BENEFICIARY OR ALTERNATE PAYEE INFORMATION (IF APPLICABLE. Check here if you are the surviving spouse or other beneficiary for the Former Participant and the Former Participant is deceased. Documentation must be provided showing current authority of the representative to file on behalf of the deceased. Please complete the information below and then continue on to Parts 4 and 5 on the next page. Check here if you are an alternate payee under a qualified domestic relations order (QDRO). The Settlement Administrator may contact you with further instructions. Please complete the information below and then continue on to Parts 4 and 5 on the next page. Your First Name Middle Last Name Your Social Security Number or Tax ID Number Your Date of Birth Your Mailing Address City, State, ZIP M M D D Y Y Y Y PART 4: PAYMENT ELECTION Payment to Self – A check subject to mandatory federal and applicable state withholding tax will be mailed to your address on the previous page. Direct Rollover to an Eligible Plan – Check only one box below and complete the Rollover Information Section below: Government 457(b) 401(a)/401(k) 403(b) Direct Rollover to a Traditional IRA Direct Rollover to a Xxxx XXX (subject to ordinary income tax) Rollover Information: Company or Trustee’s Name (to whom the check should be made payable) Company or Trustee’s Mailing Address 1 Company or Trustee’s Mailing Address 2 Company or Trustee’s City State Zip Code Your Account Number Company or Trustee’s Phone Number
BENEFICIARY OR ALTERNATE PAYEE INFORMATION (IF APPLICABLE. Check here if you are the surviving spouse or other beneficiary for the Former Participant and the Former Participant is deceased. Documentation must be provided showing current authority of the representative to file on behalf of the deceased. Please complete the information below and then continue on to Parts 4 and 5 on the next page. Check here if you are an alternate payee under a qualified domestic relations order (QDRO), or attorney-in-fact for the Former Participant. The Settlement Administrator may contact you with further instructions. Please complete the information below and then continue on to Parts 4 and 5 on the next page. Your First Name Middle Last Name Your Social Security Number or Tax ID Number Your Date of Birth Your Mailing Address M X X X X X X X Xxxx Xxxxx Zip Code
BENEFICIARY OR ALTERNATE PAYEE INFORMATION (IF APPLICABLE. Check here if you are the surviving spouse or other beneficiary for the Former Participant Class Member and the Former Participant Class Member is deceased. Documentation must be provided showing current authority of the representative to file on behalf of the deceased. Please complete the information below and then continue on to Parts 4 and 5 on the next page. Check here if you are an alternate payee under a qualified domestic relations order (QDRO). The Settlement Administrator may contact you with further instructions. Please complete the information below and then continue on to Parts 4 and 5 on the next page. [FORMER PARTICIPANT ROLLOVER FORM CONTINUES ON THE NEXT PAGE] PART 4: PAYMENT ELECTION Direct Rollover to an Eligible Plan – Check only one box below and complete the Rollover Information Section below: Government 457(b) Direct Rollover to a Traditional IRA Rollover Information: 401(a)/401(k) Direct Rollover to a Xxxx XXX (subject to ordinary income tax) 403(b) Company or Trustee’s Name (to whom the check should be made payable)
