Distribution Agreement Form printable pdf download

City of Baltimore Distribution Agreement

Please read the attached “Special Tax Notice” before completing this form.

Social Security Number

Last Name

First Name

Middle Initial

Mailing Address

City

State

Zip Code

Birth Date

Home Telephone

Office Telephone

Select one:

NEW DISTRIBUTION AGREEMENT

MODIFICATION OF DISTRIBUTION INSTRUCTIONS CURRENTLY ON FILE

Option 1: LUMP SUM PAYMENT PAID DIRECTLY TO ME. I UNDERSTAND THAT 20% OF THE AMOUNT PAYABLE WILL

BE WITHELD BY THE PLAN FOR FEDERAL INCOME TAX AND STATE TAX

) WILL BE WITHELD ON THE

(IF APPLICABLE

TAXABLE PORION OF THE DISTRIBUTION. $_______________(PARTIAL OR ENTIRE ACCOUNT BALANCE) ON

____________MONTH/YEAR

CHECK BOX FOR PRETAX ONLY.

Option 2: SYSTEMATIC WITHDRAWALS _____ YRS OR

UNIFORM LIFE EXPECTANCY

JOINT LIFE EXPECTANCY

Payment Period:

MONTHLY

QUARTERLY

SEMI-ANNUALLY

ANNUALLY

REQUESTED DATE FOR PAYMENT PAYMENTS TO BEGIN ________________ MONTH/YEAR

$______________ AMOUNT

Option 3: Direct Rollover to an IRA or another Qualified Plan

$ _______________ OR

Maximum available

Name of Institution______________________________________________________________

Mailing Address of Institution_____________________________________________________

City, State, Zip Code_____________________________________________________________

IRA or Account Number__________________________________________________________

Please check with the new trustee for this information. Neither ING Plan Administration nor the City of Baltimore will verify if this

information is correct. It is your responsibility to provide accurate information.

IMPORTANT TAX AUTHORIZATION: I have read and understand the Tax Disclosure Form regarding rollovers. I understand that

taxes are withheld on all distributions at a mandatory rate of 20% unless a Direct Rollover takes place. I understand that these funds

are taxable as ordinary income to me in the tax year I receive them. I will receive a 1099-R from ING detailing distribution amounts.

I HEREBY CERTIFY, under the penalties of perjury, that I am not a party to any suit of divorce, nor am I aware that a divorce is

pending or anticipated. If previously divorced, and if I had been married at any time while being a City of Baltimore employee, then a

copy of the divorce decree has been provided to the City of Baltimore.

I AUTHORIZE ING TO DISBURSE MY ACCOUNT OR AMEND MY DISTRIBUTION INSTRUCTIONS AS REQUESTED ABOVE.

Your signature is required to process this form.

Participant Separation Date ______________/_____________/_________________ MONTH/DAY/YEAR

Participant Signature

PLEASE RETURN THIS FORM TO: ING, Attn: City of Baltimore, P.O. Box 5179, Boston, MA 02206

Distribution Agreement Form

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