Death Benefit Claim Page 3
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13Decedent’s Name
Decedent’s Social Security Number
Income Tax Withholding
Must be completed
If you are electing both a partial distribution and periodic payment, your VA–4 or other state withholding form and W–4 or other state
withholding form and W–4 will apply to both elections.
I have completed and attached:
K Federal income tax withholding Form W–4
FEDERAL —
STATE —
I have completed and attached:
K Virginia Form VA–4
K Other State income tax withholding form (required for mandatory states)
Important note: If no withholding allowance certificate documents are submitted with this form, then withholding will take place according to
the guideline of single plus zero allowances. This applies to both Federal and State tax withholding.
Annuity Options
Complete if applicable
K I have reviewed the materials related to the annuity option offered by the Plan and have attached the appropriate annuity
election forms.
Required Signatures
Must be completed
IMPORTANT NOTE: Any person who knowingly presents a false or fraudulent claim is subject to criminal and civil penalties.
You must obtain either the signature of a notary or the signature of two witnesses.
Statement of Notary
SEAL
State of ________________ )
The above election was subscribed before me by _________________________________________________
)ss.
on this ____________ day of _____________________ , year ______________, who affirmed that such
County of ______________ )
election represents his/her free and voluntary act.
Notary Public _______________________________________ My commission expires _________________
Statement of Witnesses
The claimant whose signature we have witnessed is known to us and signed this form in our presence.
Witness Signature
Date
Witness Signature
Date
My signature acknowledges that I have read, understand and agree to all pages of this form including the Information section. I affirm that all
informations that I have provided is true and correct. I confirm that I have attached a certified coy of the death certificate.
Claimant forward to:
CLAIMANT SIGNATURE
DATE
ING Plan Administration
Attn: Virginia Retirement System
(include title if you are acting in a representative capacity)
P.O. Box 56588
YOU MUST READ ALL PAGES OF THIS FORM BEFORE SIGNING.
Jacksonville, FL 32241-6588
Phone: 1-VRS-DC-PLAN1
(1-877-327-5261)
Fax:
1-888-998-8954
Form
ING_VRS_Death
Page 3 of 5
Benefit Claim_12.30.10
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