Application For Rollover Form (Page 2 of 2) in pdf

Rollover Instructions

Follow these instructions to initiate a rollover from a qualified retirement plan or conduit IRA. See reverse for Rollover Application.

PARTICIPANT: COMPLETE APPLICATION FOR ROLLOVER

STEP 1

1. Complete the following sections of The Standard’s Application for Rollover:

2. • Participant Information

• Rollover Contribution Information

• Participant’s Signature

3. Provide the completed Application for Rollover to the Plan Administrator of your current employer’s plan for approval

and submission to The Standard Insurance.

Note: A rollover check received by Standard Retirement Services will be returned to the issuing company if a

completed Application for Rollover is not also received within 10 business days.

QUESTIONS? Call the Participant Communication Team at 800.858.5420.

•

The source of rollover funds may be a qualified retirement plan, a tax-sheltered annuity, a governmental 457 plan, or an

IRA as allowed by your Plan. The Plan Administrator reserves the right to require satisfactory evidence that your

distribution is from a source allowed by the Plan.

•

If the distribution check was made payable to you, the rollover funds must be received by The Standard within 60 days of

the date you received the distribution.

•

If you wish to rollover taxes withheld from your eligible rollover distribution, your check for the amount of the taxes must be

received within 60 days of the date you received the distribution.

•

After-tax money may be eligible for rollover, but only from a qualified plan. After-tax money must be received as a direct

rollover to The Standard from your prior plan. Certain types of distributions are not eligible for rollover, including required

minimum distributions (on or after age 70 1/2), non-taxable payments (after-tax contributions) from IRAs, periodic

payments for your life or for a period of 10 years or more, and hardship withdrawals.

PLAN ADMINISTRATOR: REVIEW AND APPROVE

STEP 2

1. Review your Plan Document to ensure the requested rollover can be accepted. More detailed instructions may be found

in Section 5 of the Administration Guide available on our PlanNet

Web site.

2. If the rollover request is acceptable, complete the following sections of the Application for Rollover Form:

• Payee and Mailing Instructions (Include Plan Number and Plan Name.)

• Plan Administrator’s Acceptance

3. To avoid processing delays, promptly fax the form to The Standard at 971.321.7998.

4. Provide a copy of the completed form to the Participant.

5. Please endorse as “Payable to The Standard” any rollover check not payable to The Standard.

PARTICIPANT: REQUEST ROLLOVER TO THE STANDARD

STEP 3

1. Request a rollover from your previous employer’s plan or conduit IRA.

If you do not request a direct rollover from your previous employer’s plan, federal income tax will be withheld at the rate

of 20% of your taxable distribution. Additional state withholding may also occur. You can roll over up to 100% of the

eligible rollover distribution, including the amount that was withheld. If you choose to roll over the amount withheld for

taxes, you must deposit the money within the 60-day period.

2. The Distribution check should be payable to Reliance Trust Company and mailed to:

Reliance Trust Company

FBO : (Participant’s Name)

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

PLEASE NOTE:

A rollover check that is received at The Standard will be returned to the issuing company if a

Completed Application for Rollover is not received within 10 business days. This completed

form must be faxed to the following number: 971.321.7998.

808477

(3/07)

Application For Rollover Form Page 2

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