligible rollover distribution from:
a qualified retirement plan
a tax-sheltered annuity
a governmental 457 plan
b.
a distribution from a traditional IRA that would otherwise be includable in my gross income.
c.
a distribution from a Conduit IRA which consisted solely of an eligible rollover distribution from a qualified plan and any
associated earnings, for which I wish to preserve capital gains and averaging treatment.
The distribution:
will be paid directly from the distributing plan to The Standard on behalf of this Plan.
is from another qualified plan; it includes after-tax contributions of $__________, which must be accounted for separately.
was paid to me on ______________________. (The Standard must receive distribution within 60 days.)
PARTICIPANT’S SIGNATURE
I verify that the information provided above is true and complete. I understand that the Plan Administrator may choose not to
accept this rollover if it would jeopardize the Plan’s tax status. I also understand that if this rollover is accepted, it will be
directed to investments based on my contribution directives in place at the time the rollover is received by The Standard. If I do
not have directives in place, the rollover will be deposited into the Plan’s Default Fund.
Participant’s Signature
Date
PAYEE AND MAILING INSTRUCTIONS
The distribution check should be
Reliance Trust Company
payable to Reliance Trust Company
FBO: (Participant’s Name)
and mailed to:
Attn: The Standard Team
1100 Abernathy Road
Building 500, Suite 400
Atlanta GA 30328
Attention: Plan No.:
808477
Plan Name:
Synergy Services 401(k) Plan
PLAN ADMINISTRATOR’S ACCEPTANCE
As an authorized representative of the Synergy Services 401(k) Plan , I certify the Plan Administrator has investigated the
rollover requested above and is satisfied that it will not jeopardize this Plan’s qualified status under the Internal Revenue Code.
Therefore, the rollover is accepted, and The Standard is authorized to invest these funds as directed and to establish the
appropriate additional accounts for the participant.
Name and Title (please print)
Signature
Date
808477
(3/07)
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