Death Benefit Claim (Page 2 of 13) in pdf

Death Benefit Claim Page 2

Decedent’s Name

Decedent’s Social Security Number

Type of Election

Must be completed

Please select the effective date and payment method you wish for your death distribution payments. The payment method chosen may be changed

in writing up to 30 days before the payout is scheduled to begin.

Once payments have started, the Plan does not allow you to change your payout method.

The effective date is the date the funds will be withdrawn from your account. If the effective date falls on a weekend or holiday, it will be

processed on the following business day. Checks and electronic transfers will be forwarded within 2 business days aftre the effective date.

Note: The effective date must be at least 61 days from the participant’s date of death.

A. K Full withdrawal

B. K Partial withdrawal followed by payments of a specified amount, or payments of a specified period, or an annuity

Phase 1: Partial withdrawal amount $ __________________

Phase 2: K Payments of a specified amount (fixed dollar): complete C

K Payments of a specified period (fixed period): complete D

K Annuity: complete the Annuity Options section

C. K Payments of a specified amount until account is exhausted

Specified dollar amount $ ____________________

Frequency: K Monthly K Quarterly K Semi-Annually K Annually

D. K Payments of a specified period

Specified time period of _______________ years

Frequency: K Monthly K Quarterly K Semi-Annually K Annually

Installments will begin as soon as administratively possible and are processed on the 1st and 15th of each month.

Please confirm which date you would like your payment processed:

K 1st K 15th

E. K DIRECT ROLLOVER — Note: The rollover check will be made payable to the financial institutions for the benefit

of the beneficiary. Provide company information below.

MAILING ADDRESS:

Company or Trustee’s Name

Address — Number and Street

City

State

Zip Code

ACCOUNT INFORMATION:

Account Number

Name on Account

Amount of Rollover

Form

ING_VRS_Death

Page 2 of 5

Benefit Claim_12.30.10

Death Benefit Claim Page 2