Death Benefit Claim (Page 4 of 13) in pdf

Decedent’s Name

Decedent’s Social Security Number

Information

INCOMPLETE OR INACCURATE INFORMATION — In the event any section of this form is incomplete or inaccurate, ING may not process

the transaction requested on this form and may require that you complete a new form or provide additional information before the distribution can

be processed.

CHANGES TO THIS REQUEST — If you need to cross out any information, you MUST initial the change to validate the change or the request

may be returned for verification.

INSTRUCTIONS — Please be sure that you remembered to:

1. Contact a ING representative for assistance in completing this form.

Provide all requested information concerning the decedent.

Provide all requested information concerning the claimant and attach a certified copy of the decedent’s death certificate.

4. Provide an appropriate tax identification number (“TIN”) for the beneficiary on the claim form and on the attached Form W-9. If the beneficiary

is an individual, provide the individual’s social security number. If the beneficiary is a trust or estate, generally an employer identification

number (“EIN”) must be provided. In cases of a trust beneficiary, a social security number may be appropriate if the grantor is living and is

also the trustee. Failure to provide an appropriate TIN/EIN may result in backup withholding equal to 31% of the payment. See the attached

Form W– 9 for more information.

Select a transaction option (i.e., lump sum distribution or periodic payment option). Read section entitled Determining How and When Payments

Must be Made to Certain Beneficiaries.

Have your signature notarized or sign this form in the presence of two witnesses. If you are acting in a representative capacity, include your title.

7. Complete the Income Tax Withholding section.

8. Attach Letters Probate or Letters of Administration if you are a personal representative of an estate beneficiary (also see Estate Beneficiaries

section). Attach your Letters of Guardianship or Letters of Conservatorship if you are the guardian of a minor beneficiary’s estate or a conservator

for the minor (also see Minor Beneficiary section).

DETERMINING HOW AND WHEN PAYMENTS MUST BE MADE TO CERTAIN BENEFICIARIES —

A. If the participant died before reaching the required beginning date (the later of age 70

or retirement) and the beneficiary is:

The participant’s spouse — You may elect to delay taking distributions until the later of (a) December 31 of the calendar year the

participant would have attained age 70

or (b) December 31 of the calendar year following the calendar year of the participant death.

Distributions must be made over a period not exceeding your life or life expectancy.

2. A non-spouse individual — The required death distribution commencement date is December 31 of the calendar year immediately

following the calendar year in which the participant’s death occurs. The account shall be in compliance with Section 401(a)(9) of the

Internal Revenue Code and over a period not extending beyond the life expectancy of the Beneficiary.

3. A non-individual (estates, trusts and corporations) — Distribution of the participant’s entire interest under the Plan is required to be

made by December 31 of the calendar year containing the fifth anniversary of the participant’s death.

B. If the participant died after reaching the required beginning date (the later of age 70

or retirement):

The Internal Revenue Code requires payments to be made “at least as rapidly as under the method in effect on the day of the participant’s death.”

The meaning of that term depends on whether the participant was receiving individual account withdrawals prior to death.

In the case of individual account withdrawals, how and when payments may continue to be made to the beneficiary depends on how the participant’s

minimum distribution was being calculated prior to the participant’s death. If the minimum distribution was, for example, being calculated over

the joint life expectancies of the participant and his/her spouse with annual recalculation of life expectancies, then payments may continue to be

made over the spouse’s remaining life expectancy only, or over a shorter period, if desired. The applicable rules in this area are quite complicated

and beneficiaries should contact their legal counsel or tax professionals for advice on how and when distributions must be taken to avoid adverse

tax consequences.

Note: The IRS may impose a penalty tax on amounts which were not distributed as and when required under the Internal Revenue Code. We do

not assume any responsibility or liability for ensuring that distributions are made timely.

Form

ING_VRS_Death

Page 4 of 5

Benefit Claim_12.30.10

Death Benefit Claim Page 4

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