request for withdrawal from a deferred … · request for withdrawal from a deferred account...

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Pentegra Retirement Services Pentegra Defined Contribution Plan for Financial Institutions (formerly known as Financial Institutions Thrift Plan) REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT IMPORTANT NOTICE: Please carefully review the Special Tax Notice Regarding Plan Payments which you previously received prior to completing this form. If you cannot locate this document, contact your Employer, log on to the Pentegra website at www.pentegra.com or contact Pentegra and a copy will be sent to you. PARTICIPANT DATA (Please Type or Print Clearly): (Only to be completed by participants who have separated from service) Name: Last First Middle Initial Current Address: Street City State Zip Social Security Number: E-Mail: Daytime Phone Number: Name of Employer: Employer Number: THIS WITHDRAWAL REQUEST IS DUE TO DISABILITY TOTAL WITHDRAWAL REQUEST Total Available Vested Balance I understand that my withdrawal may consist of taxable and non-taxable amounts. I also understand that I will be taxed on any taxable amounts distributed, including outstanding loan balances. (If you withdraw your entire account, all outstanding loan balances will be considered distributed and taxable.) PARTIAL WITHDRAWAL REQUEST A. Non-401(k) Monies Total of my own pre-1987 after-tax contributions Total of my own after-tax contributions + earnings Total after-tax and employer matching contributions + earnings (total vested amount) $ _____________ (amount must be at least $1,000) D. Profit Sharing Account (Complete only if you have a Profit Sharing Account with the Pentegra Defined Contribution Plan for Financial Institutions) Total Profit Sharing balance $ ____________ (amount must be at least $1,000) B. 401(k) Account Withdrawal Total 401(k) balance $ _____________ (amount must be at least $1,000) C. Rollover Account Withdrawal (Complete only if you have a Rollover Account with Pentegra Defined Contribution Plan for Financial Institutions) Total 401(k) balance $ _____________ (amount must be at least $1,000) E. Roth Account Withdrawal (Complete only if you have a Roth Account) I understand that some portion of this distribution may be taxable to me if it has not been 5 years since my first Roth contribution. Total Roth balance $ ____________ (amount must be at least $1,000) FORM OF PAYMENT I irrevocably elect to have (check one): All of my withdrawal directly rolled over to the IRA, Roth IRA or plan listed below. $ or % of the taxable portion of my withdrawal directly rolled over to the IRA, Roth IRA, or plan listed below and the remaining portion of my withdrawal paid directly to me. $ to be transferred to the Insurance Company listed below that will be used to purchase a lifetime income stream in the form of an annuity and the remaining portion of my withdrawal (if applicable) paid directly to me or rolled over as indicated below. The total amount of my withdrawal (including any taxable portion eligible for rollover) paid directly to me. Other _____________________________________________________________________ Some or all of your distribution may be subject to Federal and state income tax withholding. If required by law, Federal income tax will be withheld at a flat rate of 20%. If required by your state, state income tax will be withheld at the prevailing rate for your state. Income taxes that have been withheld cannot be refunded by the Plan for any reason. I further understand that this withdrawal will be deducted proportionately from the value of my account in each of the available investment funds. (Continued)

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Page 1: REQUEST FOR WITHDRAWAL FROM A DEFERRED … · REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT IMPORTANT NOTICE: ... A. Non-401(k) Monies Total of my own pre-1987 after-tax contributions

Pentegra Retirement Services Pentegra Defined Contribution Plan for Financial Institutions (formerly known as Financial Institutions Thrift Plan)

REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT IMPORTANT NOTICE: Please carefully review the Special Tax Notice Regarding Plan Payments which you previously received prior to completing this form. If you cannot locate this document, contact your Employer, log on to the Pentegra website at www.pentegra.com or contact Pentegra and a copy will be sent to you. PARTICIPANT DATA (Please Type or Print Clearly): (Only to be completed by participants who have separated from service) Name: Last First Middle InitialCurrent Address: Street City State Zip

Social Security Number: E-Mail: Daytime Phone Number:

Name of Employer: Employer Number:

THIS WITHDRAWAL REQUEST IS DUE TO DISABILITY

TOTAL WITHDRAWAL REQUEST Total Available Vested Balance

I understand that my withdrawal may consist of taxable and non-taxable amounts. I also understand that I will be taxed on any taxable amounts distributed, including outstanding loan balances. (If you withdraw your entire account, all outstanding loan balances will be considered distributed and taxable.) PARTIAL WITHDRAWAL REQUEST

A. Non-401(k) Monies

Total of my own pre-1987 after-tax contributions

Total of my own after-tax contributions + earnings

Total after-tax and employer matching contributions + earnings (total vested amount)

$ _____________ (amount must be at least $1,000)

D. Profit Sharing Account (Complete only if you have a Profit Sharing Account with the Pentegra Defined Contribution Plan for Financial Institutions)

Total Profit Sharing balance

$ ____________ (amount must be at least $1,000)

B. 401(k) Account Withdrawal

Total 401(k) balance

$ _____________ (amount must be at least $1,000)

C. Rollover Account Withdrawal (Complete only if you have a Rollover Account with Pentegra Defined Contribution Plan for Financial Institutions) Total 401(k) balance

$ _____________ (amount must be at least $1,000)

E. Roth Account Withdrawal (Complete only if you have a Roth Account)

I understand that some portion of this distribution may be taxable to me if it has not been 5 years since my first Roth contribution.

Total Roth balance

$ ____________ (amount must be at least $1,000)

FORM OF PAYMENT I irrevocably elect to have (check one): All of my withdrawal directly rolled over to the IRA, Roth IRA or plan listed below. $ or % of the taxable portion of my withdrawal directly rolled over to the IRA, Roth IRA, or plan listed

below and the remaining portion of my withdrawal paid directly to me. $ to be transferred to the Insurance Company listed below that will be used to purchase a lifetime income

stream in the form of an annuity and the remaining portion of my withdrawal (if applicable) paid directly to me or rolled over as indicated below.

The total amount of my withdrawal (including any taxable portion eligible for rollover) paid directly to me.

Other _____________________________________________________________________

Some or all of your distribution may be subject to Federal and state income tax withholding. If required by law, Federal income tax will be withheld at a flat rate of 20%. If required by your state, state income tax will be withheld at the prevailing rate for your state. Income taxes that have been withheld cannot be refunded by the Plan for any reason. I further understand that this withdrawal will be deducted proportionately from the value of my account in each of the available investment funds. (Continued)

Page 2: REQUEST FOR WITHDRAWAL FROM A DEFERRED … · REQUEST FOR WITHDRAWAL FROM A DEFERRED ACCOUNT IMPORTANT NOTICE: ... A. Non-401(k) Monies Total of my own pre-1987 after-tax contributions

DIRECT ROLLOVER INSTRUCTIONS I hereby instruct the Pentegra Defined Contribution Plan for Financial Institutions to directly roll over the portion of my distribution indicated above to: Type of Plan (check one): IRA Roth IRA

Qualified retirement plan (e.g., 401(k), profit sharing, 403(a), etc.) Eligible Section 457(b) plan Annuity Contract under Section 403(b) of the Internal Revenue Code

Name of Receiving Plan, IRA or Roth IRA: ________________________________________________________ Address of Receiving Plan, IRA or Roth IRA: ________________________________________________________ ________________________________________________________

TRANSMITTED DIRECTLY TO THE ABOVE NAMED PLAN, IRA, Roth IRA OR PARTICIPANT AS: A check sent Regular Mail

ACH (Automated Clearing House electronic transfer) - (complete bank information below) ABA# (if any) __________________________ Name of Plan, IRA, Roth IRA or Bank ______________________________

Address of Plan, IRA, Roth IRA or Bank ____________________________________________________________________ __

Branch/Plan # (if any) _________________________ Account #: ______________________________________________

Account Name: _______________________________________________________________________________________ Note: If no box is selected, a check will be mailed to the Plan, IRA, Roth IRA or participant indicated above. Income Solutions®- Lifetime Annuity Instructions I hereby instruct the Pentegra Defined Contribution Plan for Financial Institutions to transfer the portion of my distribution indicated above to the Insurance Company listed below with whom I have signed a contract: Insurance Company Name ______________________________________________________________________________

Department/Attention: __________________________________________________________________________________

Insurance Company Address __________________________________________________ State ________ Zip__________

A check will be mailed directly to the Insurance Company at the address above, unless wire instructions are provided below:

ABA# _____________________________ Name of Insurance Company ________________________________________ Address of Insurance Company ___________________________________________________________________________ Account # ____________________________________________________________________________________________ Account Name/Attention: ________________________________________________________________________________ I hereby certify that I have reviewed the “Special Tax Notice Regarding Plan Payments” within the period required by federal tax law and that I hereby waive the 30 day waiting period as allowed by law. I further certify that the plan or account that I have selected above (if any) is eligible and willing to receive my rollover distributions. I acknowledge a $75 distribution fee will be deducted from the proceeds of my withdrawal. Signature of Participant Date State of: ____________________________________ ss.: County of: __________________________________ On this __________________ day of _________________, ________________ personally appeared before me the said named __________________________________, to me known and known to me to be the person described in and who executed the foregoing instrument, and he(she) acknowledged that he(she) executed the same. STAMP OR SEAL REQUIRED (Seal) (Notary Public)

My commission expires

TP Form 108DeferWD Pentegra Retirement Services · 701 Westchester Ave, Suite 320E · White Plains NY 10604 · www.pentegra.com · Phone 1-866-633-4015 · Fax 914-694-6429