Death Benefit Claim

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DEATH BENEFIT CLAIM
Please read ALL the instructions, then complete the entire form.
If you have questions or need assistance
completing this form, please contact a Participant Service Representative at 1-VRS-DC-PLAN1 (1-877-327-5261).
K Commonwealth of Virginia 457 Deferred Compensation Plan
650271
K Virginia Cash Match Plan
650272
Please select the plan(s) for which the claim is intended.
Information Concerning the Decedent
Must be completed
Last Name
First Name
MI
Social Security Number
Mo
Day
Year
Mo
Day
Year
State of Legal Domicile at Time of Death
_____________________
_____________________
Note: A certified copy of the death certificate is required for processing
Date of Death
Date of Birth
of this death benefit.
Claimant’s Taxpayer Identification Number
Must be completed
Enter an appropriate taxpayer identification number (“TIN”) in the box below. For individuals, including minors, this is their social security
number. For other entities, such as most trusts and estates, it is their employer identification number (“EIN”). Ask your attorney for guidance.
The TIN/EIN must match the TIN/EIN you specify on the W-9 form.
TIN/EIN
Information Concerning the Claimant
Must be completed
Last Name
First Name
MI
Address — Number and Street
Mo
Day
Year
City
State
Zip Code
_____________________
Date of Birth
Home Phone
Work Phone
IF BENEFICIARY IS A MINOR, complete the following:
Minor’s Last Name
Minor’s First Name
MI
Address — Number and Street
Mo
Day
Year
City
State
Zip Code
_____________________
Date of Birth
The claimant is claiming the death benefits payable as the beneficiary and in the following capacity (i.e., self, personal representative of estate,
guardian or conservator of minor beneficiary’s estate, trustee of trust beneficiary, custodian of minor beneficiary under the Uniform Transfers
to Minors Act*, successor under small estate affidavit*, etc.):
*not applicable in all states
If you specified “self” above, please specify your relationship to the decedent (i.e., spouse, child, sister, brother, mother, father, friend, etc.):
K I certify that I am not a resident of any state other than the state shown in the home address I furnished above.
If you specified an address outside of the U.S. above, please answer the following questions: Are you a U.S. citizen? K Yes K No
If the answer to the above question is no, please complete and attach an IRS Form W– 8BEN to elect a reduced rate of withholding.
Form
ING_VRS_Death
Page 1 of 5
Benefit Claim_12.30.10

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